A third of patients don't pay ambulance bills

[emtannie]

Where did I say that? Don't put words in that aren't there.

Actually, I find Herbie's question legitimate. 4c6, I don't think that she was trying to put word into your mouth...

Let's review....

Looking farther into the problem of non-payment, what is the option when people don't pay? As someone who doesn't live in the US, and who doesn't see the health care world in the same way as many in the US, I am curious as to how this would be handled.

Someone doesn't pay their bill. I suspect that a majority of the people who don't pay are low income, on some form of social assistance, or have mental or physical health problems which prevent them from being productive members of society. I also suspect that most on this site will agree with that opinion.

So, next step... they didn't pay, so now we want to collect... collect what? and from where? do we garnishee their social assistance cheque, so now they have even less for food and rent? Which we assume that they won't use for food and rent anyways, but rather for alcohol and street drugs. I know, stereotyping, but bear with me here.

So, then next step.. we can't find any income to use for repayment.. do they have any assets? Hmm... let me think on that. NO - if they had assets, that would mean they used their income for something.. and we would have something to use as collateral for a loan, which brings us back to repayment, which we already said they don't have.

Now what? In another thread, in a discussion on the New Obama health care, many said that health care is not a right, but a privelege, something that should be paid for, and that they are willing to take the responsibility. It is obvious that there are those in society who aren't...

So again, then what? It appears that regardless of the system, there will always be those parasites who do not pay, and abuse the system. So, if they can't, or won't pay, reason follows that under the fee for service, if they don't pay, they don't get service.

But, then we get back to the "well they called 911, so we have to go"...

What a vicious circle...

[Kiwiology]

Our part charges are a bit of a touchy issue; I've seen around that the Service writes off a portion of debt that is "large", "significant", "substantial" or something like that.

Fee-for-service is unusual in our universal healthcare system but Ambulance is one of the few Health services that directly charges for use.

Why in the hell did I marked down for that?

It is a fact our service writes off a large portion of part-charge debt and the fact that they charge at all is unusual given our genrally free-to-the-end-user-directly universal healthcare system.

A lot of people do not know Ambulance response incurs a part-charge (the amount varies based on where you live) and a portion of that debt (I have heard in excess of a million dollarsa year but I do not know a more exact figure) gets written off due to non payment. I am not a bean counter so am unsure exactly why it is not pursued but I believe it has a number of reasons around cost of collection vs the part charge itself (which is nominal) and some fear of perception of the orginisation being seen negitavely if collection were pursued.

Furthermore it is an instrument of the Service's contract with the Ministry of Health that the part-charges currently in place are not raised if the contractually agreed amount of funding is to be provided from Government.

[VentMedic]

Someone doesn't pay their bill. I suspect that a majority of the people who don't pay are low income, on some form of social assistance, or have mental or physical health problems which prevent them from being productive members of society. I also suspect that most on this site will agree with that opinion.

So, next step... they didn't pay, so now we want to collect... collect what? and from where? do we garnishee their social assistance cheque, so now they have even less for food and rent? Which we assume that they won't use for food and rent anyways, but rather for alcohol and street drugs. I know, stereotyping, but bear with me here.

Over the past two years we have seen a drastic shift in who is using the ED. If you look a t the umemployment rates for this country you will find several states with double digit numbers. Michigan is almost 15%. California, Nevada, South Carolina and Rhode Island are close to 13%. This does not include the deadbeats and homeless who fell off the map long ago for unemployment statistics. California just has a car manufacturing plant close which is expected to affect over 20,000 jobs in an area that is already hard hit. Florida has thousands of school teachers out of work as does many other states. Tourism is not what it used to be which has affected health care and many other industries. And yes even health care workers are out of work due to cut backs. Nurses, despite all the talk of shortages are having a difficult time finding a job. There are alot of unemployed EMTs who thought the patch would get them an immediate job. They also use the ED for minor sprains and when they feel like they are dying from the flu even at a young age. While there may be some EMT patch holders who are drug seeking for their habits, that may not be a fair statement for all. Also, the typical ED bill for even a minor problem is over $2000.

Many of the newly unemployed are embarrassed by their situation. This also prevents them from seeking immediate help when they do need. They may also be one of those members of society that doesn't believe in being a burden to EMS and will try to tough it out at home which leads to sicker patients and longer hospital stays. Of course, if they do call and as soon as the EMTs learn the person is unemployed, the patient may get the "stereotypical" attitude. Health care in the U.S. is not always fair but some in EMS must understand that there are times when the patient can not control what happens to their health. Even those who you call noncompliant may have a good reason for not taking their meds. The side effects may be an issue and trying to get in to see a doctor again is difficult. Also those who do use the ED for their primary physicians risk being managed differently each time and this can further compound the problem.

If you get a chance to know some of the patients using the ED and even EMS, you might find that not everyone is out to screw the system. Many would prefer to be working, have insurance and not worry about when their house will be foreclosed on.

However, even those with insurance, the hospital and ambulance will be paid at a predetermined rate and not necessarily what is billed. The ED will be lucky to get $500 or $600 on a $2000 bill from many of the private (especially HMOs) or government insurances. Even for those with insurance on this forum, there is a good chance only a portion of the amount billed by the ambulance and hospital will be paid even with the deductible and co-pay you provide.

Now to be fair, there is also a group of people who usually have insurance that regularly use the ED. They are young urban professionals who like the convenience of the ED and prefer not to mess with appointments next month. They have minor illnesses and want instant gratification. This will also include those from the medical professions, including EMTs and Paramedics, who have self-diagnosed themselves and just want a script as well as expecting "professional courtesy". They know which EDs to go to and when it is the best time to be seen quickly. They know the right answers to the questions to get whatever they want and thus, even if they don't want to believe it themselves, they probably play the system more than any seasoned drug seeking street person.

Edited April 4, 2010 by VentMedic

[emtannie]

Vent, I really liked your reply. My post wasn’t to offend, but to try to point out that collections isn’t the easy answer.

Quote 4c6: “Large EMS systems need to have their own Collections Agency. Time to get what's owed.”

It isn’t that simple.

Quote Herbie “And then what? If someone does not pay their bill, does that mean we won't respond if they owe money on previous services?”

Vent makes some very good points – there are those people who want to pay, but don’t have the means. There are those who don’t want to be a burden, and wait until the situation becomes critical. And, there are those who abuse the system by using ED’s as clinics, and taking up valuable emergency services time and resources. I don’t know how the system works in the areas where Vent, Herbie, and 4c6 are…

Do hospitals have finance departments where repayment can be arranged over a period of time? Is this an option for some of those who cannot pay in a lump sum? Is this already in place? Does it work? Is there a mechanism in place to bill those who abuse the ED? Maybe a higher fee for using the ED for services that are non-critical and could have been taken care of at a clinic?

I know the fee for service has been considered here, to try to lower the abuse of the ED by those who treat it as a walk in clinic, rather than an ER. It is still in discussion phase with our health region administration – it has its own issues.

Are there social services programs where those that cannot pay can apply for partial funding?

I don’t believe that collections is the entire answer. There have to be other alternatives as well.

[JPINFV]

Are there no urgent care clinics where everyone else lives?

How about we try this. Determine no emergency exists to fulfill EMTALA and then require payment upfront before treatment? Healthcare is no more a right than food and I don't see grocery stores handing out free food to every Tom, Dick, and Harry who comes in.

[VentMedic]

Are there no urgent care clinics where everyone else lives?

Yes, but unfortunately due to cutbacks in funding, not all the services are available at all the clinics. And, some of the health care professionals that worked in these clinics are now part of the unemployed and uninsured. But then since you live in California, that should be well known to you since that state has been hit hard by the state's financial situation. I'm sure you can get just about any doctor to tell you about the problems they are having and how some have had to layoff their office staff which includes the licensed medical professionals. I know several doctors that have given up their office entirely and sought work with agencies doing home visits or becoming staff at hospitals as Hospitalists.

How about we try this. Determine no emergency exists to fulfill EMTALA and then require payment upfront before treatment?

EMTALA does have requirements as to who does the examine and determines it is not an emergency. Once that medical professional does an examine to satisfy EMTALA they may as well treat or otherwise another medical professional will have to do another examine. However, some larger medical centers have their clinic areas close to the ED to where the patient can easily be referred and still be within the guidelines of EMTALA.

Healthcare is no more a right than food and I don't see grocery stores handing out free food to every Tom, Dick, and Harry who comes in.

Not entirely true. The U.S. has food stamp and WIC programs as well as food banks which I noticed are becoming very popular even by those who once thought they were just for "certain types" of people and not for them.

Edited April 5, 2010 by VentMedic

[Dustdevil]

Not entirely true. The U.S. has food stamp and WIC programs as well as food banks which I noticed are becoming very popular even by those who once thought they were just for "certain types" of people and not for them.

Yes, but the store is guaranteed payment for those products. They are not bending over and taking a loss like the healthcare providers do.

[spenac]

Are there no urgent care clinics where everyone else lives?

How about we try this. Determine no emergency exists to fulfill EMTALA and then require payment upfront before treatment? Healthcare is no more a right than food and I don't see grocery stores handing out free food to every Tom, Dick, and Harry who comes in.

No urgent health care clinics in my area.

Medicaid or Medicare actually had a form that if the ambulance crew determined that a patients "emergency" did not meet criteria for reimbursement that actually became a financial contract so you could pursue collections. I know many services would even request a deposit along with a signature if patient still wanted ambulance transport.

You know the funny part is that I actually saw more poor people attempt to make payments even if only $5 month than those with good jobs but no insurance or where insurance, medicaid, medicare denied payment. Often I really think the poor only have their good name and they will do anything in their power to keep it.

[VentMedic]

Yes, but the store is guaranteed payment for those products. They are not bending over and taking a loss like the healthcare providers do.

The money comes from some budget the same as the state and Federal funds to the healthcare providers to support the write offs from those without insurance. Some tax money is shifted around to cover the costs of these programs and support funds. Education or other clinics may lose as money is shifted around. Thus, the store's owner may hit by taxes or another cut in services that does affect him.