At the state and federal level, lawmakers are considering bills to address "surprise" out-of-network medical bills, but their efforts largely ignore one of the main sources of these bills: ground ambulances, Sarah Kliff and Margot Sanger-Katz report for the New York Times' "The Upshot."
The most common reason for surprise bills
According to research from Christopher Garmon, a health economist at the University of Missouri-Kansas City, 51% of ground ambulance rides result in an out-of-network bill, compared to just 19% of ED visits.
"Ambulances seem to be the worst example of surprise billing, given how often it occurs," Garmon said. "If you call 911 for an ambulance, it's basically a coin flip whether or not that ambulance will be in or out of network."
The prices of ambulances are often posted online by the municipal governments that manage them, but those prices can vary widely, Kliff and Sanger-Katz write. For example, in Marion County, Florida, a basic ambulance ride costs $550 plus $11.25 per mile, while in Moraga and Orinda in California, the base rate for an ambulance ride is $2,600 plus $42 per mile.
Medicare patients are insulated from these bills. The program pays about $225 plus a mileage fee for ambulance rides, and it forbids companies from sending additional bills to its beneficiaries. But commercially insured individuals do not have the same protections—and lawmakers so far have been hesitant to fight for them.
Why lawmakers are hesitant to address ambulance bills
According to Kliff and Sanger-Katz, five states this year have passed laws restricting surprise bills in hospitals and doctor's offices. Yet of the five states, only Colorado's law mentions ground ambulance billing, requiring the state to form a committee to study the problem.
Ground ambulance billing practices also have largely been left out of negotiations in Congress on ways to address surprise billing, Kliff and Sanger-Katz report. That's largely because air ambulances are run by private companies, while ground ambulances are run by local and municipal governments, according to Kliff and Sanger-Katz.
Sen. Lamar Alexander (R-Tenn.), chair of the Senate Committee on Health, Education, Labor and Pensions and a key author of the Senate's surprise billing proposal, said surprise bills from air ambulances were more pressing of an issue because there is currently no local regulation of their prices. "Unlike air ambulances, ground ambulances can be regulated by states," Alexander said.
But advocates say there have been hurdles to regulating ground ambulances at the state level. Anthony Wright, executive director of Health Access California, worked on a California law passed in 2016 to restrict surprise bills, and had initially thought to include ground ambulances in the law.
But they ran into policy issues. For example, Kliff and Sanger-Katz explain that ground ambulances are typically funded through a combination of fees for the service and taxes. During discussions on ways to limit those fees, Wright explained there was a discussion of whether the state would need to offset the revenue lost by local governments.
There also are political difficulties to regulating the ground ambulance industry, Kliff and Sanger-Katz report.
"There is the political reality that it's hard to go after an entire industry at once," Wright said. "It's hard to have a bill opposed by doctors and hospitals and ambulances. We did manage to get a strong protection against doctor billing, but that was an epic, brutal, three-year fight."
For its part, the ambulance industry has met with lawmakers on Capitol Hill and discussed how different their industry is from other providers. Shawn Baird, president-elect of the American Ambulance Association, said, "When we talk to our members of Congress, what we really emphasize is that we're a little different from the other providers in the surprise billing discussion. We have a distinct, public process. The [ED] isn't subject to any oversight of that kind" (Kliff/Sanger-Katz, "The Upshot," New York Times, 7/22).