Nobody Wins: Are We Responsible for Our Patients` Medical Bills?

EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don’t have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we’ll pay you $50. We don’t know everything, but we do know a lot of smart people. If we need to, we’ll contact just the right experts and share their advice with you. Send ideas c/o emseditor@aol.com.

You’ve been a paramedic for years, but you’re still a little surprised when you pull up to the scene of a seemingly garden-variety MVA. What’s left of a gold-colored Nissan Altima is splayed all over the pavement, looking like somebody dropped it out of an airplane. Its sole occupant is a 21-year-old woman who drifted into the opposing lane of a narrow country road and hit a Jeep Cherokee head-on at about 35 mph. Both of her airbags deployed, but neither driver seems to be much the worse for wear except for multiple bruises. The driver of the Nissan does not recall the incident. She says she’s had fainting spells in the past, and she’s complaining of pain in the middle of her chest.

When you propose transporting her, she clearly doesn’t want to go. But in your smoothest style, you talk her into it. She tells you she doesn’t have health insurance and can’t afford a hospital bill. You reply that most people’s auto insurance will cover the medical expenses related to an auto accident, and that seems to satisfy her. There is no further discussion of costs. It doesn’t seem like a big deal, and within a few days you forget the call entirely.

Three weeks later, you’re in your boss’ office trying to remember what you said to the lady in the Nissan. Her mother has complained angrily to your boss that you lied to her daughter and coerced her into accepting transport. The auto insurance won’t cover any of the medical bills, and now your patient is saddled with $3,000 in debt. The mother cites the fact that the hospital ran a lot of expensive tests based on your testimony about the mechanism for injury, but the tests did not show anything. She says that her daughter’s credit is ruined, and she blames you.

Q. What were you supposed to do, anyhow?

A. According to numerous sources, as many as 45 million people in the United States are without health insurance. That number has increased radically since 1999, when the National Law Center on Homelessness and Poverty cited 30 million. Even then, EMSers grappled with some tough questions about when it becomes necessary to suggest, strongly suggest or even coerce some patients into accepting transport. Never doubt that most people expect you to advocate for them when they cannot make their own decisions.

Q. But has the notion of advocacy changed? Are you a good advocate when a patient incurs an unnecessary hospital bill as a result of your advice?

A. Good medicine does not always produce good outcomes. If it did, nobody would ever die. And good medical outcomes do not always come cheap. Remember, your accuser would have had a much worse complaint if you had simply ignored her daughter’s mechanism and blown off a closed head injury or an aortic tear.

Q. So, is this issue becoming uglier?

A. Ask a few people who handle EMS complaints, and they’ll say absolutely, yes. In fact, ugly is a good word, because that describes the moods of complainants very accurately. People are angry. They’re confronting us with terms like “unethical,” “deceptive” and “dishonest.”

Q. How are we supposed to get people to the hospital when they clearly need to go, especially when they are not mentating normally?

A. Try the following tips that are safe for patients, yet sensitive to their financial concerns, and remember what you learned about triage: Do the most good for the most patients.

• Avoid advising people about their insurance coverage. Health insurance is extremely complex. You’re not qualified to interpret it.
• Never lie or exaggerate, even in the best interest of a patient. You may get away with this sometimes, but you will be unable to defend yourself if you get caught.
• When forced to choose, prioritize safety first and financial impact second. As a caregiver, you have no other option.
• If you’re convinced a patient needs to go and the patient absolutely refuses, enlist the support of family members. This doesn’t always work, but it’s worth a try.
• If family members are absent, or if family members do not support your intentions, get the patient to talk to an ED physician. One backup benefit: A doc’s support can be powerful if things go south.
• Know your local refusal protocols thoroughly, and invoke them when necessary (with the aid of the police department, if possible).