Notes from the Sandwich Generation
by HomesRenewed Policy Strategist Kristin Amerling*
One often overlooked intersection we have with the healthcare industry is through use of an ambulance. Needless to say, it usually happens in an emergency, when most decisions are made on short notice without time for you to do research or do much other than receive care. But could familiarity with transportation policies of the city or town where you are living or traveling help you make sure you get to the right facility and avoid costs?
This question recently came up for my family when a dramatic ending to a visit by my parents brought us face to face with emergency care transportation policies in the District of Columbia. Thankfully the story had a happy ending but it started with the kind of phone call no one wants to receive: my mother letting me know that as they started their drive back to Florida my father got disoriented and they were now headed to a local hospital in an ambulance.
My father had three years earlier suffered a massive stroke from which he had miraculously recovered, and my parents were well versed about what symptoms could signal a recurring incident. So when my father complained of severe dizziness and nearly fell as he filled their gas tank for their drive home, my mom immediately called 911 and began their journey to get medical treatment.
What none of us considered in advance was the importance of knowing which facilities in the DC area specialize in stroke treatment. In the rush of the moment, my parents did not question the ambulance driver’s hospital choice – one he told them was dictated by a policy that directs drivers to the nearest hospital with available ER treatment. They ended up, however, in a hospital that lacked expertise and resources to do the necessary testing to ensure he was not having a second stroke.
I’ll spare you the twists and turns, but the bottom line is, we finally were able to arrange ambulance transportation to an appropriate hospital after 10 hours of waiting and negotiation with hospital administrators. He was, fortunately, not experiencing a second stroke. He got the care he needed and is fine today.
I have two takeaways from this incident: First, if you have a medical condition that could put you at serious risk, learn what medical facilities are best equipped to provide you care and what criteria guide emergency transportation, both where you live and wherever you are traveling. Many of us may have general knowledge about facilities in our own locality but might not be as likely to think about facilities in our travels–and we never know when or where a medical emergency might occur. Second, insurance plans may not always cover ambulance care costs – which can result in explosive costs for the patient.
Rules guiding the decisions made by ambulance transportation providers about where to take a person they are transporting vary by location. In DC, as my parents learned, the primary criteria guiding emergency transportation providers is the closest place that can provide available and appropriate care, an evaluation left to the discretion of the emergency transportation coordinator. According to the DC Fire and EMS Department, patients are not allowed to pick and choose facilities.
Some localities, on the other hand, expressly state that patient preference, at least in some circumstances, is taken into account. In Palm Beach County, Florida, for example, the county fire and rescue department in non-trauma cases “encourages its patients to go to the hospital that has their records and where their doctor has privileges, within reason,” while “all trauma alert patients go to the closest trauma facility,” and stroke and cardiac patients go to facilities that specialize in those conditions.
And some states have specific requirements regarding transportation of individuals with high-risk conditions. Under New York State regulations, ambulance care providers must comply with protocols requiring that patients with stroke and heart conditions are taken to designated facilities that provide that kind of specialized care.
As for costs of ambulance services, without insurance coverage the price tag is often steep. A recent Government Accountability Office report found that the emergency ground transportation costs for surveyed providers ranged from $224-$2204. Air transportation is even steeper, with average costs estimated to run between $12,000-$25,000—and depending on how remote the location, costs can even exceed $50,000.
Most insurers cover emergency transportation, but the extent of coverage may vary widely depending on factors such as whether the destination medical facility is in the provider network covered by the plan, and the plan’s deductibles policy. While the Affordable Care Act requires health insurers to apply in-network cost-sharing policies to out-of-network emergency care, it does not prevent insurers from requiring patients to pay the difference between the out-of-network provider charge and what the insurer covered. Private insurer policies will often contain detailed provisions on ambulance care coverage that you can access and review before a crisis occurs.
If you or your family member is covered by Medicare, a good overview resource on its rules is the handbook Medicare Coverage of Ambulance Services, issued by the Centers for Medicare and Medicaid Services. As this publication notes, Medicare Part B “covers ambulance services to or from a hospital, critical access hospital …, or a skilled nursing facility,” but “only when other transportation could endanger your health.” Medicare Part B will cover 80% of the ambulance costs, and if coverage is denied the patient can appeal that decision.
For my father’s recent stroke scare in DC, we needed two ambulance trips: the first one that responded to my mother’s 911 call, and then a second to transfer him to a facility to get additional specialized care. Insurance coverage for the second trip required a doctor’s order certifying that this transportation was medically necessary.
None of us wants to experience or really even contemplate emergency health situations that require ambulance transportation. I certainly hope there’s never another occasion for the phone call I received from my mother during my parents’ medical crisis in DC. However, a little advance legwork may come in handy in helping family members get the best quality emergency care, wherever they may be, without paying an arm and a leg for it.