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grogenaut 8 hours 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 6 hours 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.
otherme123 6 hours 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.
philipallstar 20 minutes ago [-]
> Only the US society seems to be unable to find a solution.
US society has been spending a fortune on USAID funding the world's social action projects, NIH funding the world's medical research, and the US military keeping shipping lanes safe (at least until recently), and taking in a million or so people a year from other countries. That vast generosity means other countries can just spend on their own citizens and feel superior for doing so. That's why all that stuff has dried up - what's the point in spending on others when they look down on you for doing so?
x______________ 1 hours ago [-]
> Only the US society seems to be unable to find a solution.
Unwilling. It's absolutely feasible to find a solution, as seen everywhere else in the world.
3D30497420 18 minutes ago [-]
Even some parts of the US have found solutions.
From the article:
> In Tulsa and Oklahoma City, meanwhile, the government buys staffed unit-hours from an ambulance operator, while households can prepay a few dollars a month on their utility bill and owe nothing if the ambulance ever comes.
wisty 4 hours ago [-]
And the US also pays a TON of tax dollars to a broken, overregulated system.
IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.
No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.
But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
master-lincoln 2 hours ago [-]
That's what a government would be for. You vote neo-liberal, you get it... (I consider both the US democrats and republicans neo-liberal)
bestouff 2 hours ago [-]
I think only the US consider the US Democrats as leftists.
philipallstar 24 minutes ago [-]
Many things about the US are far to the left of most countries. For example, birthright citizenship.
natebc 1 hours ago [-]
Only the rightists do and among them really only the loud redfaced ones.
cucumber3732842 1 hours ago [-]
>But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
17% of GDP is healthcare. So between 1:10 and 2:10 people in this country are making more than they otherwise would (note I did not say wealthier) because the system is screwed up and hoovers up more of everyone else's wealth than it ought to.
Slavery was 12% and (while obviously geographic concentration of industry plays a lot into it) it took a war for them to take a haircut.
pjc50 7 minutes ago [-]
Possibly reasonable point about labour supply ruined by an absurd analogy with slavery.
uoaei 48 minutes ago [-]
Earnings represented by GDP are not distributed evenly across a given population. That 17% of extra earnings goes to relatively few people in the States (I'm putting this very mildly, the concentration in reality is insanely lopsided).
LtWorf 52 minutes ago [-]
You see, it's better to die than to help the coloured neighbour who lives across the highway. I don't believe in this but that's USA society.
newaccount670 11 minutes ago [-]
> 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?"
Only a complete moron would think the answer to this is no. If there's no personal cost to using an extremely expensive service, every one is going to use it regardless of whether it's actually necessary. It will quickly turn into a free taxi service for anyone who wants to go anywhere near a hospital.
The only way a free ambulance system could work is if there were harsh penalties for people who abuse the system. Unfortunately, the American Democrat party has shown countless times that they have no interest in preventing fraud. Prominent Democrats like Tim Walz and Gavin Newsome have spent more time in the last year pushing laws to protect fraudsters than prosecuting them.
OKRainbowKid 2 minutes ago [-]
So in your eyes, the population of several western countries is (and has been for decades) dominated by complete morons, resulting in free or almost free ambulance rides?
grogenaut 6 hours 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.
Esophagus4 32 minutes ago [-]
He covered that in the article fairly thoroughly. Did you read it?
The anecdote illustrates the issue then he dives into the analysis.
ChrisMarshallNY 3 hours ago [-]
It’s pretty common.
I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo
master_crab 2 hours ago [-]
He’s a lightning rod only because some people get unnecessarily triggered by facts that don’t fit their world view.
mananaysiempre 54 minutes ago [-]
There’s a thin line between satire, which can convince, and sneering, which can only turn off. John Oliver, unfortunately, does end up on the wrong side of the line from time to time, and can (together with his core audience) be something of a bully when he does.
I’d also be careful about his facts: they’re usually well-researched, but by the nature of the format he only ever presents those which fit his argument, and that’s just not good epistemology. I can think of a few times when the show made me feel safer about my beliefs than I should have been feeling.
ajuc 28 minutes ago [-]
The time for this debate was 100 years ago. Now only people who can't be convinced aren't convinced, so there's no point convincing.
So why not make fun of them? There's no downside.
lazide 3 hours ago [-]
Well over a decade ago, it was $6500 for a couple mile ride to the nearest hospital, no emergency medical care necessary (just supervision). This was in the Bay Area, in California.
I can’t imagine it’s gotten cheaper.
WJW 2 hours ago [-]
That's wild. According to the website of my local ambulance organisation, a full on ambulance ride with all medical supervision etc runs between 400 and 900 euros. Typically this would be reimbursed by the (mandatory in this country) health insurance. This is in a large city in western Europe, I would expect it's cheaper in places with lower cost of living.
You could easily prepare for that situation by either having enough cash or insurance.
NamTaf 2 hours ago [-]
"Just don't be poor!"
I feel like you have missed the entire point of the article.
NoMoreNicksLeft 4 hours ago [-]
>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?"
Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.
Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.
onion2k 3 hours ago [-]
Your argument leads me to assume you think everything that causes to someone need an ambulance is the result of their choices.
Victim of a violent crime? You shouldn't have left your house.
Run over by someone else? You shouldn't have left your house.
Caught an infectious disease? You shouldn't have left your house.
Fell down the stairs? Why were you in your house!?! Don't you know how dangerous it is?!?
pshirshov 1 hours ago [-]
Well, you don't know how rotten the industry is.
Your moral social-darwinism just enriches a couple of suits, nothing more, instead of spreading the costs you could very well start by making sure the costs are not inflated.
x2..x5 multiplier is always applied to any ambulance bill as far as I'm aware. I worked in that industry.
pjc50 3 hours ago [-]
We should go further with this and require troops to pay for their own medevac. /s
pshirshov 1 hours ago [-]
Well, if what I've read is true it's already sort of a practice in russian army.
Der_Einzige 39 minutes ago [-]
Go ask SF troops what the PJs require from them if they get saved by a PJ (a branded tattoo on your ass).
I’m sure plenty of those soldiers would rather pay some money for the evac instead of a lifelong ass tat.
tancop 3 hours ago [-]
[dead]
thayne 5 hours 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.
moritzwarhier 4 hours 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.
lazide 3 hours ago [-]
Should == I wish.
mcv 30 minutes 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.
shaky-carrousel 3 hours 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.
geoffmunn 4 hours 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.
martheen 1 hours ago [-]
I can literally buy a nice house with that just outside the city. And we somehow have universal healthcare despite the average salary is not even one-tenth of American.
hnthrow10282910 3 hours 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
deepsun 6 hours 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 49 minutes ago [-]
I’d argue nobody getting into an ambulance is making an informed choice.
milleramp 6 hours ago [-]
The physician can mandate ambulance transfer.
sitharus 5 hours 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.
true_religion 3 hours ago [-]
I think the idea is that if it's mandated, then the ambulance should be covered by some kind of insurance since it was medically necessary and not just Ol' Bob, the hypochondriac, calling because his tin foil hat fell off.
sandworm101 6 hours 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.
pshirshov 2 hours 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.
Ntrails 42 minutes 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].
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.
anonym29 17 minutes 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?
chmod775 5 hours 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.
hnmullany 43 minutes 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.
IG_Semmelweiss 3 hours ago [-]
We are for learning and to be curious with our comments
I suggest to copy paste your comment into your choice of AI prompt, and ask it , "is this accurate" ?
chmod775 2 hours ago [-]
Let's ask the thing whose mistakes I iron out all day to think for me.
gruez 13 hours 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.
jjk166 12 hours 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?
justonceokay 11 hours 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.
khuey 11 hours ago [-]
I don't disagree with what you're saying but I want to point out that it's rather unusual for (American) ambulances to carry blood, and probably more of them should.
Correct. The only ambulances that typically will stock blood are specialized NICU ambulances and HEMS (helicopter). Although more progressive agencies are looking more and more at part blood products.
Spooky23 9 hours ago [-]
EMTs are like veterinarians. Lovely people who get ruthlessly exploited. Benefits are garbage unless you’re a unionized public employee.
wombat-man 9 hours ago [-]
Yeah, every EMT I know was way underpaid for how crazy stressful it was. Especially considering how expensive the ride was
jmcgough 8 hours ago [-]
EMT now is often used as a stepping stone to a career with a liveable wage, like physician.
jjk166 7 hours ago [-]
Medical supply costs for transport are very small. The labor overhead costs are overhead. Insurance is included in the estimate.
A plumber charges you $200 to come to your house, it costs the plumber $20 to come to your house. The latter value is what we're discussing here.
jasonjayr 11 hours ago [-]
TIL getting an elevator tech to just come out to look at your building's elevator is about $1600. If it's an easy fix, that's all you need to pay. If it's not, it goes up significantly....
LanceH 9 hours ago [-]
He wouldn't be much of an elevator repairman if it didn't go up considerably.
MichaelZuo 10 hours ago [-]
Don’t they need to sign something legally binding, the moment they adjust even one minor internal part?
avidiax 5 hours ago [-]
I'm not going to claim that elevator malpractice isn't possible, but no elevator is designed with a single point of failure for any safety critical system, so I don't think it's easy or likely to make a mistake that would cause a safety issue.
lazide 3 hours ago [-]
A qualified elevator technician can definitely make an elevator fail dangerously spectacularly.
They wouldn’t be qualified if they couldn’t.
cheesecakegood 10 hours ago [-]
To be fair, if you pay the repairman, your elevator also goes up :)
michaelmrose 8 hours ago [-]
Most people live in urban environments. Approaching zero are over an hour. As with most people being in urban environments most ambulance rides are in urban environments and go to the nearest hospital meaning that most rides should be under 10 minutes.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
"We mark it down based on [income]".. Obviously it's profit first (I don't mind if you don't pretend that profit is a cost). It unfortunately seems cheaper to be uninsured for many cases if you're willing to pick up a phone and discuss prices and take the risk that it may not always work out (but then again dealing with insurances has its own set of annoyances and steadily rising costs).. Not a recommendation but clearly my observation.
consp 4 hours 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.
zhdc1 2 hours ago [-]
Seems reasonable and closer to American averages than I would have expected.
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".
Atotalnoob 6 hours ago [-]
You need more than the crew in the ambulance.
Dispatch, maintenance, janitors, HR, managers.
They also need continuous training, and that is also a large salary cost for training staff (you have to pay them and the trainer).
Insanity 11 hours 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.
harmmonica 10 hours 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
vineyardmike 6 hours ago [-]
> I just want every medical service to have this exact type of breakdown
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.
jjk166 7 hours ago [-]
Insurance is included.
Atotalnoob 6 hours ago [-]
12k for insurance is not enough.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
xp84 8 hours 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.
jjk166 7 hours ago [-]
The 12k per year includes medical liability insurance.
IG_Semmelweiss 3 hours ago [-]
That number looks low.
FireBeyond 10 hours 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.
Der_Einzige 34 minutes ago [-]
The fact that so many people some gleeful to work as EMT despite the shit pay is just insane!
Esophagus4 23 minutes ago [-]
Some of them are volunteers who do it because it’s about the calling to help their communities, not pay.
Some do it because they actually want to be firefighters but it’s helpful to be an EMT as well.
Others do it because it’s an easy entry point (in the US you only need a 3 month night course to be an EMT) in their medical career on their way to better paying jobs like MD and RN.
And yes, others are grizzled and burnt out making little money.
But mostly people do it because they want to help.
somat 10 hours ago [-]
It may also be telling to figure out why no startup is offering $400 ambulance rides and dominating on volume.
userbinator 7 hours ago [-]
Almost certainly regulations. Anything even vaguely medically-related tends to be very, very highly regulated.
_carbyau_ 7 hours ago [-]
I for one would love to see a startup called say, "Trauma Team International" or "Docwagon"...
Esophagus4 20 minutes ago [-]
Ambulance.ai
(Shudders)
keane 4 hours ago [-]
Ambulnz by DocGo
socalgal2 9 hours 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
indoorfish 9 hours ago [-]
"My LLM of choice" is like when the news reporter says "confirmed by someone not authorized to speak publicly". It's not a meaningful report.
socalgal2 5 hours ago [-]
It's arguably more reliable than some rando above doing napkin math and zero actual experience or evidence
lazide 3 hours ago [-]
Not in my experience. Most LLM answers are bullshit; and they almost never say they don’t know. Most people would just look at you and say ‘I don’t know’ instead of just making something up.
failbuffer 8 hours ago [-]
Your point about LLMs aside, I'd trust the inside source over whatever carefully baked misrepresentation the PR department doles out.
sehansen 1 hours ago [-]
Unfortunately that inside source is often coached by the PR department and are just there to say things they can't get away with saying publicly or don't want to have their exact words on record. I.e. just as much a misrepresentation as the official press releases. Or sometimes even more of a misrepresentation since nobody can actually be held accountable for their words.
jjk166 7 hours ago [-]
I didn't forget the cost of insurance.
bombcar 10 hours ago [-]
You can get an ambulance for only $150k? A transit van with a few options is already $75k.
throwaway2037 20 minutes ago [-]
I agree. That number is bullshit. I Googled about it. It looks like 350K to 600K USD. Also, there is wild variance in vehicle sizes and the equipment you choose to carry.
mlsu 11 hours 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.
indoorfish 10 hours ago [-]
IKON passes don't grow on trees you know.. Someone has to rent out in Aspen.
Spooky23 9 hours 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.
SoftTalker 9 hours ago [-]
Nobody makes (federal) minimum wage these days. McDonalds employees make double that.
Der_Einzige 32 minutes ago [-]
You haven’t been to the shithole south if you believe this.
There plenty of idiots there making 2 dollars an hour and tips and thinking they’re doing well because “at least my CoL is low!”
Spooky23 8 hours ago [-]
I don’t live in a red state so we have a bizarrely low minimum.
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
11 hours ago [-]
lazide 3 hours 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.
kyleee 8 hours 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
jjk166 7 hours ago [-]
Which would increase the cost to $325, though I was deliberately excluding overhead.
11 hours ago [-]
grogenaut 7 hours ago [-]
[dead]
tbrake 10 hours 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
delichon 10 hours ago [-]
> We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Tsk-tsk.
orthoxerox 4 hours ago [-]
People (like the guy from the article) literally take Uber rides instead of ambulances, so they are a reasonable substitute good in many cases.
Estimate for an ambulance call is about £450. I suspect the main reason the US costs more is wages.
gerdesj 12 hours 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?
gruez 12 hours 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.
8 hours ago [-]
joe_the_user 10 hours ago [-]
This thread is filled with strong arguments that ambulence operators do make money with medicare.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
shusaku 1 hours ago [-]
I completely lost interest at the options part, it’s not that complicated of a concept. But substack writers have their type
dripdry45 8 hours 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.
arjie 10 hours 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.
Spooky23 9 hours 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.
Noumenon72 12 hours 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.
gruez 12 hours 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.
Noumenon72 12 hours ago [-]
I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you; no one is purchasing the right to see a movie regardless of how much it turns out to cost to show. It's the movie maker that would love to buy an option that makes you promise to buy a ticket, even if the movie turns out bad.
gruez 12 hours ago [-]
>I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
JumpCrisscross 11 hours 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.
FireBeyond 10 hours 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.
Atotalnoob 6 hours ago [-]
This is just insurance, dude
mekael 10 hours ago [-]
At the end of the day doesnt that just end up being universal healthcare but with more steps?
fuckyah 5 hours ago [-]
[dead]
mstaoru 2 hours 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.
ciclotrone 28 minutes 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.
anonym29 19 minutes 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.
pjc50 4 minutes 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.
Avicebron 12 minutes 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?
anonym29 3 minutes ago [-]
Reciprocity is great when all parties contribute equal amounts and benefit equally. Think toll roads where everyone pays the same price, only the people using the road pay for it, and everyone using it benefits from it.
It's less great when some parties are expected to give more than they receive in return (in order to provide for those who give less than they receive in return), without their consent, enforced by the state's monopoly on lawful violence, and are demonized for so little as daring to express dissatisfaction with the involuntary arrangement.
King-Aaron 4 hours 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 2 hours ago [-]
We're getting taken to the cleaners in NZ!! I think it's $50 for a westpac chopper ride...
xp84 13 hours 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.
throwaway2037 12 minutes 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.
semiquaver 12 hours 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.
xp84 12 hours 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.
SpicyLemonZest 12 hours ago [-]
But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.
xp84 11 hours ago [-]
They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
pjc50 5 hours ago [-]
The insurer is being forced to act as an insurer, by paying the $1000 they're supposed to cover.
SpicyLemonZest 4 hours ago [-]
Did they know they were supposed to cover it, or did the provider make a billing error? Even if there's no error, why is a government-run ambulance service making this the patient's problem, if the law says that they definitely have to pay? Why did it cost $1000 anyway, is that a reasonable price?
JumpCrisscross 11 hours ago [-]
> isn't the California law requiring the insurance company to act as a sin-eater here?
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
FireBeyond 10 hours 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.
t-writescode 6 hours ago [-]
> or cabulance
I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?
... do they reimburse those charges? Because wtf.
4 hours ago [-]
thayne 4 hours 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.
stephenbez 8 hours 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.
conductr 5 hours 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.
Esophagus4 15 minutes 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”
arjie 13 hours 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.
The insurers just pay the in-network fee and you call it a day.
Waterluvian 13 hours 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.
alistairSH 12 hours 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.
Freedom2 11 hours ago [-]
Many here will say that that's the cost of the freedom of choice and speech in the US.
alistairSH 1 hours ago [-]
And yet we have ICE and the FBI harassing “dissidents” every day, medical choices dictated by insurance companies, and on and on. They’ve been sold a bill of goods and just haven’t realized it yet, IMO.
ozlikethewizard 12 hours 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.
asdff 11 hours 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.
disillusioned 13 hours 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 6 hours 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 7 hours 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.
burnhamup 13 hours 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.
yamillove 12 hours ago [-]
Why didn’t you take an Uber?
the_sleaze_ 10 hours ago [-]
Last view of life: slowly bleeding out in the back of a waymo that has gotten trapped in the traffic circle in front of the ER and won't unlock its doors until it reached its destination.
thaumasiotes 6 hours ago [-]
Bring a window hammer.
asdff 11 hours ago [-]
Cleaning fee
altern8 5 hours 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.
orwin 4 hours 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.
altern8 4 hours 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.
NamTaf 2 hours ago [-]
The point is that list isn't first-in-first-out. Public waiting lists are constantly reviewed by domain medical expert committees in the public system to triage priority patients.
If you're truly urgent, you will get bumped up. If you're not urgent, you can get bumped down as others go above you.
Unfortunately, individual QoL and urgency can sometimes be disconnected, which is why pensioners getting hip replacements can get bumped down despite having loss of mobility due to heaps of pain.
Cumulatively for lots of non-urgent activities (diagnosis tests etc) that drag can add up.
Much like any commons, is no perfect system, funnily enough.
mgol94 4 hours 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.
altern8 3 hours 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...
tumdum_ 4 hours 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.
altern8 3 hours 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.
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.
ornornor 5 hours 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 5 hours 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.
hnmullany 45 minutes 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.
abeppu 12 hours 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 5 hours 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.
crnkofe 4 hours 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.
darth_avocado 13 hours 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.
JackMorgan 9 hours 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
HumblyTossed 13 hours 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.
Hnrobert42 12 hours ago [-]
But do they really? Can you point a real, evil villain saying that?
I think we are all villains here. Good healthcare coverage is just another status symbol to be attained. If the poor have it then it becomes less of a value. To some degree we are all wired this way and we all
suffer because of it.
skinfaxi 12 hours ago [-]
I'm not sure I agree. Poor health is not always obvious and your health insurance provider is not conspicuous in most interactions.
schmookeeg 11 hours ago [-]
I have had VASTLY better free health coverage (OHP, Portland OR via Providence) than the current Kaiser dreck I and employer pay significant sums for.
Healthcare is not a flex, and it my experiences on the west coast, it's an inverse correlation to wealth. :/
gruez 12 hours ago [-]
>I think we are all villains here. Good healthcare coverage is just another status symbol to be attained.
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
thesmtsolver2 9 hours ago [-]
> How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other
Do imaginary conversations in the shower count?
skinfaxi 12 hours ago [-]
See everyone who decries student loan forgiveness as an example.
mothballed 12 hours ago [-]
Government subsidized sudent loan forgiveness is a regressive tax, though, which makes it quite unpopular in the non educated that on average earn less.
ryandrake 10 hours ago [-]
The root cause is still cultural. Nobody wants to pay taxes that are helping someone else. Whether that "other" is in a different economic class, different race, different gender, has different political beliefs, lives in a different state, it's always the same mentality: "I don't want my tax dollars to pay for people I have determined to be 'others' and culturally different from me." Heaven forbid someone who doesn't deserve it or doesn't need it, get help.
thesmtsolver2 9 hours ago [-]
But that is not the topic being discussed. Is it?
joe_the_user 12 hours 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.
ethersteeds 12 hours 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.
cogman10 12 hours 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).
defrost 12 hours 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.
gkmcd 5 hours ago [-]
I don't think this is true everywhere. Queensland has the QAS[1], operated and funded by the state government. There are no (direct) fees.
Thanks for the response, it's been awhile since I used an ambulance. I've got to say, I was willing to believe, what with free Qld buses and all that jazz, but alas like WA it's "qualified":
There's no cost for ambulance treatment and transport for Queensland residents. This includes treatment and transport that takes place in other parts of Australia.
and
If you don’t live in Queensland, you’ll be charged for ambulance treatment and transport. If you have ambulance cover in another state it may cover the cost for you.
Yeah. In many countries, EMS is also heavily volunteer-based.
msftgreed 6 hours 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.
arjie 12 hours ago [-]
The ambulance that billed me in San Francisco after my accident was run by San Francisco Fire Department.
darth_avocado 12 hours 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 12 hours ago [-]
Many fire departments in the US send bills, whether responding to medical emergencies or fires.
sarchertech 11 hours ago [-]
Many makes it seem like this is common. But it extremely uncommon in the US to get a bill after a fire. There are some rural volunteer fire departments that are funded through memberships and they will bill you if you aren’t a member. But these are not common.
coredog64 9 hours 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.
joe_the_user 12 hours 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.
toomuchtodo 13 hours 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.
> 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.
> 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).
Aurornis 12 hours 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.
pclowes 12 hours 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.
cogman10 12 hours ago [-]
It's very often not a choice. But also, those rural areas are often the breadbaskets of the united states. Taking care of our farmers is important.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
Der_Einzige 20 minutes ago [-]
The farmers can go F themselves. US soybean industry destroyed by trump tariffs, all I see are news stories about the very same soybean farmers talking about voting for trump again despite the pain. Reap what you sow!
pclowes 12 hours ago [-]
We give our farmers absolutely insane subsidies already.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
defrost 12 hours ago [-]
W.Australia has a land area three time that of Texas with the bulk of the 2.9 million in population clustered about the capital city Perth.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
Every day, the Royal Flying Doctor Service in Western Australia retrieves 29 people.
pclowes 11 hours ago [-]
Australia is also going bankrupt just slightly faster than the United States. Looks like deficit spending and debt levels are only trending the wrong direction there as well.
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
defrost 10 hours ago [-]
> Australia is also going bankrupt just slightly faster than the United States.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Any other insights?
jjav 12 hours ago [-]
> It is not the government’s job to “take care of” anybody.
That is actually the only legitimate function of government.
_DeadFred_ 9 hours ago [-]
Sweet, open the borders then. It's not the government's job to take care of that (we had government long before we had 21st century style closed borders, so it's definitely not a requirement of government). More people = more money coming in.
cogman10 12 hours ago [-]
> It is not the government’s job to “take care of” anybody.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
pclowes 11 hours ago [-]
I think what I’m saying is being misinterpreted. I should have been more clear. Everybody’s definition of “taken care of” is different.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
cogman10 10 hours ago [-]
> Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
Planktonne 3 hours ago [-]
Do you think a beachside penthouse is really an equivalent example to life-saving medical care?
_DeadFred_ 9 hours ago [-]
Since the 1980s the Republican party had adopted a position of starve the beast, of screwing up these very numbers so that people can make exactly the argument you have.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
socalgal2 5 hours ago [-]
The city with the most funds per capita in the USA is SF. It's entirely run by dems. They can't pull it together or make the numbers work any better than repubs
skinfaxi 12 hours ago [-]
Why should there be ambulance deserts but not postal deserts?
pclowes 12 hours ago [-]
Directionally, I am also fine with postal deserts or at least different delivery expectations for very rural areas.
But also because Postal Service is much cheaper than an ambulance service?
darth_avocado 12 hours 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.
rconti 13 hours 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.
vlian2088 13 hours ago [-]
the reverse side of that medal is that in 'most of the world' EMS quality is ass.
cogman10 12 hours 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.
darth_avocado 12 hours 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.
jahnu 13 hours ago [-]
If you limit it to say the top 20 developed countries how does it look?
alistairSH 12 hours ago [-]
Just a quick Google indicates the UK, Germany, US, and Japan all have urban response times in the ballpark of 10 minutes.
mothballed 12 hours ago [-]
And even then they do worse than the average half brained private driver on trauma calls, since for many medical issues speed trumps capability.
msftgreed 6 hours ago [-]
Well, here it is often ass AND expensive. I'd take ass and free over ass and expensive.
groby_b 12 hours 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.
sarchertech 12 hours ago [-]
What metrics are you using for that? The US ranks fairly close to the top for out of hospital heart attack survival, which is a good proxy for emergency medicine in general.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
wbl 12 hours ago [-]
UK has had some atrocious response times.
alistairSH 12 hours ago [-]
Google is telling me that’s not the case… 7 minute target for life-threatening calls, with 90% actual within 15 minutes.
Avicebron 13 hours 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.
kaelwd 5 hours 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.
12 hours ago [-]
charcircuit 12 hours 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.
spzb 3 hours 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.
Avicebron 12 hours ago [-]
So everyone's covered unless you explicitly opt-out?
charcircuit 12 hours ago [-]
Everyone is covered and you have the ability to pay someone to take on the risk of having to pay for an ambulance.
Avicebron 12 hours ago [-]
what happens to the people who don't pay someone to take that risk when they need an ambulance?
charcircuit 10 hours ago [-]
Then they pay for the ambulance.
Avicebron 10 hours ago [-]
Well then not everyone is covered.
charcircuit 9 hours ago [-]
To me covered means that the ambulance will drive to your location.
Avicebron 9 hours ago [-]
Hey man, don't worry about it, this is an international forum, English can be difficult. You seem kind of like a more junior/early in your career guy so, I'm happy to help out and explain.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
charcircuit 4 hours ago [-]
There is no need to be condescending to me and be arrogant despite you being ambiguous over which definition of the word you were using. You could simply end the conversation, realizing we were talking past each other but instead you decided to take jabs such as implying I am ESL, implying I am bad at English, and assuming I'm early in my career in order to attempt to belittle me.
paxys 12 hours ago [-]
But that’s socialism!
yamillove 12 hours ago [-]
Virginia has a long-established local dog license taxes on dog ownership and recently proposed a tax for, among other things, walking dogs. Clearly the liberals have their priorities wrong as usual. But hey you get what you vote for.
Der_Einzige 17 minutes ago [-]
Virgina is easily one of the worst, most authoritarian states in the USA and it’s not even close
Worst driving laws in the USA by far. The entire existence of “the citadel”/VMI, the dog laws you mention, and a whole host of other authoritarian conservative nonsense.
scbrg 4 hours ago [-]
Foreigner from the socialist Nordics here, so perhaps I'm brain washed or something, but I don't get it. After some brief Googling it appears that you mean they have proposed a tax on a service that for some reason used to be tax-exempt.
Why was it tax-exempt? Why should it be?
What sets it apart from any other service where you pay someone to do something for you - such as cook you a meal, transport you somewhere or build you a house?
yamillove 3 hours ago [-]
[dead]
secult 2 hours 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?
jzer0cool 4 hours 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.
NSUserDefaults 5 hours ago [-]
Uber for ambulances, got it. Claude, get to work. We will submit for Apple app review at EOD.
a3w 2 hours ago [-]
"Honest EMT — not just rides, but better"
tedggh 9 hours 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.
SoftTalker 8 hours 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).
dostick 7 hours ago [-]
If you remove the $11,000 extortion “fee”, the remaining $1,000 is about the price found in the Western world countries.
js2 11 hours 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:
Finding out about this program was such a relief. I haven't worried about the prospect of having to call 911 since signing up.
Dove 13 hours 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.
IG_Semmelweiss 3 hours 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.
dodger-dog 9 hours 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.
msftgreed 6 hours 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.
djantje 4 hours 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.
Planktonne 3 hours 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.
mdavid626 7 hours 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.
infinite_spin 12 hours ago [-]
In a market where competition isn't relevant, the price of things is whatever you can get someone to pay for it.
standardUser 12 hours 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.
msftgreed 6 hours ago [-]
And they decide that you'll pay a percentage of what they pay each other. Which you also have no say in.
orthoxerox 4 hours ago [-]
Why won't EMS providers strip down their services to the level where Medicare/Medicaid rates completely cover their costs?
siliconc0w 7 hours 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.
mikeweiss 13 hours 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.
softdevca 13 hours ago [-]
I don't understand why taxes can be used to save property but not a person.
master-lincoln 2 hours ago [-]
because of the moral values of elected law makers and thus indirectly because of the moral values of voters
Noumenon72 12 hours 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.
softdevca 11 hours 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.
jfengel 12 hours ago [-]
Because we like property.
lokar 12 hours 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.
msftgreed 6 hours ago [-]
You've got it. Who makes the decisions? Primarily the folks with the most property.
Lio 5 hours 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.
whatever1 8 hours 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.
winrid 3 hours 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.
wewewedxfgdf 12 hours ago [-]
There should be an "Uberlance" - discount emergency pickups by Uber, at Uber prices.
mekael 10 hours 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.
paxys 12 hours ago [-]
Uber is already “Uberlance”. Most people take Ubers to the hospital unless they are literally dying (and some even then).
jmalicki 7 hours 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.
ButlerianJihad 6 hours 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.
miramba 7 hours ago [-]
Same from Argentina to Canada? Wow
comrade1234 13 hours 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.
standardUser 12 hours ago [-]
And then do what, precisely? Quit your job and find one with better insurance options?
Noumenon72 12 hours 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?"
dark-star 3 hours 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
chillingeffect 13 hours 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.
lordkrandel 5 hours 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
rado 7 hours ago [-]
Cost in Bulgaria: $0
magic_hamster 4 hours 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.
ReptileMan 5 hours 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.
anovikov 45 minutes 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.
msla 9 hours 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.
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?
uwagar 8 hours 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.
yanhangyhy 9 hours 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.
ButlerianJihad 12 hours 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.
SoftTalker 8 hours 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.
josefritzishere 13 hours ago [-]
TLDR: private equity
kirrent 13 hours 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.
jfim 13 hours 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.
deathanatos 11 hours 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 …)
jfim 9 hours ago [-]
The cost isn't about the actual mileage though, it's having two paramedics each earning about 100k/yr per ambulance, while having coverage 24x7x365. So fully loaded, the labor for one ambulance might be in the high six figures to seven figures.
jjk166 7 hours ago [-]
Except the paramedics are actually making mcdonalds wages.
13 hours ago [-]
13 hours ago [-]
DoesntMatter22 13 hours 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
Planktonne 3 hours 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.
Georgelemental 12 hours ago [-]
When you are bleeding out on the street, you don't have time to shop around for the best deal
DoesntMatter22 7 hours ago [-]
Wont matter because nobody is going to be paying 12k for a ambulance ride if there are people doing it significantly cheaper.
lokar 12 hours ago [-]
I would absolutely not tolerate and unregulated ambulance responding to my emergency.
DoesntMatter22 12 hours 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.
duskwuff 12 hours ago [-]
Someone who's having a medical emergency is certainly in no position to go comparison shopping for ambulance services.
DoesntMatter22 6 hours ago [-]
You would do it before hand of course
yamillove 12 hours ago [-]
When you get your bill, you could just double that as a tip.
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.
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.
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.
US society has been spending a fortune on USAID funding the world's social action projects, NIH funding the world's medical research, and the US military keeping shipping lanes safe (at least until recently), and taking in a million or so people a year from other countries. That vast generosity means other countries can just spend on their own citizens and feel superior for doing so. That's why all that stuff has dried up - what's the point in spending on others when they look down on you for doing so?
Unwilling. It's absolutely feasible to find a solution, as seen everywhere else in the world.
From the article:
> In Tulsa and Oklahoma City, meanwhile, the government buys staffed unit-hours from an ambulance operator, while households can prepay a few dollars a month on their utility bill and owe nothing if the ambulance ever comes.
IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.
No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.
But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
17% of GDP is healthcare. So between 1:10 and 2:10 people in this country are making more than they otherwise would (note I did not say wealthier) because the system is screwed up and hoovers up more of everyone else's wealth than it ought to.
Slavery was 12% and (while obviously geographic concentration of industry plays a lot into it) it took a war for them to take a haircut.
Only a complete moron would think the answer to this is no. If there's no personal cost to using an extremely expensive service, every one is going to use it regardless of whether it's actually necessary. It will quickly turn into a free taxi service for anyone who wants to go anywhere near a hospital.
The only way a free ambulance system could work is if there were harsh penalties for people who abuse the system. Unfortunately, the American Democrat party has shown countless times that they have no interest in preventing fraud. Prominent Democrats like Tim Walz and Gavin Newsome have spent more time in the last year pushing laws to protect fraudsters than prosecuting them.
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
The anecdote illustrates the issue then he dives into the analysis.
I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo
I’d also be careful about his facts: they’re usually well-researched, but by the nature of the format he only ever presents those which fit his argument, and that’s just not good epistemology. I can think of a few times when the show made me feel safer about my beliefs than I should have been feeling.
So why not make fun of them? There's no downside.
I can’t imagine it’s gotten cheaper.
EDIT: their own website states "If the ambulance only comes and stabilizes you on the spot but you don’t need to be transported, there are no costs." https://ambulanceamsterdam.nl/information-in-english/
I feel like you have missed the entire point of the article.
Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.
Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.
Victim of a violent crime? You shouldn't have left your house.
Run over by someone else? You shouldn't have left your house.
Caught an infectious disease? You shouldn't have left your house.
Fell down the stairs? Why were you in your house!?! Don't you know how dangerous it is?!?
x2..x5 multiplier is always applied to any ambulance bill as far as I'm aware. I worked in that industry.
I’m sure plenty of those soldiers would rather pay some money for the evac instead of a lifelong ass tat.
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.
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.
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.
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
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.
Consent for treatment is a core principle of medical practice.
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.
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.
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
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.
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.
I suggest to copy paste your comment into your choice of AI prompt, and ask it , "is this accurate" ?
>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.
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?
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.
https://www.redcross.org/about-us/news-and-events/news/10-wa...
A plumber charges you $200 to come to your house, it costs the plumber $20 to come to your house. The latter value is what we're discussing here.
They wouldn’t be qualified if they couldn’t.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
https://www.cma.ca/resources/healthcare-real/answers/healthc...
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.
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".
Dispatch, maintenance, janitors, HR, managers.
They also need continuous training, and that is also a large salary cost for training staff (you have to pay them and the trainer).
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
Check out the "No Surprises Act"
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
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.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
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.
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.
Some do it because they actually want to be firefighters but it’s helpful to be an EMT as well.
Others do it because it’s an easy entry point (in the US you only need a 3 month night course to be an EMT) in their medical career on their way to better paying jobs like MD and RN.
And yes, others are grizzled and burnt out making little money.
But mostly people do it because they want to help.
(Shudders)
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
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.
There plenty of idiots there making 2 dollars an hour and tips and thinking they’re doing well because “at least my CoL is low!”
[1] Oh, holy crap, I just got why ambulances are called that
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.
We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Tsk-tsk.
Estimate for an ambulance call is about £450. I suspect the main reason the US costs more is wages.
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?
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.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
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.
Those calls essentially cover the base business expenses.
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.
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.
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
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.
PS: An average net salary in that city was about $1700/month at the time.
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.
At that point you're in the, what, top 2% of salaries? Especially for your age band.
It's less great when some parties are expected to give more than they receive in return (in order to provide for those who give less than they receive in return), without their consent, enforced by the state's monopoly on lawful violence, and are demonized for so little as daring to express dissatisfaction with the involuntary arrangement.
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.
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.
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.
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.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
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.
I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?
... do they reimburse those charges? Because wtf.
It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.
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”
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.
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.
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.
Would your wife have been in a different location if you had made the call?
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.
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.
- 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.
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.
If you're truly urgent, you will get bumped up. If you're not urgent, you can get bumped down as others go above you.
Unfortunately, individual QoL and urgency can sometimes be disconnected, which is why pensioners getting hip replacements can get bumped down despite having loss of mobility due to heaps of pain.
Cumulatively for lots of non-urgent activities (diagnosis tests etc) that drag can add up.
Much like any commons, is no perfect system, funnily enough.
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...
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.
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.
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.
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.- 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".
Perverse incentives are the essence of what is wrong with US medical systems.
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.
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
Healthcare is not a flex, and it my experiences on the west coast, it's an inverse correlation to wealth. :/
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
Do imaginary conversations in the shower count?
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.
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.
[1]https://www.ambulance.qld.gov.au/
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.
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.
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).
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.
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.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
RFD(WA) comes in at ~ $80 million AUD / annum in state support (for better or worse - https://www.abc.net.au/news/2024-07-24/rural-gp-slams-royal-... )
They assert to have a "value" to the state of $4.1 billion AUD over 30 years - https://www.flyingdoctor.org.au/wa/
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Any other insights?
That is actually the only legitimate function of government.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
But also because Postal Service is much cheaper than an ambulance service?
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
- 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.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
So there is a solution.
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.
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.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
Worst driving laws in the USA by far. The entire existence of “the citadel”/VMI, the dog laws you mention, and a whole host of other authoritarian conservative nonsense.
Why was it tax-exempt? Why should it be?
What sets it apart from any other service where you pay someone to do something for you - such as cook you a meal, transport you somewhere or build you a house?
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.
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...
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.
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.
That seems needlessly cruel to do to people.
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.
The article is interesting, but it doesn't actually sufficiently dismiss this; it's the route cause of it all.
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.
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.
He was lucky he was hit by a car.
A slab fronted SUV or pickup would have dragged him underneath and so it goes.
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.
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.
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.
LAFD has already called Ubers for non-emergency transport to hospitals.
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.
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.
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.
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.
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.
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...
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
better to live in uk where nhs takes care of all this compassionately for free.
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.
> 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.
(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)
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