> Society should find a better way to pay for ambulances

Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.

Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).

No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.

>It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"

Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.

Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.

Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.

Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.

For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.

Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.

But humanitarian values are out of fashion, because they were never achieved globally.

So the only right people care about increasingly is their right to own property.

As someone who is not American, $10,000!!!!!! That's hard to conceive where I live. We even have a specifically free ambulance service here.

Really? Where I live a patient is always able to refuse any medical procedure or treatment, unless they’re unconscious or otherwise mentally unable and the procedure is considered necessary to save their life. They certainly can opt for a non-ambulance transfer, though here it would be free even though a regular ambulance service typically isn’t.

Consent for treatment is a core principle of medical practice.

There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.

Is it $2600? Probably not. But I think you are low-balling pretty significantly.

Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.

Replying to myself as a followup:

https://digitechcomputer.com/costs-of-ems-readiness/

Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".

+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.

I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.

Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.

That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.

Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.

As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.

Edit: spelling

Here in the Netherlands it is 877 euro for an A1 call (emergency, no delays), and 384 for B1 calls (non emergency, planable). You also get a 4.83 euro per km cost. You pay up to 375 euro if you haven't had any medical cost that year, otherwise zero.

Stand by cost are about 154 euro/hour. E.g. for sport events.

ICU transport is about 2500. All are law mandated.

The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.

Some of your estimates on this seem fine, but not this:

liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.

It may also be telling to figure out why no startup is offering $400 ambulance rides and dominating on volume.

You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?

There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.

My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you

You can get an ambulance for only $150k? A transit van with a few options is already $75k.

> Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.

Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.

Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).

However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.

The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.

You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).

Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.

> This is a short trip in an automobile, essentially a fancy uber ride.

That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.

> A new, fully equipped ambulance is about $150k.

Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.

> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.

> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles

For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).

This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.

An interesting take on the relative differences of manufacturing (and purchasing) an ambulance in the US and China: https://www.youtube.com/watch?v=8JcCISp5S64

Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.

The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.

When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.

Air ambulance is worse.

We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).

[1] Oh, holy crap, I just got why ambulances are called that

Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.

All in cost of the employee is probably double or more of your example $23 an hour wage, just to flesh out your napkin math

> This is a short trip in an automobile, essentially a fancy uber ride.

We need a regulatory body that can fine people for making analogies this bad

> How can that possibly be justified?

They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.

>The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it.

There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.

That’s wrong. The poor people who don’t pay are Medicare and Medicaid patients, and both pay for medically necessary transportation.

Those calls essentially cover the base business expenses.

One thing I'd like to point out, many of the Airlift companies, like Airlift Northwest, offer $60/year family insurance for Heli EMS. They'll bill your insurance and accept the insurer's payment as "Paid in full". They also tend to have reciprocal agreements with many other HEMS agencies.

This is just insurance, dude

At the end of the day doesnt that just end up being universal healthcare but with more steps?

I'm not sure we're talking about the same thing.

What I meant with "you have to wait months" is that if you go with the government-provided doctors and processes, they put you on a list and you have to wait for your turn. Getting an exam done can take months, and you can wait years for surgery, unless your condition is life-threatening.

If you go to a private clinic, of course you can get test results the same day and schedule any surgery within days.

Most people who can afford it go the private route. I had to do that too, which kind of pissed me off since I pay a hefty amount each month for insurance and I still have to go to private clinics. BUT, using the public infrastructure is just too inefficient. To get blood exams at a reduced price I had to schedule an appointment with my GP (days in advance), she'd send me to a specialist (about 1 week wait to get appointment), then a specialist would give me the paperwork required to get SOME of blood tests I needed covered by my insurance.

Not sure, that's why I specified "from what I understand".

BUT, most people aren't children, pregnant, or registered unemployed/very low income, so from that point of view to me it's still an insurance-centric system.

I pay a hefty amount each month and I was sick in the past and the system was so inefficient that I had to go to private doctors and clinics just to figure out what was wrong with me. I see the public insurance payments as a tax and I have private insurance to cover the costs of private doctors/hospitals.

But maybe that's just me.

Same as in the USA. They are legally required to treat you in emergency situations there, too.

BUT, they will charge you for their services afterwards--both in the USA and in Poland.

Although I suspect that the bill from the American hospital will be A LOT more...

Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.

If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.

The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.

As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.

The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.

If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.

This applies to other things as well - retirement and education come to mind.

Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.

Yea I think this is the bit thats easy to take for granted in nations with rational healthcare systems. Not only do I not get fleeced, but at no point does my healthcare feel like economic activity, a transaction, it feels like healthcare and that the provision of it is being done for the right reasons.

Medicaid is actually like this incidentally. No copays really. Too bad the electeds don't want to roll it out. The a lot of the most expensive risk pools are already on medicaid or medicare.

> My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least.

Would your wife have been in a different location if you had made the call?

Why didn’t you take an Uber?

A pretty large number of EMS is also volunteers. Basically wherever you have a volunteer fire department, you'll have volunteer EMS (if it's there).

Yeah. In many countries, EMS is also heavily volunteer-based.

St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).

In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.

Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.

You know we can have volunteer supported services be very effective, right?

I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.

Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.

Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.

But do they really? Can you point a real, evil villain saying that?

Sure, in a given public discussion, lots of people saying that show up. But substantial portion of those are shills, not necessarily people to say but who benefit from the scam. And some people who are paid, public relations people acting on the downlow, etc.

SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.

Many fire departments in the US send bills, whether responding to medical emergencies or fires.

> Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).

There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.

Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.

These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.

I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.

Choosing to live far away from others is also choosing to live far away from help.

If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.

There _should_ be some ambulance deserts.

There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.

We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.

US EMS quality isn't exactly something to be proud of. It's been private equityified. Just recently (last winter) I nearly lost an aunt because of our stellar EMS system literally doing a transfer from a hospital to a hospice. The company had only one person working, they parked the ambulance next to a snow bank, tried to wheel my aunt up the snow bank, and had her and the bed flip on them trapping them in the snow.

They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.

I think this argument is very disingenious for two reasons:

- If you’re comparing to developed nations (or some non developed ones with functioning agencies), the argument doesn’t hold true.

- If you’re comparing to the bottom of the barrel EMS (quality being ass like you said), you’re still not going bankrupt for an ambulance ride.

If you limit it to say the top 20 developed countries how does it look?

Well, here it is often ass AND expensive. I'd take ass and free over ass and expensive.

Haven't yet seen a developed nation do worse than the US. If you prefer to compare against developing countries only, sure, winning by lowering the bar to the ground is an option.

So everyone's covered unless you explicitly opt-out?

Virginia has a long-established local dog license taxes on dog ownership and recently proposed a tax for, among other things, walking dogs. Clearly the liberals have their priorities wrong as usual. But hey you get what you vote for.

And they decide that you'll pay a percentage of what they pay each other. Which you also have no say in.

Fee-for-service doesn't prevent ambulances from being considered a communal expense, it just makes sticky. There is nothing preventing a government from making ambulances equivalent to fire or police except the will.

From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.

You've got it. Who makes the decisions? Primarily the folks with the most property.

This comment is confusing because it refers to the first paragraph and also assumes when you checked your insurance you didn't find transport there. Since the parent did have transport and good insurance and a second paragraph, it sounds like you're asking "And then do what after your hospital jet flies you home, quit your job and find better insurance?"

That paragraph is somewhat incoherent at that point in the article: margins are razor thin — at a price tag of $12,000 per 6 miles or $2,000 per mile.

(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)

Wont matter because nobody is going to be paying 12k for a ambulance ride if there are people doing it significantly cheaper.

You don’t have to. You do what you want. I’d prefer to hire a company where the workers make more money. Right now they make a pittance.