Medic2Medic Podcast (Uber and Ambulances)

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ANNOUNCER: Welcome to Medic 2 medic Podcast. The weekly podcast for EMS providers, EMS leaders, EMS medical directors, and others involved in or those who have an interest in emergency medical services. Ladies and gentlemen, here's your host, Steve Cohen.

COHEN: 10-4. From the Raleigh, North Carolina. Medic 2 Medic Podcast Studios. This is Steve Cohen. Thanks for joining me. You can reach the host at Medic 2 Medic Podcast, that's medic number two medic podcast@gmail.com. You can download this episode, as well as others at ITunes, Spreaker, SoundCloud, Stitcher and Podbean. Of course, my website is has all the past episodes at Medic 2 Medic podcast.com.

Today, I am joined from the University of Kansas, David Slusky, who is a PhD and assistant professor of economics and an Oswald scholar at the University of Kansas. He also co directs the Health Policy Research Group and faculty affiliate of the Institute for Policy and Social Research. He's done a lot of research, but the reason why we have him on is because he has an EMS connection here with his research, and it's Uber versus and Ambulance. David, welcome to Medic 2 Medic Podcast.

DAVID SLUSKY: Thank you so much for having me.

COHEN: David, tell us a little bit about your background. I know I did a little bit about that, but did you always want to grow up to be a professor?

SLUSKY: Interesting question. My father is a physician and my mother has an MBA and help certainly healthcare is something I was always thinking about. But I also am kind of a quantitative and math and problem set based kind of individual. I was a physics major in college, but also doubled with international studies, worked in the corporate world for a couple of years and then saw that anybody doing the kind of public policy and business and math based research that I wanted to do was kind of in the economics profession. And so the way to use mathematical models, statistical analysis to answer public policy relevant questions that policy relevant questions.

It seemed like an attractive career to me, not to mention the ability to work with great students at the undergraduate and graduate level as well.

COHEN: David, where did you grow up?

SLUSKY: I grew up outside Philadelphia.

COHEN: Okay.

We're at, I actually spent some time in Philadelphia, actually went to Honman University. I worked at the Medical College of Pennsylvania for a few years.

SLUSKY: I Hear a little bit of Philadelphia in your dialect, something I don't hear so much out here in Kansas and I miss it very much. Yeah.

COHEN: Well, Philadelphia again, born and raised in Pittsburgh, I'm always going to be a Pittsburgh fan, Steelers, Penguins, and the pirates. When I moved to Philadelphia, I thought Pittsburgh was a great sports town, but Philadelphia was an unbelievable sports town. Still don't like the fliers, and I still don't like the Eagles, so no offense to all my

SLUSKY: I say I spent a summer in Pittsburgh when I was in high school. I got to go to the Old three Rivers and it's last year, which is pretty exciting.

COHEN: Well, the reason why I wanted to have you on the podcast is because you have a paper out that says Uber reduces ambulance usage in major cities. Well, tell me, how do you decide on studying Uber and ambulance?

SLUSKY: I think that one topic that we talk about a lot in health economics is the surprise billing that a lot of patients face. And that patients have an emergency, call an ambulance, go to the emergency room, and even when everyone's a network, get a, very large ambulance bill and ER bill, and at times when one or multiple providers in that situation and then being out of network, get an even larger bill. And not that those aren't very expensive services, those bills are calibrated to the cost of providing those services. But one thing we think about a lot in health economics is, how do we make sure individuals are getting the care they need, but not necessarily getting care that is more than they need, given the enormous financial imposition both on them, The rest of the system.

I had heard about individuals taking Uber to urgent care situations even to the emergency room. But with all great anecdotes, right, you wonder is it actually true and aggregate in the data. And so we had this opportunity working with my co author, who's a medical resident now out in San Diego to find some data on ambulances nationwide, and then combine that with Uber's data. Um, to see if we could see a pattern more broadly across the country and ended up doing so.

COHEN: Did you have any interest in emergency medical services or ambulance beforehand? Do any kind of research in that profession?

SLUSKY: I haven't specifically, though, I've certainly been a consumer of emergency medical services for myself and my family at various points. There is a parallel literature going on right now that I have been directly involved in, but I've heard a lot, but I mentioned a little bit before about in network and out of network billing in emergency settings and how we think about that some economists like these narrow networks because we think it helps direct patients to lower cost providers.

But in emergency situations, it's often much harder to navigate a network. So I've been thinking about emergency related issues until that point. I also related to that piece, think about kind of the bargaining power and market power that goes on in a variety of industries, including in healthcare. And emergencies wide situations where consumers where patients really don't have the opportunity given the timing to look around a different providers to see what makes the most sense for and see what they can afford.

So it's somewhat unique situation in the health care space that I've always thought about one way or another. But this is the first rigorous paper that I've tried to do with this area.

COHEN: I found it very interesting. And if you do research or pull EMS administrators, where do we see the most complaints come in? And it's usually within 90 days or so, it's because when the person receives their ambulance bill, and they might find some reason to complain about It could be service, it could be the attitude of the provider, it could be the cost of the ambulance ride.

One of the most common one for us is we have hospitals very close to our station. So the people that call and we go 1 mile to the hospital, and of course, with Medicare and the insurance, we're able to charge. So that's when usually we get a phone call. Says I can't believe they just took me 1 mile and I'm getting charged all this money. So we see that on a pretty regular basis.

SLUSKY: Sure, and I think question I think of one question I think about a lot is, we need ambulances, and we ambulances that are mobile emergency rooms that have incredible technology that's literally saved lives. We need that and we need that available, but that's not cheap, as you know. And how do we properly ensure that that's paid for while reducing the overuse of it is an open question.

And kind of our current strategy that we've design is something that fallen into is that we set the patient a very large bill afterwards, and the hope is that that will deter the patient.

NARRATOR: Mastercard applies their technology products and services to help create a world where everyone, everywhere has equal access to opportunity. I'm always talking about financial empowerment and sharing the stories of our community, which is why WayUp has collaborated with Mastercard, to share how MasterCards financial tools and resources support communities around the United States. To learn more about how Mastercard's in solidarity initiative is committed to helping narrow the wealth and opportunity gap, visit mastercard.com slash solidarity.

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SLUSKY: I think one of the challenges is that when even when the service is absolutely needed, the patient who's in a high deductible situation, that bill can be an enormous financial imposition. There was a study recently that a large number of Americans can't take a financial shock in the hundreds of dollars, let alone the thousands of dollars. And so that financial shock can really stress the finances of a family enormously.

COHEN: How do we properly allocate very expensive care in situations where families can't take personal financial shocks?

SLUSKY: I think conversation in kind of healthcare financing right now. The problem that we see in EMS, and I don't know if you if you saw this during some of your initial research is that each region, each ambulance service can charge very differently for their ambulance trip. Some people might charge just $100 to start off start the ambulance and then piecemeal with oxygen, medication, et cetera.

And then in some areas, it might just be $400 a $500. So there is just no standardization in leasing EMS billing.

COHEN: Were you able to look at that? Did you see that? Was that part of the study?

SLUSKY: Not with this data set. Others have looked at that. I, You know, emergency services are an extreme example of an already extreme situation where I mean, you know, I certainly have been a situation where my physician has recommended something. And I and I've wanted to say, well, what's that going to cost me versus what's the benefit of doing that versus not doing that? And that I can't even get that number in a non emergency situation. And if I can't get it in a non emergency situation, I certainly can't get it in an emergency situation. Why I don't have time to, you know, make six phone calls during business hours.

COHEN: Right.

SLUSKY: So that and also, I mean, that variation in pricing is very hard to get at as a researcher because a lot of those agreements are very proprietary. And so you need some form of large claims data. And those data agreements are amazing if a research when you can get them, but are often very hard to come by.

It's very interesting because I went for my yearly physical and they gave me this piece of paper saying, if I straight off my physical and said I had a sore throat, or I needed to talk about some other medical condition?

They were going to charge me my co pay. At least I knew that upfront. But that's very nice. But most places don't get that. There's no upfront almost when you go to the emergency room, you're not thinking about how much is going to cost me if you're in an emergency
situation?

COHEN: Some people do. We see that in the field where people say they don't have insurance and they can't afford the ambulance bill, and that puts our personnel in a very difficult situation because we tell our staff not to talk about billing because their job is to take care of that patient and that family at that time. So it's a catch 22.

Can you talk a little bit about Can you talk a little bit about your research process for this paper. But how did it start? How did you create the questions?

SLUSKY: In these studies, what we're looking for is data, variation and a counterfactual, meaning for the data perspective, we need data on a lot of ambulance volume, not one or two cities, but we need as much data as we can. Ideally data that was gathered had nothing to do with our question.
Data that's gathered directly for our question, you might worry was gathered in a way by you know, unconscious biases of some of the data gatherers. But here's the data that was gathered for an entirely different purpose, and that makes us not worry about that. Then we need variation, right?

I know, I've been talking to and kind of follow on papers and other EMS providers on what other data we could use to get these kinds of questions. We need variation. And the fact that Uber rolled out not all at once in the whole country, but in different cities at different times over a couple of years, was very useful for us.

And the third counterfactual.

And that here that the staggered rollout helped us enormously because we can see, okay, Uber rolled out in these cities in 2013, but these cities didn't have any Uber in those years. And so we were able to see kind of what other secular trends were going on in that time frame. So when constructing one of these papers, you have to think about all those different parts and how to set up your analysis.

And here we really were able to find a dataset, and I credit my coauthor very much with a lot of the heavy lifting on data set and negotiating a data agreement with them. And then matching that up to the Uber data that was not just one time for the whole country, but different times in different cities, and then putting that together to form the right counterfactual.

This observational work, you're trying to replicate what you would get in the medical literature in a randomized trial, but in the next post observational setting. Talk about some of the seven cities that you took a look at We worked with one company, we worked with Nepsis, and NMSIs aggregates across cities. We didn't have to speak to any EMSs directly. Nemsis, the National EMS information system, they had the data nationally.

We're able to work directly with them for the data. What's nice about that is not just the coverage, but also that I've done this in other projects. A lot of the challenge in compiling data sets across different geographies is the variables aren't always defined the same way and the units aren't always the same and there are a variety of harmonization issues. Working with one company that had already harmonized the data for us, were able to streamline this process substantially.

COHEN: Another question for you is how cooperative was Uber?

SLUSKY: So we didn't have to talk to Uber at all. The benefit of working of this was that every time Uber enters a new market, it announced it on its blog and it gave the geographic boundaries of that market. And so what we were able to do painstakingly, was go through Uber's blog over the last ten years, last five years. And every time they have a region, we could then figure out what SIP codes were in that region and then code them up for merging with the NMSIS data.

So the Uber market entry is public data, and so we didn't have to work with them directly at all. With the national EMS data and Uber access, it was easy for you to get that information. I guess it's probably one of your easiest research opportunities to grab data. Not quite because I think that data is proprietary, and we have to negotiate with them how to do what we call the confidential merge. They didn't want to send us back EMS data that was identifiable to any particular geographic area. This has been a challenge because lots of local reporters are calling and saying, what does this mean for my city?

And I have to say, I don't I can't say specifically because the way we did this was we sent the Uber data to MSIs, and then they merged with their data and encrypted the city. So meaning that, let's say I have data over seven quarters. I know that those quarters are all the same city, but I don't know which city it is. And we also had to negotiate with them that cities where only entered that city in that time period like San Francisco had to be excluded from the analysis because then we could have backed out from their data. Which emergency emergency ambulance data corresponded to that city. I've done papers where both sides, the independent and dependent variables are public data. Here only one side is public data. But we had to collect that public data had to scrape it ourselves. We couldn't just download it. This is not the most complicated project I've done, but I wouldn't necessarily say it's easy to compare to some of my other work.

COHEN: Well, Let's talk about the paper. Let's talk about the research. Let's talk about the result. What did you find?

SLUSKY: We found a tally significant decrease in per capita ambulance volume when Uber entered that city.

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SLUSKY: Is a relative decrease. We're thinking about that different cities for a variety of reasons have different per capita ambulance uses, by population, demographics, by density of evert rooms, by provider culture, by patient culture, and by insurance generosity. What we did is instead of looking at absolute changes, we looked at relative changes. We looked at compared to where the city was before Uber entered, what happened to it afterwards? And if you aggregate together all of those before and after comparisons, in each city, we saw about a 7% decline in the per capita ambulance volume.

COHEN: Has Uber contacted you at all about this?

SLUSKY: No. We have not spoken Uber directly.

COHEN: Why is this research so important?

SLUSKY: I think it touches on areas that are really at the top of our mind these days. One of them is Uber specifically, but also more about our kind of sharing economy and the way that our economy has really changed in the last ten or 15 years. I mean, think about, we didn't have pocket computers ten, 15 years ago, right? We didn't have we didn't have AirBNB. We didn't have Uber. We didn't have these companies that have really changed the way we consume. I think Uber specifically really changed our tastes, that people who've in New York City might have taken taxicab as part of their regular getting around. But most of us kind of in suburban or urban settings, it just wasn't part of our transportation mix. And now, I talked to lots of people who say that they are on do I get another car? Or do I just use Uber in the times we need another car? Lots of families have fewer cars and drivers now because of Uber. Also I think I my grandparents say things like taking a cab to the airport once in a while was slurred, and I think Uber has really changed our taste on that. That's part of this, and there of other and I can talk a lot more about this and we cite these in the paper. There are lots of other economics papers that use Uber in one way or another, that's been really fascinating.

The second part of the story is about healthcare bills. We're in a situation where we have expanded insurance coverage somewhat, but we're not at universal coverage yet. And that many consumers even with insurance are more and more under insured than they were before, bearing more and more of the of the kind of first couple thousand dollar of their costs. And at that time, and so the situation of getting a very large medical bill, especially when a lot of family financial situations are even more precarious than they've been in previous generations, this very much feeds into that conversation we're having And so the fact that it touches on both Uber and on health care bills, and I think especially healthcare bills in emergencies when consumers feel particularly powerless, not just because they fear for their life, but also because they end up with a very, very large bill at the end of it.

That's a very challenging situation. And so I think this paper has gotten so much attention because it touches on both of those areas.

COHEN: So what do you think the real possible real world applications will be from the outcome of your paper?

SLUSKY: So one of them, and I'd love to get your perspective on this, I know that some EMS and some insurers are talking about to have a more very mix of emergency transportation, that I mean, I can think of the numerous situations when I've been driven to not numerous, but there are situations I've been driven to the emergency room, and then you wait for hours and hours and hours, right? And sometimes the patient can't make that call him or herself, but as the patient knows, I'll go to the ER, it might take all night, but at least somebody will see me in the next couple of hours. So, as you're well aware, that there are trained people in the emergency room that thank goodness are able to properly decide who needs to be seen first in what order.

And so having that a step backward to the transportation side, I think it would be a really interesting extension of this work.

It could really help us spend a lot less overall on emergency transportation with hopefully not a lot of change in outcomes.

So do you think that'd be possible?

COHEN: I think it's possible. I think some people call for an ambulance because they think they're going to be seen faster, and you just talked about that a little bit. And we have to dispel that myth. You said by triage, and that's what happens. So if you call an ambulance for a cut finger, we might can go by ambulance, we'll take you but you might still go sit out in the waiting room and be triaged just in that. But if somebody that has chest pain, yes, they're going to be seen right away. I think it comes to public education.

I think what worries us from EMS is that and I think this paper kind of addresses it a little bit is that if some people can go to the emergency room for that minor cut, that doesn't need somebody to watch over that. But our concern is part of the risk. What happens that, I don't have insurance, and I'm having chest pain, and I call for Uber or I call for ride sharing, and I'm in the back of that car, and all of a sudden, I go unconscious.

That's the liability and risk that I would be if I was from the ride sharing component. Now, I know they're probably dealing with that on a semi regular basis with people that are intoxicated and pass out, and all they do is pull over and call for 911, call for the ambulance anyway. I think there is a give and take. I think there's got to be a lot more conversation. But I think from a standpoint, we go in triage patient, because it's been done in EMS anyway where you don't need to go by ambulance. We're going to give you a voucher to take a taxi or a subway.

COHEN: San Francisco was good for taxi and their public transportation way back when, and We look at that because that means that ambulance is now freed up to handle the critical call Absolutely.

SLUSKY: Sorry, just to clarify that transportation is on the intake side that you call 911 in San Francisco, and they give you a voucher. Another means to get to the hospital?

COHEN: Well, what happens is that they'll go out and I'm not sure if the program is still in place, but you call 911, and there was a paper done on that. I just can't remember how long ago. That you would go and the paramedics would go and assess and via their protocol and checklist, they decide if they really had to go by ambulance, and if not, they would give them a voucher or a token to take public transportation.

SLUSKY: Could that be done over a video call? Meaning could I take out my smartphone and call some 911 equivalent with video. And then have that triage assessment be done without a paramedic showing up in my house.

COHEN: Sure. Because telemedicine is very popular, especially in rural areas where there is no health care and they do telemedicine and they consult a doctor and they try to diagnose over the phone. That's been done in numerous places. There's also nurses that for insurance companies manage in call centers and do triage over the phone and make a decision about what resource. There are principles in place. There are practices in place that use telemedicine and also triage by telephone. So yes. Could it be done? Yes. Could they call an alternative number from 911? Sure. But we've done such a good job of public education to call 911 for anything. And if you talk to the telecommunicators, and 911 administrators, they get calls for everything, and they're the clearinghouse. And no matter what, if you call 911 and you hang up the phone, they're going to call you back and if you don't answer, they're going to send some kind of response.

If you call and say, I need and ambulance because I stubbed my toe, 911 is obligated to dispatch that call. A lot more education has to be done, and I just don't know how we're ever going to achieve that goal.

SLUSKY: You have a lot more experience in the provider side than I do. Do you think that should still be 911 policy? Or is there a scenario when 911 policy on we have to send an ambulance can be changed or modified?

COHEN: Well, I think with education based medicine and doing the right research and you can make your case. Sure. I think it could be changed that if we could triage and decide if you need an ambulance or not. I'm not sure cities and towns and governments are willing to take that liability. Like I said, previously, I believe that 911 is that clearinghouse and you know when you call 911, somebody's coming.

SLUSKY: I think New York City and others have tried to create a 311.

COHEN: Right.

SLUSKY: Non emergency I'm not sure if it is necessarily the right application of this, but there is some movement in more than one number. You could imagine building into smartphones, a button that you press where you don't have to remember all the different numbers.

COHEN: Right.

SLUSKY: But that we're past the point where you have the phone and your landline in your house and remember the number to some extent.

COHEN: There's an app now called Pulse Point where if somebody's having a cardiac arrest and somebody hits a button, Pulse Point will send out if you have their app and your CPR trained, we'll send you if you look closest to that emergency, that cardiac arrest, they're going to send that person there. And there are apps out there. There's a lot of developers in both technology and health and in EMS, trying to change things because we've become so addicted to the smartphone and having the one click to get that answer.

I think there is a future how we get there. I think with some of your research and other research that goes on, there's hope. What do you think is the most important thing that you found during your research for this project?

SLUSKY: I have been amazed at the number of individuals who have written in on Twitter and on Reddit and said that they've taken it over to the emergency room. That kind of some It the ideal arc in research is kind of you see a few anecdotes, you look at the broad data to see if the anecdotes are representative. And then when you find they are, that then opens the floodgates of story and anecdotes, people who said, Yeah, that's my story.

And I've seen this other work of mine as well. We've seen that enormously in the last week or two of the publicity around this paper. So that's been really fascinating to see and seeing some of both seeing people from other countries where the ambulance kind of cost sharing is very minimal and seeing what their experience is in other countries. And also some of the interactions. There have been some responses about individuals who have a more complicated relationship with law enforcement. Not calling ambulances because in some areas, law enforcement automatically shows up if you call an ambulance. And that, in itself, in addition to the cost, making them more reluctant to call 911 an ambulance and calling Uber instead. So I think that the individual stories and the overwhelming magnitude of them has been a really fascinating experience for me since putting out the results of this paper.

COHEN: With your research and the data, were you able to find out the people that were using Uber what the chief complaint was, can you name some of those chief complaints if you were able to gather that information?

SLUSKY: That's the next paper.

COHEN: That's the next paper.

SLUSKY: Not with this paper. Though we are exploring other data partners and other opportunities. To potentially emergency room claims data that can be matched to mode of arrival. We'd love to explore that in future papers. We weren't able to do that with the data on this paper.

COHEN: And when you said you're getting a lot of feedback on edit and Twitter, I'm sure the majority of those people that said they took Uber were probably in their 20s and 30s versus 50s to 80s.

SLUSKY: Part of that is the selection bias of who's on Reddit and on Twitter. But I will say on the other side of thing, I think that I remember this really with my own grandparents that the elderly giving up their car when they're healthy but not in a position where you really want them driving on a regular basis. Is an immense boss of independence. I remember having this debate with my grandmother at one point about saying, Okay, Nana, how much are you paying for your car, how much are you paying for gas, how much are you paying for insurance, how many trips are you taking? Let's do the math here and see if this makes sense.

And that kind of conversation did not get me very far. But I think that a change in culture around both smartphone use by the elderly and also Uber use has probably changed that conversation. That the elderly, I think are much more willing now to use ride sharing to get around. Than they were a generation ago, even though you use taxis generation ago. So we might not be seeing them on Twitter or on Reddit, but you can imagine a situation where an elderly person, not with chest pains, but with something else takes right sharing to go to the hospital in feat of an ambulance.

COHEN: What type of negative feedback have you gotten from this paper?

SLUSKY: I think that this paper fits into a much larger conversation about patient driven health care. And there are a variety of studies showing that when you put patients on high deductible health insurance plans, they both get less of what we broadly think of as kind of unnecessary or low low value care, but they also get a lot less of what we consider really efficient care, right? People who don't fill their blood pressure prescriptions, don't take their blood pressure medication, for example. And so there's been a lot of pushback on the. You can't expect an individual in emergency to know whether he or she needs an ambulance or not. And my response to that that's plausibly true in this situation, but we are expecting individuals to decide whether to get health care or not based on whether they can afford the cost, or whether they think the benefit is worth the cost in a whole variety of other situations. And if we think the information asymmetry and the education asymmetry between providers and patients is so large, individuals can make the kind of decisions, then that's a much broader statement that we really should consistently apply in a much broader situation and really think very differently about our current mode of rationing care. So that's been the biggest pushback and I hear that. But I think if you're going to push back in that area, we should be pushing back and having a much broader conversation about care.

COHEN: What's good about research is that it creates more questions and more research and more hopefully answers. David, is there anything else you'd like to add?

SLUSKY: Yeah. I'm just saying that I hope to do this for many, many more years. So that's the best part of research as you generate the next several questions.

COHEN: We talked about the negative feedback. Before we end our podcast. Is anybody else interpreting the data any differently?

SLUSKY: I think we talked about this a little bit. This is a very high level, kind of the most basic stat kind of paper we can write. And There have been lots of questions about kind of, well, what's the patient makes look like who's now showing up by ambulance? What's ambulance look like? What does outcomes look like? There are lots and lots of questions. This is raising. And if you feel very, very strongly about hypotheses about those questions, that can affect how you view our paper. So I think that that has happened somewhat and has given me more, more insight and more clarity about where the next questions we have to go with this research.

COHEN: Well, I'm looking forward to the next paper. And when you publish it, or you want to come back on my podcast and discuss anything about ride sharing and ambulance or anything to do with the EMS. Feel free to give me a call and we'll get you on the air. So, David, I want to thank you very much for joining me on my podcast.

ANNOUNCER: MasterCard applies their technology products and services to help create a world where everyone, everywhere has equal access to opportunity. I'm always talking about financial empowerment and sharing the stories of our community, which is why Way up has collaborated with Mastercard, to share how Mastercard's financial tools and resources support communities around the United States. To learn more about how Mastercard's in solidarity initiative is committed to helping narrow the wealth and opportunity gap, visit mastercard.com slash solidarity.

ANNOUNCER: Owning a rental property sounds like a dream until you realize how much work goes into getting it ready. Determine a competitive rent price, market proper schedule a showing (fast unintelligible speech). Whoo. Sounds complicated. Renters warehouse is here to take the hard work off your rental to do list. Qualified tenants, check. Rent Collection, check. Maintenance coordination. You got it. Go to renterswarehouse.com for a free rental analysis to find out how much your home can rent for. Or call 8162994277, because from now on, the only thing you need on your to do list is to call Renters warehouse.