WNYC The Takeaway (Surprise Medical Bills) Transcript

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MELISSA HARRIS-PERRY: People who call an ambulance in an emergency can often be met with more stress than the visit itself, a surprise bill for the cost of the ride. Ambulances are one of the biggest providers of out of network services, and out of network billing for healthcare services has become more frequent and much more costly. That's according to a new study in the journal of the American Medical Association. While Congress, the President, and the 2020 Democratic candidates have all spoken about the need to rein in health care costs, ambulance services have not been part of that conversation. Avoid the possibility of getting hit with a massive bill after the fact. Some people are opting to call someone else for help getting to the E R. 

MAGGIE: My name is Maggie, and I'm from Long Valley, New Jersey. I needed to use an UPA driver because I had a kidney stone and I couldn't drive myself. I knew it wasn't bad enough to incur the cost of an ambulance. The Uber driver was freaked out, but they were super helpful, and they got me to the hospital quickly. Tipping the Uber driver was a lot easier than dealing with the insurance involved with taking an ambulance ride.

SUSAN: This is Susan Eddie calling from San Francisco. I had severe food poisoning and massive dehydration and dragged myself into a Lyft instead of asking a friend since it was really late at night. I didn't even consider calling an expensive ambulance. The lift driver was more concerned about himself getting sick than my well being, which isn't really surprising.

HARRIS-PERRY: Many of you told us that sometimes it seems like ride hailing apps are a cheaper way to go. But that puts drivers for companies like Uber and Lyft in a really difficult position, and we'll have more on that in a bit. But first, I have two people to talk to me about why ambulances cost so much and how that impacts emergency health care. David Slusky is a professor of economics at the University of Kansas. David, welcome to the Takeaway.

DAVID SLUSKY: Thank you so much for having me.

HARRIS-PERRY: Loren Adler is an associate director at USC Brookings Shafer Initiative for Health Policy. Loren, welcome to the show.

LOREN ADLER: Thanks for having me today.

HARRIS-PERRY: I got to be honest with you. When I first heard about this story, I was pretty horrified, but I'm generally horrified by the state of our healthcare system in the United States. David, why are so many people getting surprise medical bills from ambulances?

SLUSKY: One is there's not a lot of options between an ambulance and driving your own car. Another is that you don't want to get this wrong when you're really, really sick. Another is a lot of towns only have one ambulance company and that ambulance company then gets to set the rules. Here in Lawrence, Kansas, we had an article in our local paper a few years ago that we only have one ambulance company and they don't contract. They're not a network with any of our private insurances, only with Medicare and with Medicaid. Also, in an emergency situations, consumers can't shop around. They can't find a network provider because every minute counts, and that makes them very vulnerable to this kind of exploitation.

HARRIS-PERRY: How does the system work from when I call 911 to what ambulance I get? Do I have a choice when I call 911 or 911 is just going to dispatch whatever ambulance is available? 

SLUSKY: I think it depends on the city and depends on the situation. Individuals can in some places call private ambulances directly. But in general, you call 911, they're going to at an abundance of caution, send you an ambulance. I'd love to think of a world with video calls 911 and video triage and they can get the feed from your apple watch to get your pulse and monitor your heart, but we're just not there yet, unfortunately. 

HARRIS-PERRY: We're absolutely not there. In fact, one of the surprising things about this is not just the cost, but how we get to this cost. Loren, how many ambulance companies are dare I use the phrase out of network.

ADLER: I think that term out of network for an ambulance is almost sounds like an oxymoron to people, but obviously sadly is that's not the case. So there was actually a study published yesterday in Jama that showed that 86% of all ground ambulance rides in this country are actually delivered out of network, meaning that that ambulance provider had not contracted with your insurance company, and we're only talking about people who have insurance in this situation and private insurance, so not Medicare. Obviously, that is a pretty staggering number. Lawrence, Kansas is not alone here where the ambulances are not taking insurance companies and the fundamental market failure here is just There's typically one ambulance provider.

The patient has no choice over which ambulance company is going to pick them up. Therefore, in an unregulated market, the ambulance company can basically demand whatever price they want, and often the insurance company is not going to be willing to pay full freight on that, maybe they'll pay something more like what Medicare pays, and then the patient is often left paying the balance. In the study yesterday, it seemed like on average, people were responsible for something like 250 bucks when they were taken by an ambulance, which is obviously a pretty frustrating toll
on top of needing the ambulance to begin with.

HARRIS-PERRY: Why aren't more ambulance companies in network? I want to expand on that a little bit to ask you, don't most insurance companies cover some of emergency care? If they do, why aren't ambulances part of that?

ADLER: Sure. So you're definitely correct. So pretty much every insurance company covers ambulance services and definitely covers emergency services once you're at the hospital. They are typically the insurer will almost always pay something towards that ambulance ride. So even if it was out of network, typically the insurer will pay some amount of money that they deem quote reasonable to the ambulance provider, but then because the ambulance provider really has no incentive to take anything less than whatever number they can dream up, they will typically bill on top of what the insurer is paying.

Even though the insurer is covering these benefits, they have a lot of trouble actually coming to a contract agreement with the ambulance company here.

SLUSKY: The Survey consumer finance that the Federal Reserve puts together every couple of years looks at how many Americans can take an unexpected $400 expense. The number who can't is generally around 40%. Even a relatively low unexpected bill to some Americans is a very, very large one to others.

HARRIS-PERRY: And David, I'm wondering if you can talk a little bit also about when people are calling an ambulance, this is probably one of the most vulnerable moments that most people have. They're afraid, there's something wrong. Has there been any attempt to regulate this industry because it almost feels predatory at this point to take advantage of folks who just aren't able to often make decisions for themselves.

SLUSKY: Sure. I think most of the legislation on surprise bills in general health care, which five years ago nobody was talking about. Generally, ambulances are the hardest part of it to deal with that it's easier to deal with this with hospitals and with physicians, especially when you have more players in the market and so less monopoly power. I think that the legislation is just dealing with the lower hanging fruit first before moving on to the more difficult situations.

HARRIS-PERRY: Why aren't ambulances part of any major health care cost savings proposal, at least that we're aware of?

ADLER: To start with, that is a very good question of which there is no satisfactory answer. I do think it's worth noting in this context that most localities or at least a lot of localities or municipalities in this country do regulate their ground ambulance providers. In a lot of localities across the country, they are effectively taking bids from different ambulance companies to become the sole provider in your area. And at that point, you know, when you call 911, you would get that provider, but the locality would have worked out some arrangement where either they're sort of paying out of tax dollars to the ambulance company or often is the case, even when there is this deal with the locality, the ambulance can still balance bill each patient as they see them. That the amount they can balance bill is often regulated in this case, but it is still often in the, you know, $200 or more range. Actually, I mean, in a different study, you saw average bill is like $500. So it really depends.

Part of this is that it really depends where you are across the country. It is often difficult for Congress to tackle this issue because it involves sort of sticking their foot in what has often been local regulation. And also, you're effectively would be banning the cities themselves from balance billing patients, and therefore, sort of reducing the tax base to some degree.

HARRIS-PERRY: We should also make sure that we address Loren the issue of the uninsured. What happens if you don't have insurance and you need an ambulance? What does the surprise bill look like then? Or do you even get picked up?

ADLER: They are required by law to pick you up, but again, you're really back to the situation where it really depends on where you live. There are going to be some areas of the country where you won't pay a dime because that's covered by the local tax base. In my anecdotally talking to different areas, those seem to be the wealthier areas of the country actually that deal with this out of their tax base. But in other areas of the country, you're going to be stuck with the same balance bills. In this case, it'll just be the full bill, where you might be even stuck with a little bit more money than someone who is insured, where at least their insurer chipped in some money towards. In this case, you're going to be paying the full freight, so maybe you're you're liable for $1,000 rather than $500. Obviously, not everyone is going to be able to pay that, so certainly you're going to sometimes lead to people having to declare bankruptcy or try to negotiate with the ambulance company to maybe give them a break rate. There's not that many good options here.

SLUSKY: So There is a bit of a hopeful note on this that the Affordable Care Act created a center for Medicare and Medicaid innovation within the federal government entity that regulates Medicare and Medicaid. They actually just recently put out request for proposals on what they're calling ET three, which is emergency triage treat and transport. This is a center that tries to figure out ways to reduce costs with out hurting outcomes. And so there is right now at the federal level a conversation going on about what are our options here and how can we deal with this.

HARRIS-PERRY: Now, David, there are folks who cannot take an ambulance are afraid to take an ambulance because they don't have insurance or they don't have access to ambulances. And what we're noticing and you've done research on this is that people are taking car companies like Uber instead of ambulances to get to the hospital. Tell us a little bit about the research that you've done in that space.

SLUSKY: Sure. We looked at when Uber X became available, which in about 100 cities happened at different times over a couple of years. I gave us some nice natural variation. We match this up with ambulance volume data and found that relative to where pcap ambulance volume had been before, the availability of Uber reduced ambulance volume by about 7%. We've heard numerous anecdotes from patients, from Uber drivers, from emergency medicine providers that this is something that is happening. Additionally, one of the most amazing stories we heard around this was the civil rights angle that in many places, if you call 911, the police come as well. Communities that don't necessarily want unneeded interactions with law enforcement, this was a way to get to the hospital without having that interaction.

HARRIS-PERRY: We spoke to Aziz Ba in New York City. He's been an Uber driver for about five years. He's a member of the independent driver's guild. And he told us that about once a month, he has to drive a passenger to the hospital. Let's take a listen to what his story is.

AZIZ BA: Soon as I park, they rush right in. One was just crying. The other one was screaming in pain. You know, he was like, you know, excuse me, driver. Could we just go as fast as we can because we need to get to the hospital right away. While, of course, you know, one is screaming, you know, and the other one is crying. I am going through every yellow light and eventually, I would go through pretty much every single red light all the way until I've made it to the ER.

HARRIS-PERRY: So David, I want two questions here. First of all, what impact does that have on people who are trying to get to the hospital if they take a Uber versus an ambulance?

SLUSKY: The best case scenario is it saves them hundreds if not thousands of dollars without without impacting their health. I think one thing is there are situations where you're going to the ER, you know you're going to have to wait 6 hours, but because your driving leg has swelled up to the point that it's too painful for you to drive a car. That's the situation that I think we're talking about here. I don't think we're talking about the bleeding chest pain every minute counts. They're not even going to have you sit down in the waiting room situation. There's a lot of heterogeneity here.

HARRIS-PERRY: What about the impact on drivers, and I want to play a little bit more of a Aziz's answer here.

BA: So it affects my work. I can lose my job by doing stuff like that. And I just got to mention, like, you know, this is not unusual for riders to actually get the driver to break the law.

HARRIS-PERRY: David, your thoughts on that?

SLUSKY: Ideally, this would be a role for emergency medical services. You can imagine a regular car with lights and sirens so they can legally run yellow and red lights, but isn't a full mobile emergency room the way that an ambulance is. I think that there are options here that don't require us to rely on potentially untrained ride sharing drivers who are exposed to legal liability or losing their job by doing this.

HARRIS-PERRY: Loren, any final thoughts on whether you see anything hopeful when it comes to the ambulance industry and the, the financial and economic stress that it places on everyday Americans.

ADLER: I mean, outside the stories Uber driver sort of more break my heart to hear these people kind of being forced to use ride sharing services. But it I think says something bad about our system that we have left, that we just do not have adequate regulation of ambulances in this country, and we should have some sort of federal regulation that is making it so that people can call 911 and feel confident they're not going to get hit with $1,000 bill. That there's something that shouldn't be happening here. And I think something that can be pretty easily fixed. The hope for actually for Congress to address something does not seem super hopeful this year, but I wouldn't rule it out. This is one of those instances where the more public pressure there is, the more likely Congress is to act. I think this is one of those instances where public pressure needs to force Congress to act. I also think going to your state is another place to look for. There have been a few state laws trying to address this. Maryland has a law, trying to fix this sort of market failure for ground ambulance services. Colorado passed something recently. So there is some hope at the state level, and I think people need to keep pushing on states to fix this issue as well.

HARRIS-PERRY: Loren Adler is the associate director at the USC Brooking Shaffer Initiative for Health Policy, and David Slusky, is a professor of economics at the University of Kansas.

Thanks to you both for joining us.

ADLER: Thank you.

SLUSKY: Thank you so much.