[Please note that I am in no way an expert on billing or ambulance services across the country. This rant is just based on my experiences and the limited research I’ve done. Information on billing practices changes frequently and is something that should probably be addressed in the ongoing public debate about our healthcare crisis]

There’s nothing that causes a mass convergence to ambulances to a particular location faster than an interesting trauma job. It’s not the gory details that so many seem to assume is the appeal but the opportunity to do something worthwhile for a patient that encompasses the training and skills we are taught but do not often use.

Given the countless other calls we respond to, for the most mundane things that often don’t even require a cab, much less an ambulance, the chance to make a difference is at the heart of every adrenaline junkie. For every man with a limb caught in a machine, there are thousands of toothaches, cough/cold/flu, common rashes, headaches, and attempts to get a prescription renewal through the ER. It’s so incredibly frustrating to imagine how people will complain about waiting 8 minutes for an ambulance because they need to go back after an antibiotic they received (when you brought them two days before), has not cured their complaint yet but they will quickly jump into a taxi for something we can actually do something for.

Despite having a vague idea of what his daughter did for a living, my father drove himself to the hospital during each of his three heart attacks. He felt it an unnecessary expense. It’s not that he didn’t have insurance that would have covered the cost, he absolutely did. He just didn’t think that anyone should pay such outrageous prices, not even the large for-profit corporation he was paying 35% of his fixed retirement income to for his Medicare supplement. But this wasn’t some frivolous add-on as I desperately tried to explain to him.

The entire motivation to create paramedic units was to provide critical cardiac care, an area where timing is the difference between life and a diminished quality of life or death. A paramedic crew, in addition to providing provided pain relief and supportive care, could have evaluated his EKG to determine which artery was blocked and sent that information to a STEMI specialty hospital where he would have been sent to immediately clear the obstruction, saving valuable heart tissue. The necrotic atrophy he suffered as a result of waiting caused him to become a ‘cardiac cripple’, where the most basic tasks left him breathless and exhausted. Each subsequent infarction lost him more freedom, just because he felt $1,200 was too much for an insurance company to payout for a “ride”. [my dad lived in a different city but their ambulance services and pricing mirrored NYC’s almost exactly].

But insurance companies don’t work like that anyway. It’s not as if the bill says X amount and they send off a check for that exact amount. Their payments are based on a complicated formula agreed upon by the health care provider and the insurance company.

I remember the bill one of my patients, who had Medicaid, showed me. A municipal ambulance usually showed up at her door each time she called 911, which was fairly regularly, and we charged roughly $1,200.00, at the time. But one time she called, a contracted provider in our service took her to the hospital and that bill was over $2,000. Medicaid paid out $16 for us and $22 for the private hospital provider even though we were advanced life support and the private was basic life support. She was extremely upset by the disparity that she wasn’t paying for and wrote letters to Medicaid saying that we, the municipal providers, deserved the extra $6.

It’s another issue altogether, how calling the same number for the same service results in different prices, particularly when you didn’t specifically request one provider over another. I’m not sure how the different providers operating in the same 911 system, where calls are randomly assigned, can charge different prices. I can see their need for it, but it doesn’t seem fair for the average citizen who makes the call to 911 not knowing that the billing isn’t uniform.

Healthcare billing practices in general leave plenty of reasons to be anger inducing. Good luck trying to research how they come up with pricing and payouts. It’s a secretive system that lends itself to distrust and fears of corruption The only people who are generally charged the listed amount are people with no coverage, people who I can very much understand fearing the burden of an ambulance bill added on to an already massive ER bill.

I often see on social media posts (and my family and friends tag me to see even more) how ridiculous it is that an ambulance transport costs so much when a taxi is only a fraction of that expense. “We only went two miles!” and “I was charged $2,000 for an 8 minute ride!” The taxi equivalency is incredibly frustrating as it reduces our training and equipment down to a vehicle whose sole purpose is simply to get a person from point A to point B. If a taxi would have sufficed, you probably didn’t need an ambulance.

People with a hefty co-payment or those who fear having to make explanations and justifications to an insurance provider generally don’t use our service as a taxi equivalent. But many, many people do. It’s frustrating to be used as free transportion to the hospital for someone who will spend six hours waiting in an ER for a free bottle of Tylenol because they didn’t want to pay $6 at a pharmacy. It is especially heartbreaking when the call before it involved discussions with a different, critical patient over their very valid fear of an outrageous bill which kept them from getting the critical care you know they needed.

There was once a well-publicized shooting in the area I work, of a child hit by gunfire. To be clear, everyone races to a child in distress call. Units that don’t normally join in the rush towards trauma will run towards a critical child. Even though the first unit arrived less than three minutes after the shooting was reported (because many units monitor the police frequencies), the child had already been put in a neighbor’s car to be taken to the nearest ER. “He was hit by a bullet,” they said. “What were we supposed to do?” They also told us that “the neighbor works for Uber, so he knows where he is going.”

Sadly, the Uber driver didn’t know that the closest hospital wasn’t a trauma center, which is a place equipped to provide the immediate surgery critical to saving life from traumatic injuries. Pediatric trauma centers are another specialty altogether. All the hospital they went to could do for that child is provide the same kind of stabilizing care a paramedic unit was capable of (and would have done en route), and transferred him, by ambulance, to one of the few pediatric emergency rooms in the city. The delay was detrimental and tragic.

Hospitals are not all the same and while most provide similar care for most categories there are dozens of designated specialties that are unique to different facilities. Specialty centers go to great expense to maintain a detailed list of requirements for that specialty certification. Trauma centers, for example, are required to have an operating facility fully staffed at a moments notice. Keeping an operating room ready on stand by is an expense that most hospitals will not recoup from insurance payouts from individual trauma patients, it’s why there are so few of them. There are also specialty burn centers, stroke centers, cardiac catherization, limb replantation centers and several others. And there are no hospitals in NYC that have every specialty. Also, not all specialty centers are able to accommodate the constant influx of that specialty and will go on ‘diversion’ for that specialty should they become overwhelmed.

How would anyone know all this if they were in an Uber? They wouldn’t, but we would, thanks to a state of the art mobile data terminal that all ambulances in the 911 system are equipped with. It provides real time updates of availability and hospital acceptance.

How does a municipality pay for this, and the (pitiful) salary of the EMTs and paramedics using them, along with the thousands of dollars of monitoring equipment, supplies, communications (along with salaries of dispatchers and 911 call takers), the rotation of medications, vehicles and maintenance, facilities, software, and the thousands of other surprising things that go into a 911 ambulance? In part, by sending a $1,200 bill.

If you want to give yourself a headache figuring out billing practices, here are some links:

https://time.com/198/bitter-pill-why-medical-bills-are-killing-us/