Why American ambulance rides are so expensive

https://davidoks.blog/p/why-american-ambulance-rides-are

by jyunwai • 13 days ago

336 459 13 days ago

davidoks.blog

chillingeffect• 13 days ago

This is amazingly coherent and explanatory article!

the writer really went into depth about the problem and...surprise...the answer is almost embarrassingly simple.

Everyone in the country needs to read this.

josefritzishere• 13 days ago

TLDR: private equity

jfim2• 13 days ago

The article argues the exact opposite:

The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.

deathanatos2• 13 days ago

That paragraph is somewhat incoherent at that point in the article: margins are razor thin — at a price tag of $12,000 per 6 miles or $2,000 per mile.

(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)

kirrent• 13 days ago

The piece is actually quite concise, but you're right in the other respect. You definitely didn't read it. Private equity as an explanation is explicitly rejected.

Avicebron6• 13 days ago

The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue. That’s how it’s done in the rest of the rich world. Some places, like the United Kingdom or Japan, simply fund ambulance services directly out of taxes; others, like the Australian state of Victoria, sell memberships in “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year per family.

So there is a solution.

charcircuit7• 13 days ago

from everyone the service stands ready to rescue

So compelled health insurance to use an ambulance? You could just as well make it optional and charge people without the insurance the full price.

Avicebron6• 13 days ago

So everyone's covered unless you explicitly opt-out?

spzb3• 13 days ago

One thing that's often overlooked is the cost of administering a billing system. If you're going to distinguish between the insured and uninsured you need a system that keeps track of who has insurance. You need paperwork (or digital equivalent). You need accounts payable staff to send invoices and chase up unpaid bills. It can, counter-intuitively, work out cheaper just not to charge anyone.

paxys2• 13 days ago

But that’s socialism!

kaelwd• 13 days ago

“Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year

And even if you don't pay this it still isn't that expensive - US$12873 is more than a helicopter transport would cost here. US healthcare companies somehow get away with charging insured patients 10x more than civilised countries charge uninsured ones.

arjie3• 13 days ago

You don't have to pay them unless they're specific. I got a bill 3 years after being in an accident and I asked them for the documentation they legally have to provide me (itemization, the legal basis, detailed incident record, attempts on their part to contact insurance) of how they arrived at the sum. It's been a year since and they haven't given me anything.

Besides this kind of billing is banned in California now https://leginfo.legislature.ca.gov/faces/billHistoryClient.x...

The insurers just pay the in-network fee and you call it a day.

Waterluvian• 13 days ago

The last thing I want at that time is to have to reason about any of this.

I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.

ozlikethewizard• 13 days ago

Yea I think this is the bit thats easy to take for granted in nations with rational healthcare systems. Not only do I not get fleeced, but at no point does my healthcare feel like economic activity, a transaction, it feels like healthcare and that the provision of it is being done for the right reasons.

alistairSH6• 13 days ago

This applies to other things as well - retirement and education come to mind.

Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.

asdff• 13 days ago

Medicaid is actually like this incidentally. No copays really. Too bad the electeds don't want to roll it out. The a lot of the most expensive risk pools are already on medicaid or medicare.

burnhamup• 13 days ago

Yeah, my family was hit by two ambulance bills in California in 2024, and tried to balance bill us contrary to the law. It was a really frustrating experience trying to get them follow the law. One of the ambulance companies waited an entire year to even file paperwork and still tried to get insurance and me to pay.

disillusioned• 13 days ago

My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least. Wild.

thaumasiotes• 13 days ago

My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least.

Would your wife have been in a different location if you had made the call?

TinyBig• 13 days ago

The law you've cited only applies for "emergency transport".

Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.

darth_avocado4• 13 days ago

We’re all pretending this is an unsolvable problem when really most of the world has solved it by making ambulance (EMS) funding similar to fire and police departments. Somehow in any emergency I’ve seen, all three show up, often EMS before police or fire dept, and somehow that’s a service that has to be supplemented by insurance billings.

The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.

toomuchtodo5• 13 days ago

Very much so. We could fix this. We continue to choose not to, and will for some time into the future.

Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.

https://www.nfpa.org/news-blogs-and-articles/nfpa-journal/20...

For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.

https://www.ruralhealthresearch.org/publications/1596

4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties. Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington. Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).

rconti• 13 days ago

We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.

Aurornis• 13 days ago

Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).

There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.

Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.

These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.

pclowes5• 13 days ago

I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.

Choosing to live far away from others is also choosing to live far away from help.

If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.

There _should_ be some ambulance deserts.

darth_avocado4• 13 days ago

There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.

HumblyTossed3• 13 days ago

But if we fixed it, that might help people who can't afford the ride otherwise. And we cannot have that.

  --- Says far too many people, always.

joe_the_user3• 13 days ago

Sure, in a given public discussion, lots of people saying that show up. But substantial portion of those are shills, not necessarily people to say but who benefit from the scam. And some people who are paid, public relations people acting on the downlow, etc.

Hnrobert423• 13 days ago

But do they really? Can you point a real, evil villain saying that?

vlian2088• 13 days ago

the reverse side of that medal is that in 'most of the world' EMS quality is ass.

jahnu• 13 days ago

If you limit it to say the top 20 developed countries how does it look?

groby_b2• 13 days ago

Haven't yet seen a developed nation do worse than the US. If you prefer to compare against developing countries only, sure, winning by lowering the bar to the ground is an option.

darth_avocado4• 13 days ago

I think this argument is very disingenious for two reasons:

- If you’re comparing to developed nations (or some non developed ones with functioning agencies), the argument doesn’t hold true.

- If you’re comparing to the bottom of the barrel EMS (quality being ass like you said), you’re still not going bankrupt for an ambulance ride.

cogman106• 13 days ago

US EMS quality isn't exactly something to be proud of. It's been private equityified. Just recently (last winter) I nearly lost an aunt because of our stellar EMS system literally doing a transfer from a hospital to a hospice. The company had only one person working, they parked the ambulance next to a snow bank, tried to wheel my aunt up the snow bank, and had her and the bed flip on them trapping them in the snow.

They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.

msftgreed5• 13 days ago

Well, here it is often ass AND expensive. I'd take ass and free over ass and expensive.

ethersteeds• 13 days ago

most of the world has solved it by making ambulance (EMS) funding similar to fire...

About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.

cogman106• 13 days ago

A pretty large number of EMS is also volunteers. Basically wherever you have a volunteer fire department, you'll have volunteer EMS (if it's there).

defrost4• 13 days ago

St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).

In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.

Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.

msftgreed5• 13 days ago

You know we can have volunteer supported services be very effective, right?

I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.

Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.

Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.

rcbdev• 13 days ago

Yeah. In many countries, EMS is also heavily volunteer-based.

arjie3• 13 days ago

The ambulance that billed me in San Francisco after my accident was run by San Francisco Fire Department.

darth_avocado4• 13 days ago

SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.

dlcarrier• 13 days ago

Many fire departments in the US send bills, whether responding to medical emergencies or fires.

joe_the_user3• 13 days ago

Health care in general has been solved by state sponsored medicine in most industrialized nations. And when it isn't solved by directly state sponsored medicine, it's solved by formally and informally regulated monopolies. In fact, US health care in the 1960s was made reasonable by the Blue Shield regulated monopoly.

The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.

JackMorgan• 13 days ago

I'm volunteering to help build out a nonprofit EMS authority that will tax residents and businesses in our local six boroughs to spread out the costs for ambulance transports.

We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.

I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.

We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.

I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.

The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!

And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.

We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).

Cross your fingers because this feels like our best option

coredog64• 13 days ago

Story up thread is about an ambulance ride by the San Francisco Fire Department charging a grand. So in essence the EMS funding is the fire department funding and it’s still unsolved.

kip_• 12 days ago

Well, thank goodness we don't price Fire Department response the same way.

For my city of Ann Arbor, Michigan from https://www.a2gov.org/media/4glhvywf/2025-aafd-annual-report...

FY2026 budget: $20,810,234 Structure Fires: 58 Cooking Fires: 75 Vehicle Fires: 30

So should we somehow recover roughly $127,000 from the victims of each fire?

Of course not. I and my neighbors pay taxes to maintain the Fire Department and have it ready when needed. Many may argue that we pay too much, but those unfortunate enough to actually need its services would probably say they got a great deal.

gruez6• 13 days ago

As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted. The article starts off by noting about how ambulance is an "option" for a rescue, but even though the analogy might vaguely work, it's not really needed to answer the question. That can be answered far more simply: "medicare and insurance companies pay them too little, so they have to charge everyone else more". Or, from the article:

This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.

Noumenon725• 13 days ago

"Medicare pays too little" is based on the "fee for service" model; it only makes sense if you believe the group of people who actually use the ambulance should pay its full cost.

The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.

gruez6• 13 days ago

The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it.

There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.

gerdesj• 13 days ago

Given you find this is _normal_ for a six mile ambulance ride: "and $11,670 as a “base rate.”"

What on earth would you consider normal for a helicopter ride from Exeter to London?

That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.

My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.

Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?

gruez6• 13 days ago

How can that possibly be justified?

They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.

jjk1668• 13 days ago

The average ambulance transport costs $2,673 to provide

I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.

A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.

Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.

I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?

Insanity• 13 days ago

+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.

cogman106• 13 days ago

I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.

Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.

That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.

justonceokay• 13 days ago

There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.

Is it $2600? Probably not. But I think you are low-balling pretty significantly.

Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.

mlsu• 13 days ago

Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.

harmmonica2• 13 days ago

Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.

As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.

Edit: spelling

bombcar2• 13 days ago

You can get an ambulance for only $150k? A transit van with a few options is already $75k.

tbrake• 13 days ago

This is a short trip in an automobile, essentially a fancy uber ride.

We need a regulatory body that can fine people for making analogies this bad

FireBeyond5• 13 days ago

Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.

Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.

Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).

However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.

The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.

You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).

Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.

This is a short trip in an automobile, essentially a fancy uber ride.

That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.

A new, fully equipped ambulance is about $150k.

Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.

Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.

Throw in money for gas and wear and tear, which should be quite comparable to other automobiles

For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).

This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.

somat• 13 days ago

It may also be telling to figure out why no startup is offering $400 ambulance rides and dominating on volume.

socalgal23• 13 days ago

You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?

There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.

My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you

tmnvix• 13 days ago

An interesting take on the relative differences of manufacturing (and purchasing) an ambulance in the US and China: https://www.youtube.com/watch?v=8JcCISp5S64

Spooky234• 13 days ago

Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.

The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.

When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.

Air ambulance is worse.

bandrami• 13 days ago

We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).

[1] Oh, holy crap, I just got why ambulances are called that

xp848• 13 days ago

Some of your estimates on this seem fine, but not this:

liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.

kyleee• 13 days ago

All in cost of the employee is probably double or more of your example $23 an hour wage, just to flesh out your napkin math

jjk1668• 13 days ago

Replying to myself as a followup:

https://digitechcomputer.com/costs-of-ems-readiness/

Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".

consp• 13 days ago

Here in the Netherlands it is 877 euro for an A1 call (emergency, no delays), and 384 for B1 calls (non emergency, planable). You also get a 4.83 euro per km cost. You pay up to 375 euro if you haven't had any medical cost that year, otherwise zero.

Stand by cost are about 154 euro/hour. E.g. for sport events.

ICU transport is about 2500. All are law mandated.

The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.

lazide5• 13 days ago

The ambulance operator also gets stuck with the costs of all the ambulance rides which are never paid for - which is, statistically most - because of things like homeless folks, people giving false names, etc.

Which, notably, are so common, because it is financially ruinous to not do it.

They can’t decline transport for anyone with an emergency, regardless of ability to pay.

closewith2• 12 days ago

A new, fully equipped ambulance is about $150k.

This is definitely not true. A base model unequipped ambulance may be in that ballpark. A fully equipped ambulance will vary wildly in cost based on clinical level but will be about $250-500k in the US.

Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Maybe for BLS or non-emergency ambulances in a low-utilisation role? For ALS/Critical Care or higher in a busy jurisdiction it's going to be significantly higher.

kelnos2• 12 days ago

This is a fine example of coming up with some "plausible" numbers to support a conclusion, but all of the "plausible" numbers are actually wildly incorrect.

A new ambulance will probably run 2-4x what you quoted. Gas/maintenance will not be comparable to a regular automobile; it will be significantly higher. Paramedic wage (though there will probably be more "cheaper" EMTs out there than paramedics) seems right, maybe a little high for some markets. $12k for liability seems shockingly low; I wouldn't be surprised if you're off by an order of magnitude.

Regarding salaries, you're not just paying for the people in the ambulance. You're paying for dispatch, operators, support staff, administration, etc. You're also paying them 24/7, not just for the times that the ambulances are actually making trips.

You also left out the cost of medical supplies and equipment, both of which need to be maintained and replaced.

JumpCrisscross2• 13 days ago

As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted

Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.

FireBeyond5• 13 days ago

One thing I'd like to point out, many of the Airlift companies, like Airlift Northwest, offer $60/year family insurance for Heli EMS. They'll bill your insurance and accept the insurer's payment as "Paid in full". They also tend to have reciprocal agreements with many other HEMS agencies.

mekael2• 13 days ago

At the end of the day doesnt that just end up being universal healthcare but with more steps?

Atotalnoob3• 13 days ago

This is just insurance, dude

arjie3• 13 days ago

You’re right. The cost of the service not matching the direct cost is something we’re familiar with - that’s just fixed cost and entirely normal (happens with books, movies, etc).

This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.

Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.

Spooky234• 13 days ago

That’s wrong. The poor people who don’t pay are Medicare and Medicaid patients, and both pay for medically necessary transportation.

Those calls essentially cover the base business expenses.

dripdry45• 13 days ago

That 150k figure I believe is quite outdated. New ones are running 300k or more. The ambulance vehicle providers have been bought up by private equity and the lead times are now years to get one.

pjc504• 13 days ago

Comparable UK costs: https://www.kingsfund.org.uk/insight-and-analysis/data-and-c...

Estimate for an ambulance call is about £450. I suspect the main reason the US costs more is wages.

manarth2• 12 days ago

Wages for which role?

UK – Newly Qualified Paramedics (Band 5): £28,407 – £34,581. USA - $38,000 to $48,000: £28,323 – £35,777

Sure, there's a bunch of different tax treatments and work-benefits between the countries, but I don't think it's the cost-of-labour that is making the USA more expensive.

shusaku• 13 days ago

I completely lost interest at the options part, it’s not that complicated of a concept. But substack writers have their type

veunes5• 12 days ago

Most of the cost is keeping crews, vehicles and equipment available for the call that may or may not come

comrade1234• 13 days ago

Check your insurance to make sure you have transport. It's the same in Switzerland - it's an extra line on your insurance.

My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.

standardUser2• 13 days ago

And then do what, precisely? Quit your job and find one with better insurance options?

Noumenon725• 13 days ago

This comment is confusing because it refers to the first paragraph and also assumes when you checked your insurance you didn't find transport there. Since the parent did have transport and good insurance and a second paragraph, it sounds like you're asking "And then do what after your hospital jet flies you home, quit your job and find better insurance?"

softdevca2• 13 days ago

I don't understand why taxes can be used to save property but not a person.

jfengel• 13 days ago

Because we like property.

lokar2• 13 days ago

Sure you do. Most people don’t own property. Most of the taxes are paid by people who do. And elections are decided by people with property.

msftgreed5• 13 days ago

You've got it. Who makes the decisions? Primarily the folks with the most property.

Noumenon725• 13 days ago

The article explains why; regulators sometimes can't foresee that their decision to consider something fee for service will eventually prevent it from being considered as a communal expense.

softdevca2• 13 days ago

Fee-for-service doesn't prevent ambulances from being considered a communal expense, it just makes sticky. There is nothing preventing a government from making ambulances equivalent to fire or police except the will.

From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.

master-lincoln2• 13 days ago

because of the moral values of elected law makers and thus indirectly because of the moral values of voters

mikeweiss• 13 days ago

Where I live (NJ) you don't pay if your picked up by a town run rescue squad. But you don't always know who's responding... Such a strange system.

xp848• 13 days ago

I tell this story every time ambulance costs come up because it might be helpful to anyone. I once lived in San Francisco in the mid-2010s. In SF, the SFFD operates the vast majority of ambulances in the city. As in, 80%+. I once had the need to go to the hospital urgently and called 911. The ambulance that showed up was SFFD. They transported me and I recovered safely. I then got a bill from them saying that my insurance had refused to pay for it - apparently that insurance company (they're lucky I've forgotten which one, as naming and shaming health insurance people is one of my favorite hobbies) had refused to contract with SFFD, making them "out of network." Yes, an out of network ambulance. And remember, there's at least an 80% chance that an SFFD ambulance will show up, and I've never heard of them offering a menu of ambulance companies to the caller who's likely having a heart attack, bleeding, etc!

So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.

So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.

And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.

Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!

Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.

semiquaver• 13 days ago

  > discovered the "life hack" of having an extremely inadequate network

The article covers this. Ambulance providers are strongly incentivized not to join insurance provider networks, and as a result more than 80% of ambulance rides in the US are “out of network”. So the inadequacy of the network is probably not the insurer’s fault.

xp848• 13 days ago

Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.

If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.

The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.

FireBeyond5• 13 days ago

As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.

The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.

If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.

stephenbez• 13 days ago

Was this Cigna? Same thing happened to me in SF in the same timeframe.

It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.

xp848• 12 days ago

Not surprising. They clearly care(d) a LOT about the regulators asking questions. I was actually shocked that this mechanism was surprisingly effective at reining in abuses from insurers.

It could have been Cigna -- I've cycled between probably every possible insurer during my career. Dirtbags, the lot of them.

thayne2• 13 days ago

I had a very similar experience. Except unlike you I wasn't aware of that requirement at the time, and ended up paying all of it. I did complain to the insurance company that the amount I owed didn't seem right, and they told me it was my fault for using an out of network ambulance.

throwaway20373• 13 days ago

    > I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.

First: Hats off -- nice work.

What annoys me the most about this story: There should be a disportionately large penalty that the insurance must pay to the health care regulator for cases like this. It would discourage this kind of illegal behaviour.

xp848• 12 days ago

Agree. I would be utterly shocked if this exact same scam didn't play out for every ambulance call in San Francisco (And according to this article, it's actually completely normal that the "networks" are nonexistent, so multiply that by every city and town!)

What percentage of patients are likely to be taking ANY action that leads to insurance paying? Either spending (as someone else shared) 5 phone calls trying to convince them, or knowing what regulator to file a complaint with - those are the only options. All other options involve someone else eating that cost. I bet less than 10% get them to pay, so the fine should start at $10,000 - and escalate if they show no improvement.

testing22321• 12 days ago

Unreal you have to go through this in the richest country in the world.

Family members have been in ambulances a few dozen times over the decades. There is no concept of a bill or paperwork for it. Like borrowing a book from the library.

stasomatic• 12 days ago

Branded GPL-1s cost $1-1.5K a month in the States without insurance coverage, $25 with coverage. Something's rotten, I doubt big pharma eats the difference, they'll get theirs.

DoesntMatter229• 13 days ago

I think the answer is very simple. Regulation. If there was no regulation or very little then anyone could open up an ambulance service and the cheapest costs and the best service would win.

Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.

Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked

lokar2• 13 days ago

I would absolutely not tolerate and unregulated ambulance responding to my emergency.

DoesntMatter229• 13 days ago

You don’t have to. You do what you want. I’d prefer to hire a company where the workers make more money. Right now they make a pittance.

Georgelemental4• 13 days ago

When you are bleeding out on the street, you don't have time to shop around for the best deal

DoesntMatter229• 13 days ago

Wont matter because nobody is going to be paying 12k for a ambulance ride if there are people doing it significantly cheaper.

Planktonne5• 13 days ago

The idea that everything gets better if we remove all regulation is one we know doesn't work. It's the model we've tested repeatedly, before each piece of regulation, and it always leads to negative outcomes.

hackeraccount• 12 days ago

So the argument is that any piece of regulation will always lead to a positive outcome?

How is that possible?

DoesntMatter229• 12 days ago

Can you name some?

Dove• 13 days ago

I think one of the most aggravating things about interacting with the health care system is losing control of cost/risk/reward tradeoffs. The mandatory transfer and ambulance ride in the linked story are an excellent example. I think I'd have walked out against medical advice in that circumstance, but there is the constant danger of being subjected to similar costs, both monetary and physical, when I am less conscious or at a serious informational disadvantage. The need to bring a patient advocate with you to the hospital whose role echoes both doctor and lawyer is becoming quite serious.

infinite_spin• 13 days ago

In a market where competition isn't relevant, the price of things is whatever you can get someone to pay for it.

standardUser2• 13 days ago

The genius part is that the negotiations that determine how much they can get away with charging completely excludes the consumer. Two for-profit entities, with no mandate to actually provide care, decide how much they should pay each other.

msftgreed5• 13 days ago

And they decide that you'll pay a percentage of what they pay each other. Which you also have no say in.

wewewedxfgdf• 13 days ago

There should be an "Uberlance" - discount emergency pickups by Uber, at Uber prices.

paxys2• 13 days ago

Uber is already “Uberlance”. Most people take Ubers to the hospital unless they are literally dying (and some even then).

mekael2• 13 days ago

Years ago i slid down a bannister at a dance club, caught my foot, flipped over backwards, and landed on a barstool. Having grown up poor as dirt, i knew that calling an ambulance would be at least a grand if not double that. I called an uber to take me the 15 blocks to the hospital.

Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).

The number of people here in the US who use uber as an ambulance is waaay higher than you would think.

jmalicki2• 13 days ago

Unlike an ambulance, an uber driver won't be able to keep a hemodynamically unstable patient alive for a 30 minute transport.

LAFD has already called Ubers for non-emergency transport to hospitals.

jmalicki2• 11 days ago

LACFD, and they encouraged the patients to call ubers, didn't call them themselves (I couldn't find the cite).

https://www.cbsnews.com/losangeles/news/la-county-changes-am...

ButlerianJihad2• 13 days ago

There is a gigantic business called "NEMT" "Non-Emergency Medical Transport" that has been filled by taxis and rideshares for decades. I first discovered this service when I broke my leg in 2006, and Medicaid was paying for taxi vouchers so that I could travel to far-flung orthopedic appointments over the span of 9 months. Otherwise I'd be on the bus, on crutches: ouch!

So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.

In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.

Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.

ButlerianJihad2• 13 days ago

I had an ambulance ride on Thanksgiving Day last year. And the punchline was that with my ACA insurance, the "ambulance run" co-pay was $1,200. (Of course my total ambulance bill was around $1,310.)

There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.

The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.

But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"

Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)

One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.

But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.

But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.

SoftTalker4• 13 days ago

Yeah I would bet the vast majority of ambulance rides are never paid for. Homeless, street people, the impoverished, the uninsured, the unemployed... none of them will ever pay a dollar much less thousands for an ambulance ride. And in many areas those are the people who disproportionately use ambulance services.

phil21• 12 days ago

The key advantage to an ambulance ride is bypassing the Triage Nurse.

This is going to depend on where you live/the particular hospital. A lot of "frequent fliers" figured out this loophole and started abusing it where I previously lived, so there was no way around the triage nurse.

paytonjjones• 13 days ago

I've treated people with panic disorder who, if there were no cost involved, would probably have called an ambulance monthly for suspected heart attacks.

I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?

weezing3• 12 days ago

They eat the cost, at least in my country.

abeppu• 13 days ago

Aside from the funding mechanism being a premium that everyone pays, the other part of the motivating story here that seems downright silly is:

- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.

- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.

Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".

contubernio• 13 days ago

Sharing costs generates institutional incentives to keep costs down. Individualizing costs generates institutional incentives to charge more.

Perverse incentives are the essence of what is wrong with US medical systems.

js2• 13 days ago

There are parts of the U.S. that do this already. Ambulance rides are already subsidized by taxpayers in most places, thanks to public funding for fire departments; and a growing number of places have taken this further.

Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:

https://www.wake.gov/departments-government/emergency-medica...

dqv• 13 days ago

Finding out about this program was such a relief. I haven't worried about the prospect of having to call 911 since signing up.

yanhangyhy• 13 days ago

i think i read many warnings or jokes about this: when go to usa, dont call an ambulance because it's so fucking expensive..to compare, in china, it usally cost less than 100USD.

msla• 13 days ago

In 2020, Congress passed the No Surprises Act, which banned surprise balance bills for most parts of emergency care. But by necessity, it exempted ground ambulances from the law: actually restricting the practice would have rendered much of the EMS industry insolvent.

Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.

Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.

Here's a PDF about the No Surprises Act:

https://www.cms.gov/files/document/a274577-1a-training-1-bal...

dodger-dog• 13 days ago

"On appeal, his insurance agreed to cover $9,967 of the charge—better than nothing, but it still left him on the hook for about $3,000."

Tell the insurance company to wait to release the funds until you talk to the ambulance company or to release the funds directly to you.

Tell the ambulance company they can take the $9,967 or get zero.

msftgreed5• 13 days ago

This isn't sustainable. You really want every person who is dealing with this bureaucracy to manage negotiating between their insurance and their EMS? After they've just had a significant accident/health issue?

That seems needlessly cruel to do to people.

tedggh• 13 days ago

“ This time he didn’t have a choice. He was loaded into an ambulance for a six-mile transfer, evaluated without additional treatment, and sent home the same night.”

This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.

SoftTalker4• 13 days ago

Yeah you're always free to decline medical services. Nobody can make you go to the hospital (unless you're unconscious or in delirious but then you aren't deciding anything).

whatever1• 13 days ago

Taxi / shuttle service also needs trained professionals, high fixed cost investment on specialized equipment, 24/7 availability.

I am shuttled to the airport at 4 am and paid $30.

It did not cost 20k per ride. So ambulance providers charge that much because they can. There is no real competition.

grogenaut2• 13 days ago

He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.

As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).

My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.

This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.

We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.

onion2k• 13 days ago

I don't think the question is "Should ambulances be a thing?" though. It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"

The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.

grogenaut2• 13 days ago

Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).

No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.

otherme123• 13 days ago

Society should find a better way to pay for ambulances

Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.

frenchman_in_ny• 12 days ago

I've been there before. I had a high deductible health plan, it was December & I hadn't used any of my premiums... I had a heart attack (I didn't know it at the time). And my mind went to "but my premium! I know, I'll walk myself to urgent care instead of taking an ambulance to the hospital"

PearlRiver2• 12 days ago

I remember this came up during COVID. The government was worried that homeless people and illegals would be afraid to report symptoms. GPs are specifically free and don't have to ask for papers or insurance to combat these health crises.

deepsun3• 13 days ago

but you make the choice

No US doctor would ever tell you how much any procedure would cost (even though they know, at least "in-network" doctors).

But if in your EMT you inform the patient of the potential costs of the ride, then yea, I agree they make an informed choice.

tonyedgecombe• 13 days ago

I’d argue nobody getting into an ambulance is making an informed choice.

culopatin2• 12 days ago

You’re getting in an ambulance, not calling a cab. You’re probably unconscious, maybe at least disoriented, overwhelmed, concerned about what’s happening more than doing math. Also you’re there on the floor bleeding, what’s your alternative? “Nah don’t worry, I’ll figure out this exposed fracture in the uber, I got points with them so it’s cheaper”?

milleramp• 13 days ago

The physician can mandate ambulance transfer.

sitharus• 13 days ago

Really? Where I live a patient is always able to refuse any medical procedure or treatment, unless they’re unconscious or otherwise mentally unable and the procedure is considered necessary to save their life. They certainly can opt for a non-ambulance transfer, though here it would be free even though a regular ambulance service typically isn’t.

Consent for treatment is a core principle of medical practice.

chrisra• 12 days ago

And what would they do if you refuse?

sandworm101• 13 days ago

> We scale it down depending on income and type of event. We're not massive sticklers about it.

That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the only persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.

thayne2• 13 days ago

I had an accident where I had a concussion and other injuries that put me in a lot of, and the people I was with called an ambulance for me, and I wasn't really in a state to decline, but if I had been, and knew how much it would cost, I would have. The ambulance ride was, of course, out of network. As were some of the doctors that treated me once I got to the hospital. It was the first time I dealt with a major medical expense as an adult, and it came as quite a shock when the bills came several months later, that said I was responsible for about $10,000 for the ambulance (plus a lot more for the hospital), and a good chunk of it didn't even count towards my deductible because it was out of network. I later learned I should have contested that since it was an emergency, and insurance is supposed to cover out of network service in an emergency, but I was young and inexperienced with dealing with health insurance companies. Oh, and it was about a 10 minute ambulance ride.

I guess my point is, sometimes you don't have a choice, but you still end up with a massive bill. And also, that experience definitely had a chilling effect on me calling 911.

geoffmunn• 13 days ago

As someone who is not American, $10,000!!!!!! That's hard to conceive where I live. We even have a specifically free ambulance service here.

moritzwarhier• 13 days ago

Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.

Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.

For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.

Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.

But humanitarian values are out of fashion, because they were never achieved globally.

So the only right people care about increasingly is their right to own property.

shaky-carrousel• 13 days ago

Being concussed should count as not being fully aware. And making someone pay something that he was made to accept while not fully aware should be denounced as a scam.

mcv• 13 days ago

Can't you simply argue: I never agreed to this, so I'm not obliged to pay this?

Americans love to pretend that healthcare can somehow be a free market (it can't), but a free market requires voluntarily entering into a transaction. Costs that can be forced upon you without your agreement need to be tightly regulated and subject to clear caps.

veunes5• 12 days ago

This is exactly the part that makes "you can always refuse" feel a bit theoretical

hnthrow102829102• 13 days ago

I fainted once and my wife called an ambulance as I was unconcious due to Covid.

I was fully aware when the ambulance arrived and refused. They peer pressured me very hard anyways. It was a 1 mile drive and cost me $14,000

mikeodds• 11 days ago

You do have to question why representatives of the people have not managed to address this

getpokedagain• 12 days ago

> He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.

Disagreed. Someone who is cogent and not intoxicated and not a stroke victim can't always make the best choices. Your decision making can be compromised by I dunno the fucking pain of a broken toe bone.

Seeking help should not be interpreted as a sign of weakness and made into a maze where only the most rational can escape with minimal bills. The longer we leave this cognitive dissonance where the land of the free roughly translates to land of the free to get fucked we are going to continue to have instability.

Ferret7446• 11 days ago

By that logic no one can make choices for themselves, because people are never in the absolute theoretical optimal mental state.

veunes5• 12 days ago

I think your department is probably closer to what people imagine ambulance billing looks like

uwagar• 13 days ago

its horrible to think when u are caught up in something serious that calling an ambulance could ruin your life later.

better to live in uk where nhs takes care of all this compassionately for free.

rado• 13 days ago

Cost in Bulgaria: $0

weezing3• 12 days ago

Same in Poland. Even uninsured junkies get a free ride.

dostick• 13 days ago

If you remove the $11,000 extortion “fee”, the remaining $1,000 is about the price found in the Western world countries.

siliconc0w• 13 days ago

Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.

miramba• 13 days ago

Same from Argentina to Canada? Wow

mdavid626• 13 days ago

Anywhere else in the world it’s possible to do this orders of magnitude cheaper.

But yes, it’s because of “options” and not because of greed.

Some group of people tries to extract as much money as possible. You can call this capitalism. I think it’s a big scam.

Lio2• 13 days ago

a car hit him; he did, in his words, “a little flip” over the vehicle, landed in the road

He was lucky he was hit by a car.

A slab fronted SUV or pickup would have dragged him underneath and so it goes.

Lio2• 12 days ago

OK for those that seem to dislike the suggestion that pickup trucks and SUVs kill more than cars do here's a study from the BMJ.

Specifically, with regard to the shape of the front of the vehicle:

A large recent study in the USA found that, as compared with the low and sloping front end of a traditional passenger car, the odds of pedestrian fatality increased by 45% if the striking vehicle had a tall and sloped front end; increased by 44% if the striking vehicle had a tall and blunt front end; and increased by 26% if the striking vehicle had a medium-height and blunt front end.

https://injuryprevention.bmj.com/content/32/1/16

lordkrandel• 13 days ago

This is the best article of HN ever, so detailed and explaining, and engaging. I have a message for all US readers, this is simply nonsense. Putting blame on the hurt in the moment of need, discussing money over his own health, is something demons do. I hope you will realize someday

ReptileMan• 13 days ago

Because America healthcare is stuck in the middle - it is semi socialized. You get both the negatives of socialized and free market ones. Either make it full socialized or remove all state money (this includes tax breaks and incentives) and allow competition.

chmod775• 13 days ago

The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.

The author does not understand how private equity extracts money. The high-liability and heavily scrutinized business is intentionally left with little profit: the actual profits are funneled up the supply chain. This is why private equity buys "nonprofit" hospitals - they can now control who that nonprofit buys services and equipment from.

hnmullany2• 13 days ago

I worked in private equity as an analyst in the 90's - we looked at an ambulance service that was up for sale - the underlying operating margins (before you load on debt) were pretty reasonable, although I don't remember the details.

veunes5• 12 days ago

Thin operating margins don't really settle the greed question when the ownership structure is complicated

NSUserDefaults• 13 days ago

Uber for ambulances, got it. Claude, get to work. We will submit for Apple app review at EOD.

a3w• 13 days ago

"Honest EMT — not just rides, but better"

ornornor3• 13 days ago

I had to call an ambulance in Switzerland where ambulance prices are freely set by the operator (except in a few cantons which are enforcing reasonable flat rates)

A 5 minutes ride cost 1500.- (more or less the same in USD)

Because I had used a good broker to pick my insurance plan, I was left with “only” 500.- to pay out of pocket for the ride.

In Quebec, as a resident, going 3 blocks in the ambulance cost us about 500 CAD if I remember correctly.

mc3301• 13 days ago

Yeah, I had a Canadian friend who was in a motorcycle accident. He could see the hospital from where he crashed. He begged the paramedics to let him walk, but they judged he should not.

He was billed 600$.

The paramedics' judgment as to whether he should or shouldn't have isn't the debate here. They likely made the safe call.

vinay427• 12 days ago

Similar story here in Switzerland, with a 0 minute ride (they decided I didn’t need to be transported) that resulted in a bill of about 600-800 CHF.

ornornor3• 12 days ago

Oh wow. They were cool with me they said if we transport you it’ll be expensive. I didn’t have a car, I was living pretty high up a hill, it was midnight, and I had lost quite a bit of blood already so I thought “fuck it I’ll find out how expensive it is once I’m fixed”. But they wouldn’t have charged me if they hadn’t transported me (at least that’s what it sounded like)

I guess I made the right call because I fainted in the ER later from blood loss.

ornornor3• 12 days ago

To add, Switzerland is a little weird with accident vs disease.

If it’s an accident (ie sudden, unavoidable, unpredictable, more or less) it’s great because you have nothing to pay, you don’t even need to worry about the bill and there is no deductible and everything is covered no questions asked.

If it’s a disease, then it’s the regular insurance rules which can be quite arcane and you’re never sure what’s going to be covered and how much.

My transport was from adverse consequences of a surgery and so they deemed it not an accident, and that’s why I had to pay.

conductr2• 13 days ago

I spent a lot of time in healthcare finance and across most medical service industries the Medicare rate is actually not a loss. It’s a common thing said as it’s not super profitable, but it’s usually not a huge loss. It’s pretty close to what the cost of care should be. It just doesn’t give the extra padding for extremely fancy clinics, hospitals, admin and executive compensation, and often PE investor margin expectations. It’s usually slightly positive on contribution margin and given the volume of Medicare in the mix there’s enough flow through to cover reasonable overhead and perhaps slim margins. But, whenever I see a claim that the true cost of service is 10x over the Medicare rate, it’s a huge red flag there’s some financial shenanigans at play. Saying that Medicare is a loss, leaves the impression that it leaves a huge hole to fill so other payers need to pick up the bag in a huge way. This kind of lazy analysis blindly perpetuates this misconception. If they wanted to add value here, they should have performed a “what should an ambulance ride cost?” type analysis. You have to really strip out costs that are unneeded, excessive, and account for profit margin similarly. There’s no way $13k makes any sense for the service described. We need sensible cost controls in this industry. The industry hands these people blank checks when they can hide behind out of network, etc. It’s still captive price gouging.

Esophagus44• 13 days ago

[if the article’s analysis is true] cost controls would reduce the supply of ambulances, since the article claims Medicare actually is a loss.

You have claimed it isn’t, but you haven’t really provided much evidence other than “there’s no way that’s true, trust me, I used to work somewhere in healthcare finance”

conductr2• 12 days ago

Thats fine, I'm a passerby making a comment on their work on a platform that they may not even be aware of. If you look closer I’ve done more than they have by simply raising the concern and I’m not authoring an article attempting to educate people on the industry. I think it’s perfectly fine to question someone’s assertion based on experience alone. Basically you’ll have to do more to convince me what you’re saying is true is what I’m saying. That’s the same feedback a teacher would give a student on their homework. It takes data that I don’t have to do the analysis which is probably also why they didn’t do it. But I don’t think it’s completely off the mark to mention that I’ve been an insider at multiple healthcare service companies that like to claim they lose money on Medicare yet they opt to accept Medicare patients. When we consider denying Medicare we realize they are such a large part of the mix that they allow us to be as profitable as we are. It’s almost always a misconception of what “losing money” means. Price gouging the few patients that can afford it, is only profitable if all your expenses are already covered and economies of scale are at play, which is what Medicare is good for.

altern84• 13 days ago

I live in Poland and despite being Europe from what I understand they don't have socialized healthcare. You need to buy insurance from the government, or private (I have both). If you don't have it, you don't have a right to healthcare.

Then, if you go to public doctors or hospital you still have to wait months for an exam or years for surgery. BUT, I've never heard of anyone going bankrupt from getting sick, or being scammed by their insurance not covering costs.

From what people make it sound, in the US you don't have socialized healthcare, getting doctors and exams is quick, but you also get scammed by insurance companies who will try their best to get out of paying, and I've definitely heard about people going bankrupt because they got sick.

mgol94• 13 days ago

that's not true, access to the emergency medicine (and transport) is a constitutional right in Poland, you don't need NFZ coverage for that.

altern84• 13 days ago

Same as in the USA. They are legally required to treat you in emergency situations there, too.

BUT, they will charge you for their services afterwards--both in the USA and in Poland.

Although I suspect that the bill from the American hospital will be A LOT more...

orwin2• 13 days ago

I dislike sentences like 'you still have to wait months for an exam or years for surgery'. Depends on the exam or surgery.

- Blood test: wait time (after your 12 hour fast) is likely 15-30minutes in most of Europe (even eastern Europe. I should know, I do one every 3 month).

- pet-scan/x-ray: at most a few hours if your area is truly underserved, in my experience, less than an hour (but I needed it 4 times, so it might be small sample size).

Specialists will make you wait for sure if it doesn't sound life-threatening for deeper exams, and especially exams that requires surgery, but the only example I have on hand is my mother's boyfriend who got his in less than two weeks, and his cancer removal surgery was planned within 3 months after the tumor biopsy (you need to change your diet at least a month before surgery to prevent complications and improve healing, so the true delay caused by wait time is ~2 month). They also explicitly said that if his cancer was more aggressive they would have given him a month to prepare according to my mom.

But yes, in Europe especially, convenience surgery can take a year (my intern lips and teeth took 17 months) (and you pay a bit out of pocket), when in the US you can be done within days.

altern84• 13 days ago

I'm not sure we're talking about the same thing.

What I meant with "you have to wait months" is that if you go with the government-provided doctors and processes, they put you on a list and you have to wait for your turn. Getting an exam done can take months, and you can wait years for surgery, unless your condition is life-threatening.

If you go to a private clinic, of course you can get test results the same day and schedule any surgery within days.

Most people who can afford it go the private route. I had to do that too, which kind of pissed me off since I pay a hefty amount each month for insurance and I still have to go to private clinics. BUT, using the public infrastructure is just too inefficient. To get blood exams at a reduced price I had to schedule an appointment with my GP (days in advance), she'd send me to a specialist (about 1 week wait to get appointment), then a specialist would give me the paperwork required to get SOME of blood tests I needed covered by my insurance.

tumdum_2• 13 days ago

they don't have socialized healthcare

You have free healthcare for children (up to 18 years old), pregnant women and registered unemployed. Moreover, any working person can (for free) add their spouse and parents. Plus people can apply for free health insurance if they have very low income.

altern84• 13 days ago

Not sure, that's why I specified "from what I understand".

BUT, most people aren't children, pregnant, or registered unemployed/very low income, so from that point of view to me it's still an insurance-centric system.

I pay a hefty amount each month and I was sick in the past and the system was so inefficient that I had to go to private doctors and clinics just to figure out what was wrong with me. I see the public insurance payments as a tax and I have private insurance to cover the costs of private doctors/hospitals.

But maybe that's just me.

nazgob• 13 days ago

That’s not exactly right. You are eligible, you just need to do something to get it. Ie if you register as unemployed, you will get insurance. Same with university students.

King-Aaron• 13 days ago

Here in Australia, you can be 2,000km in the bush and an ambulance will fly out to you and fly you back to the city for free.

That being said, we also have private ambulance companies here that will sting you for a huge bill if you don't have private ambulance cover.

RowanH• 13 days ago

We're getting taken to the cleaners in NZ!! I think it's $50 for a westpac chopper ride...

sevenseacat• 12 days ago

Yay for the RFDS.

If only ground ambulances were as universally awesome

orthoxerox2• 13 days ago

Why won't EMS providers strip down their services to the level where Medicare/Medicaid rates completely cover their costs?

crnkofe• 13 days ago

I don't get this US medical system. And the more I get to read about it the less informed I feel. Sounds like every involved medical service out there is just to rip the patient off.

djantje• 13 days ago

Its a collective emergency service, which can save lives.

If by law this service is required and you bill only the rides, you get this, high bills per ride.

It would be nice to see a chart of countries with cost of ambulance rides, cost for the patient and average response times.

jzer0cool• 13 days ago

So what is the practical advice to avoid high costs? Also for foreigners, long ago had a friend visit from Asia and wave away ambulance after a potential serious injury (waiver not to be transported) knowing of the high medical costs.

magic_hamster• 13 days ago

This was a fun read, however, I feel that the actual essence is quite thin.

It can be summarized in a short sentence: The cost comes from being always prepared with teams and equipment, and few privately insured riders subsidizes everyone else, getting very high surprise bills - this can and should be a shared community tax which would effectively allow free ambulance rides to almost everybody.

It's an excellently written post though. I suspect people read this author for the experience, more so than actual information. I just wonder if they should just do prose and go wild with their skill instead of coating a few predictable facts with so many layers of color.

winrid• 13 days ago

My fun ancedotal story about US healthcare:

Kaiser transported me 4hrs in a ambulance to get surgery and I think I just paid the $200 ER fee

But then they would never cover an MRI for an issue with the same leg.

It's like we're almost done with this project guys, come on.

dark-star• 13 days ago

Wait, being transported in an ambulance costs money? Man, every day I learn new things about how shitty the US health system is, and I'm more and more happy to not have to worry about deciding if I'd rather die or be broke in an emergency

Planktonne5• 13 days ago

The standard answer is greed

The article is interesting, but it doesn't actually sufficiently dismiss this; it's the route cause of it all.

IG_Semmelweiss2• 13 days ago

Great article. One item that it avoids touching even though it clearly insinuates it - the solutions.

And among the solutions, there's one that is briefly alluded to, but skipped around like a hot potato.

What if EMS were to refuse services for those who don't pay for the option on a monthly basis? And for the rest, if they choose to pay "on the spot" they can be OON like everyone is now? Why give out a free (or subsidized) option out, at all ? After all, I dont think it is illegal to turn away Medicare & Medicaid patients if you are not in-network with them.

We pay for other types of insurance. EMS insurance seems like a natural fit for a family.

secult• 13 days ago

Usually, when some system is getting outdated, the system gets replaced or updated to fit the needs. Does this system work for the majority of USA, or not? Do I read it correctly, that the poor people have medicare/medicaid and therefore it's fine for them, the average person has some health insurance and don't mind spending a few thousands of dollars once in a while when his life is in stake?

mstaoru• 13 days ago

Just a personal anecdote. I was living in China, my father was visiting and fell ill (anemia). We needed to go to the hospital and decided to call an ambulance vs. calling a car because it could enter the gated compound. For a 3 km ride the price difference wasn't even a concern. A car would cost ~$3 and an ambulance ended up about $30.

PS: An average net salary in that city was about $1700/month at the time.

pshirshov6• 13 days ago

I worked at a company which was doing medical billing for ambulances among other things.

Essentially, the bills are always inflated so when the settlement comes the providers get 20..50%. The crucial procedure is so called "medical coding" where medical notes (sometimes - scrawled on paper with a pencil) are being turned into bills - and that's where additional codes are getting added and more expensive codes are selected. There are books and guidelines on how to do the coding and some automated logic which "fixes" filled forms to bump the amounts a bit.

If the insurance (less frequently - the patient) pays more - that's just a bonus.

Billing itself gets a small fraction of the bill usually amounting to $20..50, they don't profit from inflated bills directly but the clients would select you on the basis of average settlements. Dispatchers also get little fractions. Things are very different when it comes to helicopter ambulances, where the bill could easily get to hundreds of thousands and everyone involved gets a lot. In fact, all the operators prefer to work with helicopters because of that, everyone involved references ground operations as "crap" or so.

Can't say for whole industry but that's what I've seen at one particular place working with several providers/dispatcher companies.

From what I can remember about the ground reality, a $12K bill would mean that they expected to actually get $3..4K. A typical ground bill for some particular region the company operated at was settled at $500..$2K while an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.

Ntrails2• 13 days ago

an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.

Those numbers made me blanch somewhat! Having been in a helicopter (aka Air Ambulance) in the UK, all of which operate as charities iirc, I was curious about their costs.

The average cost of a helicopter mission is £4,748* and the average cost of a critical care car or rapid response vehicle mission is £2,054*[1].

https://www.airambulancesuk.org/about-us/facts/

eesh

ano-ther• 13 days ago

Those are more sane numbers (unless you go by helicopter across the US).

Also found this intriguing in your source:

London’s Air Ambulance crew made history in 1993 by performing the world’s first successful pre-hospital open-heart surgery at the roadside.

pshirshov6• 13 days ago

In the UK maybe, but in the US you should expect higher bills for _ground_ transport. Like literally, the linked story is about $12K bill for short distance ground transportation not involving any complex procedures. The cases I vaguely remember did include long lists of medical codes.

gosub1002• 12 days ago

There are stories where the air ambulance sues patients who are still in ICU because getting paid depends on being first in line to file the lawsuit.

closewith2• 12 days ago

I tried to find the asterisk there to see the details, but could not.

FWIW I think that HEMS cost is significantly under costed, as the London HEMS H135s run about £2,500 per flight hour on direct flight costs alone, so I suspect the £4,748 figure is referring to that alone.

I think a closer estimate is probably total annual operational costs divided by total shouts, (£18 MM / 2,000) or about £9,000 per shout.

Even that's an under costing, as the clinical personnel, equipment, and liability is shouldered by the NHS. A pure costing is probably closer to 2-3X that per clinical flight.

Still an order of magnitude less than the commercial US operators.

anonym293• 13 days ago

$500k? There entire helicopters you can just buy outright for less money than that. Does the $500k ride come with the helicopter itself included in the purchase?

pshirshov6• 13 days ago

I do vaguely remember seeing some bills with such figures. I've been literally developing various OCR and medical coding crap to process the cases and I've seen plenty of real cases. Some cases had eye-popping bills attached, yes.

The $500K spike was some sort of a highway accident response, can't recall any additional details apart from some serious head/brain trauma.

Keep in mind that everything gets significantly inflated, x2 multiplier is guaranteed, x5 is likely, x10 is not uncommon. Again, from what I can remember.

Also keep in mind that billed != settled. If I recall correct, that bill was settled at something around $55K. That was many years ago.

alistairSH6• 12 days ago

Uh, a new Bell 407 is north of $4 million and that's before it's equipped for medical flights. You aren't buying one of these for $500k used, at least not one that's air worthy. Eurocopter EC135 are a bit cheaper, but not by much.

anovikov• 13 days ago

This problem just doesn't exist anywhere else in the world. Ambulance is just another truck. There are some fees involved with having priority on the road and some regulations, but it's just another truck. It won't cost (to anyone - i mean OF COURSE it is free for the actual patient) over a hundred euros or so to do a simple across-city ambulance ride anywhere in EU, maybe 2x the price of a cab.

That's corruption and nothing more. End it and imprison everyone who ever had a tangential relationship to this system, for life - to ensure no one will try to pull this sort of "regulatory capture" again.

anticensor• 11 days ago

To be precise, a minibus.

hnmullany2• 13 days ago

I worked in private equity in the 90's and looked at one of the big regional ambulance service companies that was up for auction. The underlying operating margins were fairly reasonable - the private equity owned companies only have issues because of their debt load.

ciclotrone• 13 days ago

Last year I had appendicitis in Italy, where I live. I called a cab to reach the nearest hospital, since I didn't feel so bad as warranting an ambulance. I got accepted, visited, transferred to the larger nearby hospital by ambulance, appendectomy, 4 nights stay, and I was provided with the drugs for the convalescence. When I was dismissed I took another cab back.

Total expense: ~25€ for the two taxi rides.

Very happy to pay my taxes, and very happy that when I don't need it myself, they go into financing the healthcare services for others that may or may not be able to pay out of pocket.

anonym293• 13 days ago

This sounds like a great deal if your annual taxes are less than your annual unsubsidized medical expenses, and a terrible deal if your annual taxes stretch into the six figure range as a young healthy person.

Avicebron6• 13 days ago

Doesn't this young person theoretically become older and less healthy as time passes? How many young people have six figures in taxes and not understand reciprocity?

pjc504• 13 days ago

annual taxes stretch into the six figure range as a young healthy person

At that point you're in the, what, top 2% of salaries? Especially for your age band.

rpunkfu• 12 days ago

tldr: greed

panny• 12 days ago

His mistake was going to an American hospital at all. For what he paid, he could get a round trip ticket to literally anywhere in the world, then just get realistically priced medical care. The entire American medical establishment needs to end. It's cancer. I won't go. Not even if the alternative is my death. I just won't go. I should probably get some kind of dogtag to wear that explicitly states this if I'm ever knocked unconscious. Just leave me in the ditch man, American medical care is a fate worse than death.

veunes5• 12 days ago

Yet "the payment model is broken" and "some prices are absurd" can both be true

quentindanjou• 12 days ago

If there is no emergency way to contact an ambulance in network then there should be no in- or out-of-network.

Calling 911 does not give you an in-network and there no way to know in advance unless calling your insurance (in business hours, giving that you are not dying... which you probably are)

JKCalhoun• 12 days ago

I was handling my moms bills when, at an independent living home, she was sent twice by ambulance for minor falls.

As the article says, thousands of dollars for these 5 minute drives.

(Fuck "credit score") I sent a check for $20 for each of the two bills. And I then did the same the next month when the bills came again.

I repeated this $20-a-month routine for a few years before, in both cases, they ended up closing the accounts-billing after perhaps $500 or so was paid.

everdrive• 12 days ago

Can anyone explain why coverage networks even exist? What exactly makes it so expensive for an insurance provider to deal with an out-of-network health care provider? That same health care provider would not be expensive for an in-network insurance provider. I have no sense whatsoever for why the same health care provider would be expensive in one case and inexpensive in another case.

memcg• 12 days ago

I called 911 last year when my wife was unresponsive in Maryland. At least 10 vehicles arrived in under 10 minutes. EMTs worked to revive her for 30 minutes doing what they described as the same care she would have received at the emergency room.

She was transported to the hospital because she had a slight heart beat. Had she been declared dead at home, police and other staff would have helped process the death report and application for death certificate. I did not receive a bill or provide insurance information.

tsoukase• 12 days ago

It's simple. Ambs in the US are all private companies. Everywhere in the world private ambs are also extremely expensive and public ones free of charge. There is no truly public amb ride in the US.

Henchman212• 12 days ago

We don't even have public toilets. We do have laws criminalizing homelessness though!

moribunda• 12 days ago

3rd world country.

Henchman212• 12 days ago

Why? Because fuck you, that's why.

Welcome to America. It's a business. Gimme my money.

summarybot• 12 days ago

What are the margins on an ambulance ride?

weezing3• 12 days ago

You guys pay for an ambulance ride?

lofaszvanitt• 12 days ago

What a selfish society the US have. 900 bucks for a fn ambulance. I enjoyed my stay when I was there, but living there.... seems to be a fucked up, soulless, dog eat dog, sell your own mother for 3 pennies kinda devil ridden place.

doby111• 12 days ago

In India, there's a quick commerce company (Blinkit) which offers free ambulance service, under 8 minutes TAT. Just broken systems, I guess.

Why American ambulance rides are so expensive

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