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The Milbank Quarterly Sep 2020Policy Points Out-of-network air ambulance bills are a type of surprise medical bill and are driven by many of the same market failures behind other surprise medical...
UNLABELLED
Policy Points Out-of-network air ambulance bills are a type of surprise medical bill and are driven by many of the same market failures behind other surprise medical bills, including patients' inability to choose in-network providers in an emergency or to avoid potential balance billing by out-of-network providers. The financial risk to consumers is high because more than three-quarters of air ambulances are out-of-network and their prices are high and rising. Consumers facing out-of-network air ambulance bills have few legal protections owing to the Airline Deregulation Act's federal preemption of state laws. Any federal policies for surprise medical bills should also address surprise air ambulance bills and should incorporate substantive consumer protections-not just billing transparency-and correct the market distortions for air ambulances.
CONTEXT
Out-of-network air ambulance bills are a growing problem for consumers. Because most air ambulance transports are out-of-network and prices are rising, patients are at risk of receiving large unexpected bills. This article estimates the prevalence and magnitude of privately insured persons' out-of-network air ambulance bills, describes the legal barriers to curtailing surprise air ambulance bills, and proposes policies to protect consumers from out-of-network air ambulance bills.
METHODS
We used the Health Care Cost Institute's 2014-2017 data from three large national insurers to evaluate the share of air ambulance claims that are out-of-network and the prevalence and magnitude of potential surprise balance bills, focusing on rotary-wing transports. We estimated the magnitude of potential balance bills for out-of-network air ambulance services by calculating the difference between the provider's billed charges and the insurer's out-of-network allowed amount, including the patient's cost-sharing. For in-network air ambulance transports, we calculated the average charges and allowed amounts, both in absolute magnitude and as a multiple of the rate that Medicare pays for the same service.
FINDINGS
We found that less than one-quarter of air ambulance transports of commercially insured patients were in-network. Two-in-five transports resulted in a potential balance bill, averaging $19,851. In the latter years of our data, in-network rates for transports by independent (non-hospital-based) carriers averaged $20,822, or 369% of the Medicare rate for the same service.
CONCLUSIONS
Because the states' efforts to curtail air ambulance balance billing have been preempted by the Airline Deregulation Act, a federal solution is needed. Owing to the failure of market forces to discipline either prices or supply, out-of-network air ambulance rates should be benchmarked to a multiple of Medicare rates or, alternatively, air ambulance services could be delivered and financed through an approach that combines competitive bidding and public utility regulation.
Topics: Air Ambulances; Fees and Charges; Financing, Personal; Health Care Costs; Health Policy; Humans; Insurance Coverage; Insurance, Health; Prevalence; United States
PubMed: 32525223
DOI: 10.1111/1468-0009.12464 -
CMAJ : Canadian Medical Association... Nov 2021
Topics: Air Ambulances; Humans
PubMed: 34810169
DOI: 10.1503/cmaj.210354-f -
International Journal of Biometeorology Oct 2023Ambulance data has been reported to be a sensitive indicator of health service use during hot days, but there is no comprehensive summary of the quantitative association... (Meta-Analysis)
Meta-Analysis Review
Ambulance data has been reported to be a sensitive indicator of health service use during hot days, but there is no comprehensive summary of the quantitative association between heat and ambulance dispatches. We conducted a systematic review and meta-analysis to retrieve and synthesise evidence published up to 31 August 2022 about the association between heat, prolonged heat (i.e. heatwaves), and the risk of ambulance dispatches. We initially identified 3628 peer-reviewed papers and included 48 papers which satisfied the inclusion criteria. The meta-analyses showed that, for each 5 °C increase in mean temperature, the risk of ambulance dispatches for all causes and for cardiovascular diseases increased by 7% (95% confidence interval (CI): 5%, 10%) and 2% (95% CI: 1%, 3%), respectively, but not for respiratory diseases. The risk of ambulance dispatches increased by 6% (95% CI: 4%, 7%), 7% (95% CI: 5%, 9%), and 18% (95% CI: 12%, 23%) under low-intensity, severe, and extreme heatwaves, respectively. We observed two potential sources of bias in the existing literature: (1) bias in temperature exposure measurement; and (2) bias in the ascertainment of ambulance dispatch causes. This review suggests that heat exposure is associated with an increased risk of ambulance dispatches, and there is a dose-response relationship between heatwave intensity and the risk of ambulance dispatches. For future studies assessing the heat-ambulance association, we recommend that (1) using data on spatially refined gridded temperature that is either very well interpolated or derived from satellite imaging may be an alternative to reduce exposure measurement bias; and (2) linking ambulance data with hospital admission data can be useful to improve health outcome classification.
Topics: Humans; Ambulances; Hot Temperature; Temperature; Hospitalization; Cardiovascular Diseases
PubMed: 37495745
DOI: 10.1007/s00484-023-02525-0 -
F1000Research 2020: This review aims to describe the activities of nurse practitioners (NPs) and physician assistants (PAs) working in ambulance care, and the effect of these activities... (Review)
Review
: This review aims to describe the activities of nurse practitioners (NPs) and physician assistants (PAs) working in ambulance care, and the effect of these activities on patient outcomes, process of care, provider outcomes, and costs. : PubMed, MEDLINE (EBSCO), EMBASE (OVID), Web of Science, the Cochrane Library (Cochrane Database of Systematic Review), CINAHL Plus, and the reference lists of the included articles were systematically searched in November 2019. All types of peer-reviewed designs on the three topics were included. Pairs of independent reviewers performed the selection process, the quality assessment, and the data extraction. : Four studies of moderate to poor quality were included. Activities in medical, communication and collaboration skills were found. The effects of these activities were found in process of care and resource use outcomes, focusing on non-conveyance rates, referral and consultation, on-scene time, or follow-up contact s: This review shows that there is limited evidence on activities of NPs and PAs in ambulance care. Results show that NPs and PAs in ambulance care perform activities that can be categorized into the Canadian Medical Education Directives for Specialists (CanMED) roles of Medical Expert, Communicator, and Collaborator. The effects of NPs and PAs are minimally reported in relation to process of care and resource use, focusing on non-conveyance rates, referral and consultation, on-scene time, or follow-up contact. No evidence on patient outcomes of the substitution of NPs and PAs in ambulance care exists. : CRD42017067505 (07/07/2017).
Topics: Ambulances; Canada; Humans; Nurse Practitioners; Physician Assistants
PubMed: 33456765
DOI: 10.12688/f1000research.25891.1 -
Clinical Medicine (London, England) Nov 2022As more healthcare is provided in non-hospital settings, it is essential to support clinicians in recognising early signs of clinical deterioration to enable prompt... (Review)
Review
As more healthcare is provided in non-hospital settings, it is essential to support clinicians in recognising early signs of clinical deterioration to enable prompt intervention and treatment.There are intuitive reasons why the use of the National Early Warning Score 2 (NEWS2) in out-of-hospital settings may enhance the community response to acute illness by using a common language across healthcare. An additional advantage of the use of NEWS2 in community settings is that it is not disease specific and requires no expensive technology or great expertise to take a full set of observations that can be an indicator of clinical acuity.However, concerns have been expressed as NEWS2 was developed in acute hospital settings that it may not be applicable in community settings; this review shares some of the practical ways that NEWS2 can support clinical practice along with the emerging published evidence.
Topics: Humans; Ambulances; Emergency Service, Hospital
PubMed: 36427884
DOI: 10.7861/clinmed.2022-news-ooh -
BMJ Open Dec 2023Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response... (Review)
Review
OBJECTIVES
Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation.
DESIGN
A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included.
RESULTS
Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances.
CONCLUSIONS
Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies.
Topics: Humans; Ambulances; Emergencies; Prospective Studies; Emergency Medical Services; Time
PubMed: 38101827
DOI: 10.1136/bmjopen-2023-073394 -
BMC Emergency Medicine Aug 2022Research examining paramedic care of back pain is limited. (Review)
Review
BACKGROUND
Research examining paramedic care of back pain is limited.
OBJECTIVE
To describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics.
METHODS
We included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews.
RESULTS
From 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data.
CONCLUSION
Paramedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.
Topics: Allied Health Personnel; Ambulances; Back Pain; Emergency Medical Services; Emergency Medical Technicians; Humans; Referral and Consultation
PubMed: 35945506
DOI: 10.1186/s12873-022-00699-1 -
The American Journal of Emergency... Jun 2023Advance care planning can help provide optimal medical care according to a patient's wishes as a part of patient-centered discussions on end-of-life care. This can... (Review)
Review
BACKGROUND
Advance care planning can help provide optimal medical care according to a patient's wishes as a part of patient-centered discussions on end-of-life care. This can prevent undesired transfers to emergency departments. However, the effects of advance care planning on emergency department visits and ambulance calls in various settings or specific conditions remain unclear.
AIM
To evaluate whether advanced care planning affected the frequency of emergency department visits and ambulance calls.
DESIGN
Systematic review. This study was registered in PROSPERO (CRD42022340109). We assessed risk of bias using RoB 2.0, ROBINS-I, and ROBINS-E.
DATA SOURCES
We searched the PubMed, Cochrane CENTRAL, and EMBASE databases from their inception until September 22, 2022 for studies comparing patients with and without advanced care planning and reported the frequency of emergency department visits and ambulance calls as outcomes.
RESULTS
Eight studies were included. Regarding settings, two studies on patients in nursing homes showed that advanced care planning significantly reduced the frequency of emergency department visits and ambulance calls. However, two studies involving several medical care facilities reported inconclusive results. Regarding patient disease, a study on patients with depression or dementia showed that advanced care planning significantly reduced emergency department visits; in contrast, two studies on patients with severe respiratory diseases and serious illnesses showed no significant reduction. Seven studies showed a high risk of bias.
CONCLUSIONS
Advanced care planning may lead to reduced emergency department visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research is warranted to identify the effectiveness of advanced care planning in specific settings and diseases.
Topics: Humans; Emergency Service, Hospital; Nursing Homes; Ambulances; Dementia
PubMed: 36958094
DOI: 10.1016/j.ajem.2023.03.004 -
PloS One 2022Despite emergency ambulance services playing a pivotal role in accessibility to life-saving treatments in Malaysia, there are still numerous gaps in knowledge in terms...
BACKGROUND
Despite emergency ambulance services playing a pivotal role in accessibility to life-saving treatments in Malaysia, there are still numerous gaps in knowledge in terms of their utilization and cost. This leads to current policies on procurement, maintenance, and allocation being predicated on historical evidence and expert opinions. This study thus aims to analyse the cost and utilization of ambulance services in selected public health facilities in Malaysia.
METHODS
A cross-sectional study was employed involving 239 ambulances from selected hospitals and clinics. Ambulance service utilization was based on the number of trips, distance and duration of travel obtained from travel logbooks. A mixed top-down and activity-based costing approach was used to estimate the monthly cost of ambulance services. This constituted personnel, maintenance, fuel, overhead, consumables, ambulance, and medical equipment costs. The utilization and costs of ambulance services were further compared between settings and geographical locations.
RESULTS
The average total cost of ambulance services was MYR 11,410.44 (US$ 2,756.14) for hospitals and MYR 9,574.39 (US$ 2,312.65) for clinics, albeit not significantly different. Personnel cost was found to be the main contributor to the total cost, at around 44% and 42% in hospitals and clinics, respectively. There was however a significant difference in the total cost in terms of the type and age of ambulances, in addition to their location. In terms of service utilization, the median number of trips and duration of ambulance usage was significantly higher in clinics (31.88 trips and 58.58 hours) compared to hospitals (16.25 trips and 39.25 hours).
CONCLUSIONS
The total cost of ambulance services was higher in hospitals compared to clinics, while its utilization showed a converse trend. The current findings evidence that despite the ambulance services being all under the MOH, their operating process and utilization reflected an inherent difference by setting.
Topics: Ambulances; Cross-Sectional Studies; Malaysia; Health Facilities; Emergency Medical Services
PubMed: 36331901
DOI: 10.1371/journal.pone.0276632 -
Australasian Emergency Care Sep 2022Overcrowding decreases quality of care. Triage and patient administration are possible bottlenecks. We aimed to identify factors influencing door-to-triage- and... (Observational Study)
Observational Study
BACKGROUND
Overcrowding decreases quality of care. Triage and patient administration are possible bottlenecks. We aimed to identify factors influencing door-to-triage- and triage-to-patient administration-time in a prospective observational study at a tertiary care center with 70,000 patients per year.
METHODS
Measurement of aforementioned times at convenience-sampled time intervals on 16 days. Linear regression modelling with times as dependent variable, and demographic, medical and structural factors as covariables, testing for interactions with risk factor "weekend".
RESULTS
We included 360 patients (183 female (51%)). Median door-to-triage-time was 6 (IQR 3-11) minutes, triage-to-patient administration-time was 5 (IQR 3-8) minutes. Overall door-to-triage-time was significantly shorter during weekends compared to weekdays (absolute difference 3 (IQR 1-7) minutes; 5 (IQR 3-8) vs. 8 (IQR 4-15) minutes, p < 0.01). Other influencing factors were closing hours of non-emergency department healthcare facilities (3.5 min more), number of ESI 2 patients seen during the interval (3 min more for each patient per hour), and ambulance activity (2 min more for each patient per hour brought by ambulance).
CONCLUSIONS
Day of time and week as well as frequency of patients with urgent conditions and those brought by ambulance significantly increased door-to-triage times. This should be kept in mind when organizing ED workflow.
Topics: Ambulances; Emergency Service, Hospital; Female; Humans; Prospective Studies; Tertiary Care Centers; Triage
PubMed: 35074290
DOI: 10.1016/j.auec.2022.01.001