Non-emergency ambulance runs burden, add to cost of Lexington's EMS system

bmusgrave@herald-leader.comFebruary 15, 2014 

From coughs, nausea and sore throats to more bizarre calls — bad dreams, intoxicated behavior and someone who needs a Band-Aid — Lexington ambulances are often tied up with "sick cases": medical runs that would be better handled at doctors' offices or walk-in clinics than hospital emergency rooms.

A Herald-Leader analysis of six years' worth of fire and ambulance data shows that the city's firefighters responded to 26 percent more sick cases and generic injuries than any other type of call in the past six years.

Sick cases can be serious: A stomachache can turn out to be appendicitis. But callers often are suffering from a lingering illness rather than an unexpected medical emergency, said Battalion Chief Brian Wood of the Lexington Fire Department.

"We have a percentage of the general population that will use us as a doctor," Wood said. "We constantly have to tell them, 'Look, that's not our role.'"

Some callers refuse to go to the hospital once they are checked out or medicated by EMTs.

And that's a problem.

The city can't charge an insurance provider or a patient if the patient isn't taken to a hospital. According to data provided by the city, about 25 percent of all EMS runs are never billed.

Of the remaining runs, which are billed, a little more than half are collected.

In 2013, the last full year of data, ambulance crews responded to 33,328 total calls, about 92 a day. Of that total, there were 11,829 unspecified "sick cases" and "injuries." The fire department doesn't track how many of those calls are non-emergencies. But Wood estimates that 10 percent to 20 percent of the 11,829 sick/injury calls didn't require emergency help.

As the number of calls grows, so does the cost to taxpayers.

Collection rates for ambulance bills are slightly higher than 50 percent, according to data provided by the city. From January 2010 to July 2013, the city had more than $20 million in outstanding ambulance bills.

Lexington Fire Chief Keith Jackson said the fire department doesn't track calls of the chronically ill and other people who routinely call when they are sick.

"We are just trying to give them the same quality treatment," Jackson said. "The 'frequent flyers' (are) just part of the innate culture of EMS here in Lexington."

Some people, for example, won't take their insulin, Jackson said. In other cases, families "want to push the easy button and call us so we can haul them to the hospital."

"If they call, we are going to come," Jackson said.

Other cities similarly struggle to handle such calls.

In Cincinnati, where the fire and EMS crews are combined in one department just as in Lexington, anecdotally they see a similar problem.

"Abuse of the 911 system — that's been going on my whole career," Cincinnati District Chief Anson Turley said.

The trend illuminates a national problem, experts say. It's caused partly by people who had fallen through the cracks of the old health care system. As more people found themselves without adequate health insurance, or altogether uninsured, they turned to emergency medical crews for non-emergency ailments.

With the passage of the Affordable Care Act, which requires people to obtain health insurance, some think that the number of people turning to the EMS for health care will decrease.

"It's a very common problem. It happens all the time, all across the country," said Chuck Kearns, president-elect of the National Association of Emergency Medical Technicians.

Many callers simply don't know any better, but there are those who intentionally abuse the system, said Kearns, who has been a paramedic and EMT in Florida for 30 years.

Such calls are expensive to taxpayers and ambulance providers, and they put undue strain on paramedics and EMTs.

They can also be dangerous. While an ambulance is busy with a sick person, it could delay response to someone having a heart attack or a stroke.

"There's some true danger to the community for these low-priority calls, or inappropriate calls," Kearns said.

No easy solutions

Several times a week, all of Lexington's 10 front-line ambulances, and the three they keep in reserve, are out on runs. It then falls to the fire truck crews to respond — and they do, Wood said. That's often when you see a fire truck responding to a medical call.

But Wood said he can't think of a case in which crews were tied up with non-emergency calls and it dramatically delayed treatment.

Fire department officials and emergency dispatchers are quick to say that the issue isn't as black-and-white as it seems.

WKYT rode along with acting officer Jason Neil, right, and paramedic Eddie Raymond, who drove, as they responded to emergency calls. The two spoke about frequent callers.

Here's a complicated example: The family of a Lexington woman, whom Woods described as "a diabetic who doesn't take care of herself," called for an ambulance 115 times in the first three months of 2013 and averaged about 20 calls a month for the rest of the year.

That woman, whom Wood would not identify because of medical privacy laws, cost the fire department about $20,000 in taxpayer-bought medical supplies in 2013, he said.

"Every time she gets low blood sugar, they call us to come fix her," Wood said.

After firefighters revive her — often with an intramuscular injection that costs $169 a shot — she refuses to be taken to the hospital, so the city can't bill her.

"If we don't place you in the ambulance and take you to the hospital, there's no charge," Wood said. "But it still requires quite a bit of expenditure in time, manpower, fuel, wear and tear on the trucks to drive out there."

The department spends between $20,000 and $30,000 a month on supplies.

But firefighters can't ignore the call because, in her case, it's a life-threatening emergency — the type that firefighters are sworn to handle.

"That one time we say 'We're not coming' could be the time she dies, and you're looking at a multi-million-dollar lawsuit," Wood said.

The Lexington department has no pending lawsuits involving its medical care. Its counterparts in Louisville have had several, Wood said.

Another patient who calls regularly has racked up almost $20,000 in supplies on 290 runs since 2008, Wood said. On some of the runs, they take the patient to the hospital; other times, they don't.

Emergency dispatchers categorize calls and diagnose ailments as best they can over the phone — often with little information given by callers in a state of panic. What sounds like an emergency often is not, and vice versa.

"What we consider a non-emergency, to a lot of people it's a dire emergency, and we are here to make sure they get the help they called for," said Deborah Robinson, a telecommunicator supervisor in the fire department's 911 call center.

Wood said the department has struggled for years to figure out how to deal with the problem but ensure that everyone gets emergency medical treatment if they need it.

"The bottom line is: We want you to call," Wood said.

Cost dwarfs collection

According to data provided by the Urban County Government, city crews made 32,976 medical runs in the past fiscal year, which ended June 30, but the city was able to bill for only 24,422 runs: those that ended at a hospital. That means no one was billed for 8,554 of those runs, or 26 percent.

Analysis of the past three years of data by the Herald-Leader shows that on average, 25 percent of ambulance runs don't result in transport to an emergency room, typically because the patient refuses to go or EMTs deem it unnecessary, according to the data and fire officials.

Ambulance runs put some money back into the city's coffers, but not as much as they take out.

The city contracts with Software Development Inc. to bill patients and their insurance companies for ambulance rides. The charges range from $715 for basic transport to $1,100 for "specialty care."

Many patients don't pay the full amount, or they can't afford to pay at all, Wood said.

In fiscal 2012, the city collected more than $6.6 million for ambulance runs. In fiscal 2013, it collected $6.8 million, according to data provided by the city. For 2013, that's a little more than 53 percent of what could have been collected.

However, that pales in comparison to what it costs to run and staff the ambulances. The fire department's yearly budget last year was $56 million.

It's difficult to say how much it costs just to run the emergency medical services because all firefighters are trained EMTs and paramedics. The fire department has struggled in recent years to make its budget, leading to brownouts of some fire stations to control costs. Bill O'Mara, the commissioner of Finance and Administration, said the charges for ambulance fees were never meant to cover all the costs.

"We are not allowed to make a profit because we are a government agency," O'Mara said. The department is simply trying to cover more of the costs.

O'Mara said that until about six years ago, the city's ambulance rates were the lowest in the region. It has since raised its rates. It also has gone through several collection agencies to try to find one that will beef up the city's collection rate. Last fall, the city hired a national collection agency. It's paid a percentage of what it collects. From July 2010 to December 2013, the city had more than $20 million in uncollected EMS payments.

O'Mara said the 53 percent collection rate is standard for the industry.

Collection rates of between 40 percent and 65 percent are considered typical, according to experts and studies in the Journal of Emergency Medical Services.

Councilwoman Peggy Henson, who chairs the Urban County Council's Public Safety Committee, said the issue is complicated. On the other side of the issue are Lexington residents. Henson said she has heard from constituents who didn't call an ambulance and put family members in danger because of the costs. She also has heard from residents who have needed an ambulance and can't afford the bill.

"I know there was a man who called me who had to call an ambulance because he couldn't get his wife into his truck," Henson said. "He got a bill for $400, and that's on top of what the insurance paid."

Henson said she would like to see whether the fire department can accurately track how many calls are not medically necessary so the city can get an idea of how big the problem really is. Better public education on when to call and when not to call 911 might also be needed, she said.

Mayor Jim Gray said that abuse of emergency medical services is not unique to Lexington.

"This is a problem all over the country," Gray said. "It's a symptom of our nation's health care delivery system. Yes, of course the collection rate should improve. But our fundamental policy is that when we get a call, we respond, ready to offer the best care possible."

Josh Kegley contributed to this article. Beth Musgrave: (859) 231-3205. Twitter: @HLCityhall.

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