The Discord Between Agony and Arithmetic

You may have seen the New York Times Editorial Board  discussing  the discord between agony and arithmetic we all confront when opining on Maria Cramer's tweet about the Boston woman injured by the subway train begging her rescuers not to call an ambulance, because she could not afford the $3,000 charge.

It appears no ambulance was called, though the injured woman (with twisted, bloodied, skinned leg) has been reported to have been hospitalized. Her rescuers and bystanders may have recognized the wisdom in her fear. 

Yes, she apparently wanted help.  It is reported that bystanders organized to rock the subway car to free her leg as it was trapped between the train and platform. But, she couldn't afford ambulance transport to follow up care. Surely, bystanders wondered if she was insured but some of them, even then, probably knew that ambulance transport is often only modestly covered for the commercially insured.

Ambulance services are confusing because our health care system is confusing.  A Medicaid beneficiary would likely have first dollar coverage for that ambulance ride in Massachusetts. A commercially insured individual would likely not. A Medicare  beneficiary would have limited coverage at a negotiated rate.

In Boston, Boston Emergency Medical Services is a public safety agency, one of the oldest ambulance services in the nation. This is an increasingly antiquated system. A number of municipalities and counties have moved to no public ambulance service. Even in Boston, however, public does not mean free to the recipient of the services.

If there is a better example of the patchwork nature of our health care system than ambulance services, I don't know it.  There are about 14,000 ambulance services across the country, run by governments, volunteers, hospitals and private companies.  It can be hard to know what kind of ambulance service you have called, your friends or family have called, or a stranger concerned about you may have called. Whoever called the ambulance, if you accept the services (even if you don't accept the actual transport, in some cases), you will be billed and not the individual who summoned the ambulance. You  are, in short, at the mercy of others. 

The woman injured on the T? She, then, was begging for the mercy of others to ,first, release her foot and, second, not saddle her with a $3,000 medical transport bill she could not afford. Could she use Uber or Lyft, both  eager to enter the market for non-emergency medical transport? Would an Uber or Lyft driver have been willing to pick up a passenger apparently unable to stand fully on her own, bloody,  and in visible pain?  What if she somehow masked her circumstances until the ride was underway? Uber drivers are facing this with some regularity, apparently, and do not like the liability risk.

The story of how ambulance charges ended up so sky high is also a story of medical innovation, inconsistency, and patch work development. More could be done pre-hospitalization, so more expensive gear was added to the ambulance and more expensive training for the ambulance attendants.  Your ambulance is chosen for you by the ambulance dispatcher and, in many places, charges may vary depending upon the complexity of the training and equipment sent to attend you.

I could go on and on.  But I did have to wonder if the "don't call an ambulance" fear was even bigger than the $3,000 possible  ambulance bill.  You see, your ambulance attendants choose your hospital and the one they choose may well be out of network.  Then, you could be looking at a lot more than a $3,000 charge.