Legislation to fix surprise medical billing won't apply to ground ambulances, but may produce data that will spur their inclusion

The new law will apply to air ambulances of Lifeguard Emergency Services of Eastern Kentucky and those of other U.S. ambulance services, but not to their ground ambulances. (Lifeguard photo)

The congressional fix for surprise medical bills, contained in the legislation to keep the government open, provide pandemic relief and do many other things, does not apply to ground ambulances, which "have the highest out-of-network billing rate of any medical specialty," The New York Times reports.

Congress "had little data on the actual costs of ambulance trips, and worried about tussling with the local governments that often oversee these services — especially those whose budgets have been battered by the economic downturn," Sarah Kliff and Margot Sanger-Katz report for the Times.

Research by Dr. Karan Chhabra of Boston's Brigham and Women’s Hospital found 71 percent of ambulance rides "have the potential to generate a surprise bill, with an average cost to the patient of $450," the Times reports. "Whether an ambulance company chooses to pursue this bill is something his research cannot determine, which is why it is merely potential." An earlier study found most ambulance rides "resulted in an out-of-network bill, a substantially higher rate than the medical specialties that the new legislation covers."

In the world of surprise medical bills, $450 is relatively small, and many ambulance services write off unpaid out-of-network bills as bad debts. But the new Congress could extend the new law — which President Trump signed Sunday night and will take effect in 2022 — to include ground ambulances.

"Medicare, which pays ambulances set rates and bans surprise billing for the patients it covers, is reviewing its payment rates," the Times reports. "As part of that process, the government is collecting detailed data from ambulance companies about their costs and prices. And the surprise-billing legislation passed this week establishes a commission to study the problem of ground ambulance bills, another way for lawmakers to learn more about how things are currently working."

Rural hospitals seek help in covid-19 response legislation, which is blocked by Democrats, who say it's too friendly to corporations

This story and its headline have been updated since initial publication at 2 p.m. Saturday.

The Kentucky Rural Health Association is urging its members to ask Senate Majority Leader Mitch McConnell, their senior U.S. senator, to include help for rural hospitals in the third coronavirus package being written in the Senate.

"Prior to covid-19, one in four hospitals were at risk of closure – but this has dramatically accelerated with growing workforce, equipment, bed capacity strains. Rural hospitals are telling us they have only weeks left of cash flow," KRHA Executive Director Tina McCormick said in an email.

She said the rural hospitals' proposal "would allow the most financially vulnerable rural hospitals . . .to convert to a status known as Critical Access Hospital and would allow them to receive a slightly enhanced Medicare reimbursement rate. Please contact Sen. McConnell to request support of this."

Many interests are trying to get help in the legislative package. They include advocates of long-debated legislation to control surprise medical billing and control drug prices, Inside Health Policy reports. For surprise billing, the package "is viewed as the last vehicle for the legislation for some time," Ariel Cohen writes. "There’s no telling when lawmakers will return to the Capitol, due to the global pandemic."

UPDATES, March 21-22: "The effort fell flat," Cohen reports. The bill "includes several Medicare and Medicaid extenders, which jeopardizes the surprise-billing and drug-pricing policies that were excluded. Congress is already talking about writing another stimulus bill."

In a press release Saturday afternoon, McConnell said bipartisan agreement is still needed to produce a bill, and suggested that long-debated proposals that haven't moved before may not make it: "Two days ago, the press reported that a senior member of House Democratic leadership told his colleagues, 'This is a tremendous opportunity to restructure things to fit our vision.' Well, let me suggest that is exactly the wrong approach right now. That is exactly the kind of thinking that could bog down these urgent discussions. . . . This is not a political opportunity. This is a national emergency."

Saturday night, McConnell issued a release saying the negotiations were nearly done. “I have asked committee chairmen to draft final legislative text that reflects their compromise products and deliver that text later this evening. “This would allow all senators to review the complete bipartisan text in advance of our first procedural vote at 3 p.m. tomorrow.”

Sunday afternoon, The Washington Post reports, "Negotiations sputtered in the Senate on Sunday over an enormous stimulus bill to keep the economy afloat during the coronavirus crisis, threatening at times to devolve into all-out partisan warfare even as a desperate nation sought relief. But the sheer magnitude of the potential calamity kept lawmakers at the bargaining table as negotiators on both sides said they must deliver to slow the financial landslide that is disrupting millions of businesses and households by the day." McConnell delayed an initial procedural vote "as it became clear it would fail due to Democratic opposition, moving the vote from mid-afternoon to evening to allow more time for talks." Democrats said the Republican bill "is tilted too far in favor of corporations and doesn’t include much oversight for $500 billion in loans and guarantees that could go to firms selected by the Treasury Department."

Later, McConnell held the procedural vote, and it failed because Democrats did not vote to proceed with his bill. Afterward, he was "angrier than we've ever really seen him," MSNBC's Josh Letterman said. McConnell said on the Senate floor, "We had a high level of bipartisanship in five different working groups . . . members who were participating were reaching agreement, and then all of a sudden the Democratic leader and the speaker of the House show up and we're back to square one." But Sen. Jeff Merkley, D-Oregon, told MSNBC that McConnell had lost Democratic support by removing some provisions from the final bill draft. Just before 9:30 p.m., Democratic Leader Chuck Schumer told CNN that he was negotiating with Treasury secretary Steven Mnuchin and making progress. Much of the Democratic unhappiness was about limited oversight of a $500 billion loan fund that Mnuchin would control.

Sen. Joe Manchin, D-W.Va., told Charleston's WOWK-TV, "Mitch McConnell’s proposal fails miserably at protecting the people most impacted by covid-19. It fails our first responders, nurses, private physicians and all health-care professionals in both hospitals and rural clinics across the board."

UPDATES, March 23: McConnell tried to schedule another procedural vote for 9:45 a.m. Monday, 15 minutes after the opening of trading on the New York Stock Exchange, but Schumer blocked that, and the vote was scheduled for noon. As it again fell short, "Near-pandemonium erupted on the Senate floor with lawmakers venting fury," The Washington Post reports. McConnell issued a long press release with his floor speech, in which he said:

“. . . When the Democratic House passed their “phase two” bill, even though Senate Republicans would have written it very differently, we sped it through the Senate and passed it quickly without even amending it.

“I literally told my own Republicans colleagues to “gag and vote for it,” for the sake of building bipartisan momentum. Because Republicans understand that a national crisis calls for urgency and bipartisanship.

“It is time for that good faith to be reciprocated. It is time for Democrats to stop playing politics and step up to the plate. . . . "

Health-care interests, using TV ads that hide who's paying for the air time, fight legislation to limit surprise or 'balance' billing; some ads come from air-ambulance companies, the big players

This ad claims the bill would help insurance firms and hurt patients.

Unknown people and businesses are giving millions of dollars to kill legislation nearing passage in Congress that would protect consumers from surprise medical bills. That's who's paying for those ads you're seeing on television. They're called "dark money" groups because they don't reveal their contributors.

"Pity the poor consumer trying to understand the coming congressional debate," writes journalist Trudy Lieberman, who considers patients' point of view. She says surprise bills have heaped "staggering amounts of debt ... on unsuspecting patients after they believed insurance had paid for their care. Those bills are growing rapidly and ensnaring more and more Americans in what has become one of the medical industry’s most unsavory business practices."

Lieberman notes a study just published in the journal JAMA Internal Medicine: "The number of surprise bills for both ER and inpatient admissions are rising. In 2010, about 32% of all ER visits resulted in surprise bills. In 2016, nearly 43% did. Surprise bills for inpatient admissions jumped from about 26% to 42% over the same period. What’s more, the average amount billed to patients for ER visits nearly tripled and the cost for inpatient admissions more than doubled."

With the TV ads, "the special interests that benefit from socking patients with additional bills" are trying "to convince consumers that any congressional efforts this fall to correct the surprise billing problem may actually harm patients," Lieberman writes. Noting the "Harry and Louise" ads that helped kill the Clinton health-care plan in 1994, she says "This kind of advertising works."

Lieberman says the industry is fighting hard because it fears "any kind of cost containment . . . something sorely needed, and bitterly fought for decades by the medical businesses whose incomes are at stake." 

The advertisers include a dark-money group called Another group, Doctor Patient Unity, which is targeting eight Republican senators, including Kentucky's Rand Paul and Majority Leader Mitch McConnell. KARE-TV in Minneapolis notes in an analysis that one of the bills "doesn’t set actually set rates for out-of-network procedures, but instead sets benchmarks for how much out-of-network providers can collect if a surprise bill shows up," Lieberman notes. "But in a TV ad that lasts a few seconds, how would the viewer be able to make that distinction?

University of Southern California research via Brookings Institution

"The air ambulance industry, which has gained notoriety over the last few years for its surprise billing tactics, too, has added its own ads to the confusing pile of persuasion aimed at the public," Lieberman reports. "According to OpenSecrets.org, the industry has spent hundreds of thousands of dollars on TV and radio ads" using the name Global Medical Response. "The scary message is that air medical services are at risk. More than 30 bases have closed this year, disappearing from rural communities that need these services the most, the ad says."

The ad urges viewers to contact Congress about the surprise-billing legislation. "It’s not hard to see that someone living in a remote rural area might just do that," Lieberman writes. "Never mind that in the last few years media stories have revealed how families have been financially devastated from air ambulance bills, and that state laws are ineffective in regulating this industry."

"And if all this isn’t confusing enough," Lieberman writes, "there’s yet another group, called the Coalition Against Surprise Medical Billing. It represents large employers, health insurance agents, and business associations like the National Business Group on Health." This coalition wants to eliminate "balance billing," the main type of surprise billing, when "a patient is involuntarily treated by an out-of-network doctor, and wants to require health insurers to reimburse out-of-network providers based on local market rates negotiated by local providers. That would avoid what it calls a cumbersome arbitration process, the approach preferred by the aforementioned doctors’ groups.

Steve Wojcik, vice president of public policy at the National Business Group on Health, told Lieberman, “I believe that the investor-driven physician staffing firms fear that if our preferences become law, their business model — go out of network and raise prices — is shot.” He added, “Everyone agrees on banning balance billing. The disagreement is over payment rates and processes for determining payment for out-of-network physicians.”

Lieberman concludes, "The scary TV ads flooding the airwaves from this group or that mask the real issue. It all comes down to money and who gets how much. . . . How this turns out is anyone’s guess right now, and it may be that Congress has been sufficiently spooked by the TV ads targeting its members that it will be too timid to pass any legislation addressing this growing problem. But there’s one thing we do know from the history of health care battles: The longer the legislative fixes twist in the wind and the attack ads run, the less likely any real protections for patients become."

National study finds Kentucky seniors are among biggest users of ambulances; state has a shortage of paramedics and EMTs

By Melissa Patrick
Kentucky Health News

A study aimed at providing a snapshot of how ambulance use varies between states found that Kentuckians on Medicare are among the heaviest users in the nation.

The study, conducted by the Rural and Underserved Health Research Center at the University of Kentucky, looked at Medicare beneficiaries using both ground and air ambulance services, the number of miles they were transported per year and per day, and the number of days of services they used in a year. The researchers said they used Medicare data because the benefits are the same nationwide, making it easier to make regional comparisons.

It found that Kentucky, Alabama, South Carolina, Tennessee and West Virginia were the top five states in ambulance use for all of these measures in 2012-14, with Alaska, Arizona, Colorado, Hawaii, Nevada and Utah at the bottom of the list.

Parsing data by regional census divisions, the study found found that 13 percent of Medicare beneficiaries in the East South Central division (Kentucky, Alabama, Mississippi and Tennessee) used a ground ambulance service and traveled almost 33 miles per year, on average -- the most of any division. The typical usage in the region was two days a year, with an average trip of 16 miles.

The study found that in 2014, Medicare beneficiaries in New England had the highest ground-ambulance usage and the Mountain division had the lowest. It found those in the Southeast (East South Central and South Atlantic) traveled further per year and per day, and received transportation more often than other areas of the U.S. The West North Central states (Kansas, Missouri, Iowa, Nebraska, Minnesota and the Dakotas) were transported more miles per day per beneficiary, but also traveled fewer days per year.

Air transportation was most prevalent in the West (comprising the Mountain and Pacific divisions), but the report points out that the number of people using air ambulance service was small compared to ground transportation.

The report also includes data from a 2013 Centers for Disease Control and Prevention survey that found patients 65 years and older represented almost 16 percent of emergency-room visits, but represented almost one-third of those arriving to the ER by ambulance. It also found that patients living in the South (38.3 percent) were the most likely to arrive by an ambulance, compared to the West (24.9 percent), Midwest (22 percent) and the Northeast (14.8 percent).

The researchers said they plan to do further research on the regional differences in ambulance use, noting that a quick look population, rural status, poverty and disability data didn't provide clear reasons for the regional differences.

Why does it matter?

The researchers say the study is important because it will help policy makers make better decisions about their ambulance services, which provide a vital service to communities.

"From our study, we believe policymakers and researchers need to consider differences across the regions of the U.S. when evaluating reimbursement and rules about usage," they write. "When looking at changes in the supply of ambulance services in an area, we need to consider the current rate of usage of those services. An area which relies more heavily on these services would react differently to a change in policy than an area with lesser usage."

The report notes that many ambulance services are at risk of scaling back or closing their doors because of finances. For example, they noted that Letcher County has had to reduce its ambulance service funding because of a loss of revenue from the coal severance tax.

Another challenge facing ambulance services in Kentucky is staffing. "We've got more paramedics in the state than we've ever had, but paramedics are doing more than we've ever done." Mike Poynter, the executive director of the state Board of Emergency Medical Services, told Kentucky Health News. "We're not just in the back of an ambulance anymore."

Because paramedics have so many options these days, Poynter said this has put a strain on ambulance services that are in geographic locations that are hard to staff or that can't pay a competitive salary.

For example, he said paramedics are increasingly being hired by emergency rooms, which usually offers higher wages and better benefits; that many of them are going back to nursing school because it pays more; that the influx of air-ambulances, which requires a minimum of four paramedics on board, has taken more than 200 paramedics out the traditional workforce; and that paramedics and EMTs are following the money, often living in one county, but working in another that pays a higher wage.

Kentucky news media have been reporting on these shortages. Lexington's WKYT-TV reported that the administrator of the Owen County EMS estimated a 35 percent paramedic shortage across the state. Louisville's WDRB reported that the shortage of both paramedics and EMTs has caused agencies to compete for workers, and Hardin County, which recently filled all of its positions, increased its salaries by 20 percent for part-time employees in an effort to retain more employees. The Cincinnati Enquirer reported that Northern Kentucky will need 175 new paramedics within five years, adding that the Cincinnati State Technical and Community College is launching a new training class to help meed this need. The State Journal of Frankfort reports that the city's fire-EMS agency has opened a new paramedic training program.

Poynter said one of the profession's greatest challenges is that policymakers and the public don't really know "what we do or how we do it," noting that the training to become a paramedic lasts at least 18 months, and many paramedics have advanced degrees in emergency medical care. "We've got to do better in educating the decision makers on what we actually do and how vital our role is in the community."

Patients may be liable for big bills from air ambulances; state House panel approves bill calling for study of companies' charges

Air ambulance services have enabled rural Kentuckians to get advanced emergency care more quickly, but there's a catch.

"Increasingly, the service also can mean the difference between getting well at a price you can afford or at a price that could push you over a financial cliff," Trudy Lieberman writes for Rural Health News Service. "Air ambulances have become the centerpiece of a nationwide dispute over balance billing, a practice that requires unsuspecting families, even those with good insurance, to pay a large part of the bill."

On Wednesday, March 16, the state House Banking and Insurance Committee approved a bill calling for a study of air-ambulance charges. House Bill 273 was sponsored by Rep. Tom McKee, D-Cynthiana, "after a constituent of McKee’s was transported to the hospital via air ambulance after a fall, but it was an unexpected bill for thousands of dollars not covered by insurance which really knocked him off his feet," Don Weber reports for cn|2's "Pure Politics."

Rep. Tom McKee

"McKee says having more information about emergency care transportation may have allowed the individual to avoid the high cost," Weber reports, quoting him: “I have learned in looking at it that certain air-ambulance companies provide a subscription service for perhaps as little as $50 a year, that you can have coverage to know if you need to be transported, the full cost would be paid. As we move forward, I think we’re going to learn a lot more to at least inform people.”

McKee said the charges, which can run well into five figures, may seem huge “but those air-ambulance companies have to keep people on duty and have to have a full crew ready to go at a moment’s notice. But, I think as citizens, we all need to know where we are in regard to being transported and things like we’ve learned, a subscription service could be available.”

Some committee members said they want to see if the charges are justified. “It’s nice to know what the cost is, $40,000, but if it only costs them $8,000 to do it,” said Rep. Steve Riggs, D-Louisville. “So we have to learn more than just what the average retail cost is, we have to also learn more about what the profit margin is.”

Lieberman reports that your air-ambulance bill may not be covered "because the provider is not in your insurer’s network," but "Sometimes it’s impossible to tell if a provider belongs to a network or not. When you are wheeled into the operating room, are you going to ask the anesthesiologist if he or she belongs to the hospital’s network? How many accident victims suffering from trauma are going to direct EMS workers to check if the air service is in or out of network before they’re lifted to a hospital? You can also get stuck even if the ambulance company is in the network. An insurance payment may not come close to covering the cost.

“Rates ambulance companies charge private patients are much more than they are charging to Medicare or Medicaid,” whose rates are too low to suit the companies. Consumers Union Programs Director Chuck Bell told Lieberman. “The air ambulance industry has grown rapidly, and prices have shot up a lot with some companies trying to make a quick buck.”