For many Americans, the last few years have been a crash course in understanding the complex landscape that is our healthcare system. Regardless of your political leanings, it’s hard to deny that the current system is difficult for the average American to navigate.
On a recent Saturday morning, I opened the Austin-American Statesman to a story about the sticker shock of ambulance bills and the likelihood that they will not be paid for by your private insurance.1 The article profiled the case of a pregnant woman named Sandy Bayne who was in a pharmacy when she experienced what she described as a sudden and profuse nosebleed that wouldn’t stop. Concerned, she called her father, a physician, for guidance and he instructed her to call 9-1-1, which she did. The woman was transported to an emergency department, the nosebleed stopped on its own and she was quickly discharged.
Bayne later received an ambulance bill for $867 and was surprised it was not fully covered by her private insurance—Blue Cross Blue Shield of Texas. Like many Americans, she has a high-deductible plan and, at the time of service, had not satisfied her policy’s $2,500 annual deductible, which left her responsible for the entire bill.
This is a common conundrum for patients, and there is growing interest to be more informed about care quality and cost. One recent study in JAMA Internal Medicine described the imperfections of the current system. Researchers attempted to get the bundled cost for a hip replacement on a patient without insurance. Many of the hospitals contacted could not provide the cost information and the variation between those that could was as much as tenfold.2 This problem is not the case in ambulance service, where fee schedules include only a few different prices depending on your level of service plus mileage.
A simplified fee schedule does not, however, mean that ambulance patients are any more informed. It may be against policy for providers to discuss fees with patients, either out of concern that the cost may alter the patient’s transport decision or that it may create a customer service issue. Further, patients do not make good consumers of ambulance service because they do not have advanced opportunity to shop for quality or compare prices. The decision point is in a time of urgency for them and, in many communities, the 9-1-1 ambulance provider is predetermined.3
But what if a patient wants to be informed about their ambulance service coverage? To test this capability, I inquired with my private insurance provider: Blue Cross Blue Shield of Texas, the same provider Bayne had. Let’s take a look at what a patient might encounter:
• March 13: Using the message center within my health plan’s website, I ask for the information on my coverage. Specifically I want to know what is considered a medically necessary ambulance transport and how much of the bill would be covered.
March 14 (+1 day): A customer service representative replies and is unable to answer my questions, but is forwarding my message to “a specialist in the area.”
• April 7 (+25 days): Lindsey T. replies to my inquiry with the following message: “If the call is determined to be a true emergency, then an ambulance claim would be covered. When services are rendered by an in-network ambulance provider, you would have 100% coverage once the $3,500.00 individual deductible has been met.”
I understand what this means, but it does not go far enough to answer my questions. So I replied and asked: “Thank you. Can you please send me the definition of a “true emergency?” Does “in-network provider” automatically mean the ambulance provider serving the 9-1-1 service area you are in? In other words, I’m assuming I’m covered for a 9-1-1 ambulance in the City of Austin, but if I am in a different city, am I still covered?”
• April 9 (+27 days): A customer service representative replies and is unable to answer my questions, but is forwarding my message to “a specialist in the area.”
• April 29 (+47 days): Silvia L. replies: “If services do not meet emergency diagnosis criteria, then services will be considered as outpatient hospital services. An in-network provider is a provider that is contracted with Blue Cross Blue Shield of Texas. These providers may be contracted under only certain plans that we offer to our members. So when determining if the provider is in-network, the provider must be accepting the contracted plan that the member is on.”
Based on this answer, do you think Austin-Travis County EMS is a contracted provider? I doubt it.
When I read Bayne’s story in the newspaper, I was looking through my EMS lens. To be honest, I was a little critical of her use of an ambulance for her event and her surprise at the cost. But as I approached this from a patient’s perspective and attempted to become an informed consumer, I quickly learned that’s easier said than done.
So where does that leave us? It remains important that we don’t let the potential cost of ambulance care and transport persuade a patient who needs help. That said, it might be time to become more transparent with patients about cost and coverage. For example, giving patients a fee information card or displaying fees in the patient compartment. Whatever the answer is, it would require staff training and careful scripting. Ambulance service leaders need to recoginize the changing paradigm of healthcare and support patients who want to understand and navigate a system that is not designed for their benefit.
REFERENCES
1. Roser MA. (2014, April 12). Even with insurance, that EMS bill could cause sticker shock. Austin-American Statesman. Retrieved June 5, 2014 from www.mystatesman.com/news/news/local/even-with-insurance-that-ems-bill-could-cause-stic/nfYZZ/#05256416.3458239.735365.
2. Rosenthal JA, Lu X, & Cram, P. (2013, June). Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure. JAMA Internal Medicine, 173(6): 427-432.
3. Stout JL. (1985, January). 1985: A turning Point. JEMS, 10(1), 105-106, 108.
