Hacker News Reader

Comment by lostlogin | Hacker News Reader

If you're prepared to socialise some of it, why not go the whole hog. Is there anyone who thinks that ambulances should e user pays? It simplifies things too, as a fair portion of accidents have a blameless victim, so the cost makes them a victim twice.

View on HN

The problem is when it's totally socialized (like medicare), you end up with people abusing the service. If an ambulance ride costs you less than a taxi or even bus, and you're an asshole, you use an ambulance (in some places, provided by paramedics, so the direct costs are high -- in some places they also send a fire truck, so you end up with like 20 highly-trained guys and $500k of equipment) to go to a routine checkup. 3-5 times a week.

You could probably waive charging direct costs if you had some other way of deterring abuse, but they essentially always have to respond to 911 calls, so the only way I could think of doing so would be to arrest someone who misuses the service. A policy of informally losing the bill for legitimate calls might work, or doing the standard drug dealer "first one's free" strategy. But I don't think $100-500 for an ambulance would break most people, particularly with insurance; a charity could also cover the bills for some people.

Simple solution: if a reasonable person would think the ambulance was unnecessary, the patient is billed for time. If necessary, it's socialized.

Some wilderness rescue services have an interesting take on it. If what you were doing was really stupid (like, hiking up and skiing a mountain in the middle of the night, during a storm), they bill you, but if you really just got screwed (fell and broke your leg), it's free.

That makes a huge amount of sense.

I also think if you got "saved" by wilderness EMS, and were in a position to do so, you'd probably really want to donate money or other resources (time? promotion? something) to thank them.

No you don't, because there's no obligation for the ambulance officers to pick you up and take you. A taxi is in the business of taking anyone they can anywhere they can. An ambulance is not. The only time they'll offer you a ride is if they judge that you may need of it, so already qualified ambulance officers have deemed you a possible candidate requiring their services. Moreover, they've only got one destination - the hospital - and it's not as if many people want to go there willingly. It's not as if you can call up an ambulance to pick you up and take you down to the pub for the night. If the ambulance officers are qualified to recognise medical emergencies (they are - that's their job) then they're qualified to determine who requires ambulance transportation and can filter patients accordingly.

The problem with 'a charity covering the bill' is that you then need people to donate out of goodwill. That doesn't often happen.

There's already fines and punishment for abusing emergency support systems (e.g.: calling 000/911/your country's equivalent). Even if you abuse that, and even if you mislead the call centre operator to dispatch an ambulance to your house, they're not going to ferry you to your desired location unless your vitals show reason to consider it a possible requirement.

Ambulance services are free here, insofar as you pay for a small tax on every rates bill (said rates cover ambulance and waste management services) edit: Apparently not since 2003 - it's now simply just covered by the State. There's no out-of-pocket expense. I can guarantee you that we don't have ambulances running people not requiring their services around 24/7.

The liability for refusing to transport a patient to ER who claims certain symptoms would be huge. Even doctors won't make that call in the US; there's no way an EMT or paramedic would.

And, if they're evaluating you on scene, even if they decide not to transport, they've already rolled the truck(s) to see you, which is probably much of the cost.

That's not true at all. If you call 911 (or someone calls for you), and you don't want to go to the hospital, you have to sign a form saying we offered to take you, but you are choosing not to go.

As rdl pointed out, the liability is just too high to refuse to take someone to the hospital.

When I lived in the UK, I called for an ambulance. The responder listened to my situation and told me I didn't sound high enough risk, so I got a taxi. I didn't get the sense this was unusual.

However, it wouldn't surprise me if the liability issues were very different in the UK.

Even in silly Poland (not to speak of Netherlands) abuse of ambulance service is treated very seriously. If the hospital makes the case that you made a call either as a prank or frivolously, you're in a world of trouble.

The argument isn't that they shouldn't get care, or even that they should have to pay for transport, but that they should be guided (using cost incentives, in the US market model) to use the most appropriate transport. ALS, BLS, mobility-but-not-EMS, or taxi). The problem is there are a lot of places in the US where "take an old person to see a doctor for a checkup" requires using BLS or even ALS ambulances, which is crazy, because ambulance would be covered but taxi would not be. It's better to just give these patients taxi vouchers, if you want the government paying for it, for $10-20, vs. a $100-500 direct-cost ambulance ride.

There's a separate argument about who should pay for what services, but "care should be delivered in the most cost-effective way to get the best patient outcomes" is independent of that.

I can confirm this, works just fine in Germany and ambulances are free (i.e. covered by mandatory health insurance). And even if it would be abused - which I really can't imagine - I'd much prefer 100 idiots free riding to the hospital to one person dying because he can't afford the trip.

I was always told that here (Austria) if you call the ambulance but are not in actual danger you have to pay for it, and that it's very expensive. But you can call an emergency physician if you're not sure if somethings wrong which is free in any case afaik. They will examine you and make a determination if you need to go the hospital. My mother once called them because she was concentrating so hard on her heartbeat while trying to sleep that she started to panic because she thought it wasn't beating normally. The emergency physician examined her and deemed everything normal, made her calm down, and then just left. I was told if she had called the ambulance it would have cost a lot.

What good is a free ride if it only takes you to a hospital?

A lot of patients need to go for visits with doctors at the hospital or in an associated complex. Many of those patients don't need special medical transport, or at the very least could go with BLS, but there are places where ALS gets used for everything and thus is very expensive. Medicare patients don't see this, but the reimbursement from Medicare to EMS is very small, too. If you have a substantial elderly or sick population, it can be a real problem.

If you talk to EMTs you'd find most calls are for elderly people with heartburn. Yes, some people abuse the system. Maybe offer one free ride a year or something.

Where are these elderly heartburn patients you speak of? I can think of one in the past few months...

Lots of 'fall down go booms' and 'they just aren't acting right' (yeah... it's called 'getting old')

In SF it seems to be a small population of seriously mentally ill, drug addicts (both OD and drug-seeking), those with ongoing conditions which they fail to manage properly, etc.

There probably should be a cheaper way to treat them than sending SF Fire over and over to the same addresses. And that way would probably be both more comfortable for the patients and lead to better long-term outcomes. Maybe more extended inpatient care for them (in a low-cost-per-day facility)?

These has got to be some sort of war-on-drugs or drug policy thing going on here. Why is this so bad where you are, while it isn't a massive problem where I am (New Zealand). Sure there are drug problems (Meth and alcohol are hitting headlines too often), but you rarely seen the sorts of scenes I saw on a brief visit to SF.

SF ends up with drug addicts/mentally ill from an area of maybe 30-50mm people, due to what are perceived (correctly) as more welcoming city services, culture, etc. Add to that the war on drugs and weird issues with medical care for the poor (medi-cal), lots of Vietnam era veterans, etc., and one of the most dysfunctional city/county governments I've ever seen. (Detroit and New Orleans are worse, but those cities are poor; SF is rich).

Reply on news.ycombinator.com