Ambulance ride: $543
Oxygen: $2 per minute
Cardiac monitor usage charge: $30
Knowing the inflated costs on your medical bill are paying for the emergency treatment of someone else's paper cut: Priceless.
Some things health insurance does cover. For everything else, there's cost shifting.
As absurd as this scenario might appear, it happens more often than one might readily believe. And the 911-call for a paper cut is not an exaggeration, nor are the costs listed for ambulance expenses for legitimate emergencies.
R. Shawn Rogers, director of the Emergency Medical Division of the Oklahoma Department of Health, said emergency calls for paper cuts, stubbed toes, splinters, an overall feeling of "blah" and other non-crises are commonplace.
On average, he said, emergency responders wind up not transporting one out of every four people they speed through the streets, sirens-a-blazing, to rescue.
Not every one of those people who make up that 25 percent of emergency callers has a completely clean bill of health, however. Many have actual medical problems for which they need treatment, but those problems aren't exactly "emergencies," either.
"We get the whole gamut," said Tina Wells, spokeswoman for Emergency Medical Services Authority in Tulsa. That gamut ranges, she said, "from actual emergencies to a sore throat because the person doesn't have access to a doctor."
For many Tulsans, ambulance calls and emergency room visits are the way to go for treatment of common ailments like head colds, sinus infections and pink eye. They use emergency services as their primary health care since no other option is available to them because they either don't have health insurance or the health insurance they have only kicks in for catastrophes.
Emergency services, though vastly more expensive than regular checkups and preventative care, are bound by law to treat every person seeking treatment without regard for their ability to pay or their level of health coverage.
Jan Figart is, not only an associate director of the Community Service Council of Greater Tulsa, but also the organization's resident expert on all things health insurance-related. In 2004 and 2005, she said, 15.9 percent of the population of the United States was uninsured. The state of Oklahoma didn't fare quite so well, though, with 19.2 percent of its people walking the tightrope of life without the safety net of health insurance. Still worse, though, was the City of Tulsa, with 24 percent of its people uninsured.
Figart said lack of health coverage is the driving force behind dramatic premature deaths because many who lack coverage don't seek out care for chronic conditions.
An uninsured person with diabetes, for example, is unlikely to take insulin medication, since he can't afford it out-of-pocket if he isn't able to afford insurance, she said. He might be able to get by for a while through careful monitoring of his diet, but an emergency situation is bound to ensue eventually.
And when emergency responders do come to the rescue of our hypothetical uninsured insulin shock victim (let's call him "Earl"), a simple shot of insulin isn't going to do the trick, said Figart. At that stage, extensive (and expensive) treatment in the intensive care unit would be needed to minimize permanent damage to Earl's kidneys, which will add yet another condition for which health insurance would be mandatory for any who could afford it.
Since Earl can't, though, he isn't likely to live very long with permanent kidney damage going untreated after he leaves the ICU. His short life would be punctuated by several more visits to the ER before he finally dies of health insurance-deprivation.
While people like Earl pay a price for their lack of health coverage that cannot be quantified, they don't pay for the treatment itself.
Melanie Christian, spokeswoman for the Tulsa Health Department, said uncompensated hospital and ER care in the five largest Tulsa County Hospitals was $56 million in 2003.
Wells said a full 21 percent of EMSA patients pay nothing because they are uninsured or underinsured. For her regional division, which covers Tulsa, Bixby, Sand Springs and Jenks, she forecasts that uncompensated care will account for 10,014 transports in fiscal year 2008, at a cost of more than $3.3 million.
Cost to whom, though? The prices of gas, manpower, medical supplies and other essential operating expenses don't go down for EMSA or for hospitals when their patients don't pay. If they want to keep their operations going and keep saving lives, they have to find a way to pay for the fuel, manpower, dialysis and all of the other elements that went into Earl's treatment.
This is where the magic of cost shifting comes in.
"Cost shifting is about the only way we keep this propped up," said Rogers.
Ambulances and hospitals raise their prices for the people who pay their bills to cover the costs of those who don't. Figart said patients with private insurance pay $1.26 on the dollar to foot the bill for the uninsured.
Brother's Keepers, Capitalist Style
Since those with insurance wind up paying their own expenses along with others', insurance premiums go up, thereby making health insurance even less affordable. As a result, fewer get coverage, and the ranks of the uninsured grow.
As fewer people get health insurance, fewer people remain to fund the system, and the house of cards that is the American health care system becomes increasingly unstable.
And that house of cards is beginning to fall.
"I just hope you understand how serious this is," EMSA CEO Steve Williamson told members of the Oklahoma Board of Health last year.
"In this day and age, if you believe every Oklahoman should have immediate access to an ambulance -- well, that day is gone," he warned.
At issue was the increasing deterioration of the EMS "safety net" due to an inability to keep up with costs.
Rogers explained that cost shifting isn't enough to cover expenses, and the problem is exacerbated by the federal government's Medicare cuts of recent years.
Wells pointed out that 43 percent of EMSA patients are Medicare subscribers and, she said, due to Medicare reimbursement cuts, providing service to those subscribers will result in a deficit of $720,610 next year.
Rogers said that when the new Medicare reimbursement scale is fully implemented in three years, payments to EMS will be 27 percent below average provider costs.
Between 911 calls for paper cuts, lack of health coverage and Medicare cuts, many ambulance services are buckling under the weight and giving way.
"The emergency system is stretched so thin because it's trying to handle what other systems aren't handling, because the United States health care system is the most expensive and the least efficient in the world," said Dr. Gordon Deckert of the state Board of Health.
Approximately 40 ambulance services in Oklahoma have shut down over the last five years, Rogers said, leaving 10 Oklahoma communities "completely orphaned," including Haskell County and Drumright.
Tulsa's ambulance services are comparatively stable and not likely to have to shut down any time soon, but that doesn't mean the problem doesn't affect Tulsans. When a community loses its ambulance service, the emergency medical services of neighboring communities are stretched even thinner by being required to respond to emergencies in those communities, Rogers explained.
So, if someone in a nearby community without an ambulance service stubs his toe and calls an ambulance, that's one less ambulance that will be available to save a life in Tulsa in a real emergency, regardless of whether that person has adequate health insurance.
Rogers estimated that, if the trauma system goes uncorrected, 500 Oklahomans will die each year from lack of access to emergency treatment.
"Medical emergencies strike without warning or regard to socioeconomic factors, so medics must be on call and prepared to respond 24 hours a day, seven days a week," said Rogers. "The problem is, the public expects emergency medical services but does not provide consistent public funding."
So, what can be done about it?
In Tulsa, Williamson recently proposed a monthly fee of less than $4 to be tacked on to utility bills to pay for ambulance services, which would bring in more than $4 million in funding for EMSA.
Also, Rogers said that if communities were granted more freedom by the state to tax themselves to cover ambulance services, such as raising ad valorem taxes, it might go a long way toward alleviating the problem.
He also said public awareness of the costs incurred by utilizing emergency services for primary health care might discourage frivolous 911 calls and save resources for real emergencies.
Would these measures be enough to fix the problem, though?
Based on the enormity and complexity of the problem, these and many other proposals might seem like the proverbial band-aid on a bullet wound.
Rogers was careful to point out that neither he nor the state Department of Health have official positions on the matter, but echoed Deckert's comments about the U.S. health care system being the most expensive and least efficient in the world.
The U.S. health care system, he said, spends an average of $6,000 a year per patient. The next most expensive in the world is Switzerland, which spends $3,000 a year per patient.
"The rest of the world has national, mandatory health coverage," said Rogers. "Many experts maintain that we are going to have to move to national coverage."
With a private insurance-driven system, he said, the U.S. is "no longer on a level playing field" with other industrialized nations that have national health coverage.
"The Japanese are able to support a massive car industry" with their national system, said Rogers.
Meanwhile, he said, America's "emergency care system is creaking under the load."
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