“BBQ, definitely BBQ.”
After hours of tense negotiation, my partner and I had finally decided that the new BBQ joint in town was the perfect solution to our dinnertime dietary requirements. It had beaten out all the fast food joints in the city and edged out the usual mainstays of our culinary repertoire. We drove there with almost gleeful anticipation and with full recognition of our accomplishment. We’d been decisive; we’d thoroughly considered all our options and made a decision that was going to affect the lipid content of our coronary arteries for years to come. We backed into the parking lot and unbuckled our seatbelts.
And of course, the special camera that our dispatchers use to ensure we never get to eat sold us out, and off went our tones, dashing all hopes of evening sustenance.
Ruined Dinner Plans
We departed lights and sirens into the night for the unresponsive male patient at a private residence. It was about a four-minute response from the BBQ joint we had so acrimoniously been ripped from, and we arrived to find a family member of the patient flagging us down. It was a modest but well-kept residence whose owner was lying in bed snoring. His family seemed to know the drill and cautioned us that the “last few times this happened, the medics had to sit on him.”
Predictably, the patient’s blood sugar was in the low double digits, and a carefully placed IV followed by a bolus of D-50 was all that was needed to bring him around to full consciousness. He seemed pleased to be back among the waking and quickly understood what had happened. He wasn’t a regular, but he appeared to have been through this enough times to know what happened to him when he went hypoglycemic.
I completed a thorough and detailed assessment, like I always do, to ensure there weren’t any concomitant medical conditions I may have missed. I found nothing. The patient was fully alert and denied chief complaint. He had no stroke-like or neurological symptoms, and everything checked out within normal limits. Planning on a quick sign-off and a dash back to my BBQ paradise, I whipped out my clipboard and asked the patient, “So if you’re feeling OK now, will you be needing anything more from us tonight, sir?”
His wife replied, “Oh no, you’ve got to take him to the hospital. Medicare won’t pay for this unless you take him to the hospital.”
Obviously, our service is sending bills for services rendered in refusal care. I didn’t know that, but I can understand it because this is an expensive bill for our service to eat. We expended an IV set-up, an IV medication and the requisite miscellaneous items to use them with. We also responded with an ambulance staffed by people who had the skills and knowledge to administer all the things we used, diagnose the problem and rule out other conditions to the extent possible and legally allowed.
Those things are all valuable, and they cost my service money. I get that we might want to recoup some of our expenses. I also get that the patient wants his primary payment provider to cover his medical expenses. What I don’t get is why the system is set up so we have to transport the patient so Medicare will pay the bill.
It’s like this: Our service would have billed a few hundred dollars to come pop a line in this guy, sweeten him up and leave him to a peanut butter sandwich or a “Kaiser Cocktail.” In fact, prior to the patient saying something about being billed, I assumed it was a free service we offered. However, because Medicare won’t pay for that service, the patient wished to be transported to the hospital, so he wouldn’t be charged any out-of-pocket expenses. Medicare ends up paying thousands of dollars more than it would have if it simply covered our on-scene treatment because it gets socked with the bill for the transport, as well as a bill for the emergency department (ED). Medicare will pay for the unnecessary transport and ED costs, but it doesn’t think the much cheaper alternative of letting paramedics treat and release is valuable.
This is a prime example of waste and unnecessary healthcare spending that could be alleviated by a simple change in the rules. This practice is the norm and has been going this way since I’ve been riding the ambulances. It didn’t make any sense when I started, and it doesn’t make any sense now. I can’t even estimate the unnecessary dollars that this costs Medicare and the taypayers in the grand scheme of things. I can only imagine how much money would be saved if Medicare would pay the cheaper bill as the alternative.
Here’s what Medicare has to say on the topic:
“The Medicare ambulance benefit is a transportation benefit and without a transport, there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.”(1)
What I have to say is that this policy puts an unnecessary burden on ambulance services which must eat the costs of all Medicare patients who refuse care. This policy causes wasteful spending on the part of Medicare for patients who present to the ED via ambulance in order to avoid an out-of-pocket bill. This is a slam dunk. Changing this rule in just this one instance would save Medicare gobs of money while helping ambulance services survive in the face of dwindling reimbursements. This is a clear, poignant example of how EMS could work with its various payment sources to cut costs and improve real reimbursement for services. This change alone would save an amount of money that’s staggering to the individual taxpayer, and it’s not the only change that EMS could help with.
As a profession, we need to frame the EMS payment reform debate as how we can save the healthcare system money though innovation.
Now is the time. EMS people are folks who would much rather solve a problem they have using duct tape and tongue depressors rather than buy a pre-made solution to a problem they don’t have.
1. U.S. Department of Health & Human Services. www.cms.gov/manuals/Downloads/bp102c10.pdf