Consequences of Hard Billing

[WuLabsWuTecH]

I'm curious if anyone else has seen these effects in their area. I've always known that when people start billing in an area, there can be changes in people's behaviour when calling 911. But now the next district over (remember we have large districts, ours is 190 square miles; the district to our south is 410, though they have usually 3-4 squads on at a time) is hard billing. If you don't pay the bill, they send it to collections.

We noticed that there have been an increase in the number of runs lately in the very south portion of our run district, right at the county line. Apparently, some people have been requesting us when calling 911, and the dispatchers have been telling them that unless the units in their county are out, he cannot dispatch us for mutual aid. This has led to the unintended consequence of people driving up to our county, and THEN calling 911. Yes, if you can drive up this far north, then you are probably OK, and a lot of these runs are BS, but there have already been a few runs I've been on since the summer when they started this that were critical patients (1 unresponsive 80 yof, 1 ~30 yom resp. arrest).

While we do soft bill out of district residents at a higher rate (250 vs 50), and only for a "vehicle cost recovery charge" (i.e. not for medical services) , it is soft billing, and a lot cheaper than the district to our south (almost 700) which is hard billed.

 

[ffemt8978]

We do a combination of "soft" and "hard" billing and have seen no unintended consequences of it.

Our soft billing works like this...as long as you come in periodically and make some type of payment (even $5.00), we won't send you to collections. If we can't get a hold of you and you don't ever come in to make any type of payment, then we send you to collections.

It has worked well for us, because our patients feel like we're working with them (at least the ones that make some type of payments). As far as the deadbeats that we can't ever get in contact with because they keep ducking our calls and throwing away our bills, well...those are the types of people that a collections agency is really good at dealing with.

 

[Shishkabob]

My agency will send it to collections.



Part of the lower call volume can be attributed to the free-loaders who finally realize that it's a service with a bill, and they quit calling 911 for reasons they shouldn't.



But, at the same time, there are some people (read: the uneducated ones who abuse the system) who don't care about their credit score.

 

[WuLabsWuTecH]

I don't know if you have any way of knowing this, but after going to hard billing, have you had any cases where the patient was worse off because they waited to call?

Obviously I see that in my neighbouring district scenario, but I'm wondering if you know antecdotally or otherwise of things like that happening?

 

[mycrofft]

Wu, your billing manager should bill their home county.

Some local areas tried billing out of county residents like that. It was shouted down after a year or two.

 

[the_negro_puppy]

Fortunately (or unfortunatly) for us, Ambulances treatments and rides are fully covered through state taxes therefore no up front cost for state residents.

Obviously we have high rates of abuse. :wacko:

 

[WuLabsWuTecH]

Some local areas tried billing out of county residents like that. It was shouted down after a year or two.

We bill them as an out of district resident but still that's only 250 compared to 700-800 for their home district.

Why did the taxpayers (who presumably were the ones that influence their own agency's billing practices) shoot down billing people more who didn't already pay taxes into the system?

Another district nearby us figures out how many runs they took in the previous year for their own district's residents, and divide their operating budget by that number to see how much it costs per run. Since the residents have already paid this, they don't get billed, but non-residents pay at this rate. It's a whopping $1700 for an ALS run!

 

[mycrofft]

Shot it down...

Seemed unneighborly. ALso a matter that they would need to rewrite their regs extensively.

There are also "duty to act", reciprocity and mutual aid issues on the line.

 

[fortsmithman]

If the person is a homeowner then the outstanding balance is added to their property tax bill. If not then I do believe the town writes it off as uncollectible.

 

[Veneficus]

Welcome to America, who claims to be the best healthcare in the world. (But talk is cheap)

It is commonly known more than 47 million people are without healthcare coverage.

Countless others are underinsured, and very rarely mentioned is the working poor. People who just eek out a living when they are not sick.

Medical bills are now one of the leading causes of bankruptcy, and financial issues the number 1 cause of divorce.


As the economy declines, more and more people are shut out of non emergent care. Which doesn't mean they do not need care, only they can't get it.

In lower socioeconomic classes, the cost of medicine is the main and largest reason by far for not seeking healthcare is cost.

That is when they enter in to the "emergency system." Which designed in the 1960s for car accidents has changed into the main means of primary care for a large portion of the population.

They need an ambulance and emergency room, not because they are in medically life threatening circumstance, but in an economically threatening circumstance.

We know using the emergency system is inefficent, does not improve patient status in any meaningful way, and costs a fortune. But it is all that is available.

As the price of medicine increases much higher and faster than wages, in a pay to play system, eventually there will be a whole group of the population who simply cannot afford any healthcare at all.

What you are seeing is simply market forces, they choose the cheaper service, because they simply cannot afford the local one. They may be choosing your service or no service.

 

[WuLabsWuTecH]

Seemed unneighborly. ALso a matter that they would need to rewrite their regs extensively.

There are also "duty to act", reciprocity and mutual aid issues on the line.

That already happens here in the city. When we do mutual aid, we don't bill, but when the bigger city comes into us, they do bill our residents. So in an effort to recoup our costs (since 80% of our runs are now mutual aid) we will start billing runs outside of our district. If our residents are outside of our district, and we get called to mutual aid, they still will not be billed.

Medical bills are now one of the leading causes of bankruptcy, and financial issues the number 1 cause of divorce.

...


What you are seeing is simply market forces, they choose the cheaper service, because they simply cannot afford the local one. They may be choosing your service or no service.

What bugs me isn't that I have a higher run volume now. I don't mind taking care of sick people. As a matter of fact, that's why I got into medicine. There are two things about this that bother me.

First, and foremost, is that people who have a genuine emergency are driving 15-20 minutes, and then having to wait another 15-20 minutes to get medical help. The purpose of billing may have been to reduce the overtriage run volume (those who don't need EMS but call anyway) but it's also causing undertriage to occur.

The second thing is that those people who drive over the line and don't need EMS. They clearly have the means to get to the hospital! And they don't need us for what they are experiencing. So why are we called? You would think that even if we are cheaper than their own district, that driving there yourself would be the cheapest option of all right?

 

[Veneficus]

First, and foremost, is that people who have a genuine emergency are driving 15-20 minutes, and then having to wait another 15-20 minutes to get medical help. The purpose of billing may have been to reduce the overtriage run volume (those who don't need EMS but call anyway) but it's also causing undertriage to occur.

The second thing is that those people who drive over the line and don't need EMS. They clearly have the means to get to the hospital! And they don't need us for what they are experiencing. So why are we called? You would think that even if we are cheaper than their own district, that driving there yourself would be the cheapest option of all right?

I don't know your service area, I am from Northern OH, but it sounds as if you are becomming the provider of first resort.

Sick or not, they may be comming to you to find out if thye need to get to the hospital. So when you encourage them to go, they think they are sick enough to need it. So basically your service confirms their suspicion that they need help and it is serious enough to need a hospital.

That will affect both of the populations that you speak of.

For all intents and purposes, your service is basically providing primary care referral.

As an emergency agency, you are probably not set up for treat and release or telling people they do not need to go to the hospital and to get something OTC.

It is not that your agency is at fault, it is just an unfortunate circumstance of the modern problems with the US medical system and politcal climate and I think you will see it get much worse before (if) it gets better.

 

[WuLabsWuTecH]

We are in the south central ohio area. We have the ability to do treat and releases, but our chief likes to keep those at around 10-20%. We had a couple of cases where we were called back to the same address later for something that became much worse.

I'm gonna talk to the chief and see if he knows what they bill our people for mutual aid. It almost never happens because we are the professional department, and if anything they are the ones having trouble getting out the door, but I'm curious as to what their policies are on that.

 

[Veneficus]

We are in the south central ohio area. We have the ability to do treat and releases, but our chief likes to keep those at around 10-20%. We had a couple of cases where we were called back to the same address later for something that became much worse..

I am going to guess that 10-20% because of the billing.

But honestly, since the accepted numbers of actual emergency cases is between 5-10% those numbers are reversed in my opinion.

Sometimes people get worse, that is normal.

 

[WuLabsWuTecH]

My understanding is that it has nothing to do with billing. Since we bill at $50 a run for residents of the area, that barely covers the cost of running the truck. Much less says anything about personnel and supplies. If we didn't have to run all the way up to columbus, that would save even more money right there.

He's worried about liability of turfing people and us missing something. Sometimes things will be missed, and there would be no way to tell short of a crystal ball, but it still looks really bad.

I would say about 25% of our runs are actually emergent. Another 10% borderline ok to go POV, but I wouldn't mind taking them.

 

[JPINFV]

He's worried about liability of turfing people and us missing something. Sometimes things will be missed, and there would be no way to tell short of a crystal ball, but it still looks really bad.

Obviously you need to get better at the buff so that you can prevent the bounce.

Why, yes, I am currently rereading HoG.

 

[Veneficus]

My understanding is that it has nothing to do with billing. Since we bill at $50 a run for residents of the area, that barely covers the cost of running the truck. Much less says anything about personnel and supplies. If we didn't have to run all the way up to columbus, that would save even more money right there.

He's worried about liability of turfing people and us missing something. Sometimes things will be missed, and there would be no way to tell short of a crystal ball, but it still looks really bad.

I would say about 25% of our runs are actually emergent. Another 10% borderline ok to go POV, but I wouldn't mind taking them.

That is the cost of doing business

 

[WuLabsWuTecH]

Obviously you need to get better at the buff so that you can prevent the bounce.

Why, yes, I am currently rereading HoG.

I missed something...

 

[JPINFV]

Turfing: the act of getting rid of a patient (really more applicable to hospital medicine as EMS always turfs their patient to someone else).

Bounce: A patient who was turfed who comes [bounces] back to you.

Buff: To polish and make good. When done correctly it reduces the chance that a patient can bounce back.

If you haven't read House of God, go out and buy it. It's definitely worth having in your library.

 

[WuLabsWuTecH]

is thie the book that references the gomers? I've been meanign to read this since i first took an emergency med class a few years back as an undergraduate, but I just have not gotten around to it!