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No matter how bad 'ambulance billing' is, things could be worse ...

Original post made by Jay Thorwaldson on Feb 2, 2009

The billing operations of the Palo Alto Fire Department's life-saving paramedics program need emergency care.

That's what city officials and the public learned this week with the release of a special City Auditor's report on billing irregularities that may have cost the city tens of thousands of dollars -- perhaps several hundred thousand -- in recent years.

This report caught my personal attention for several reasons. One was a general interest in city flaws that cost money that could be better spent on services and projects of real value rather than being wasted.

Another reason is from the past: The paramedics program was created as a result of a five-part series of investigative articles I wrote for the erstwhile Palo Alto Times many years ago, in 1971, in fact.

Those articles resulted in the creation of the paramedics program, after the late Joe Carleton took up the cause and lobbied the City Council and city officials. The articles outlined serious, sometimes life-threatening shortcomings of the private ambulance services locally and statewide.

These were not just billing problems -- they were problems with inadequate (if any) training, ambulance crews not knowing streets, how patients were handled in cases of serious illness or accidents, and cut-throat competition between firms.

So no matter how serious the current billing problems are -- and they seem quite serious, as outlined in Staff Writer Gennady Sheyner's coverage this week -- things could be worse. Thus far, no allegations or reports have surfaced about problems with patient care emanating from the life-saving service, which next year will be observing its 40th anniversary.

At the time of the series, one medical official estimated that proper training and operation of an emergency-response service could save at least eight lives a year in Palo Alto. Let's see, 8 x 40. Ö

The core problem at the time was that state law required ambulance crews to get First Aid training within a few months of getting a job with an ambulance firm, as I recall. But because most employees of ambulance firms -- who often had to put in 90-hour shifts -- were young and single, the pattern was that an attendant would quit one company just shy of the required time and get a job at another.

This created a life-and-death "musical chairs" pattern of virtually untrained crew members never getting trained, unless they were lucky enough to land on a crew with a more experienced member who knew something.

The result was that some patients were permanently paralyzed or more seriously injured by being handled ineptly, while others simply died in transit from heart attacks or other acute illnesses.

The high rotational turnover also left ambulance crews with no one who knew the local streets.

A colleague of mine at the Times was thrown from her horse along Alpine Road when it shied at some construction work for the new I-280 freeway. She suffered a broken hip. When the ambulance headed back toward Stanford Hospital, the driver turned right at Alpine and Junipero Serra Boulevard. My friend, in pain but looking out a side window, had to tell them they were going the wrong way and that they needed to jog left and right to get onto Sand Hill Road to get to the hospital. Oh. OK.

A fire official recounted how firemen were dropped off at corners of tricky subdivisions -- such as the Greenmeadow or Barron Park neighborhoods -- to wave the ambulance crew in the right direction. Just follow the string of firefighters.

Then there was the cut-throat competition.

I first heard about companies racing each other to pick up patients to get the lucrative transport fees, then confirmed with multiple sources.

In one instance in East Palo Alto, an officially dispatched ambulance crew from San Mateo County arrived at the address of a heart-attack victim to find him being wheeled out of the house on a gurney by a Palo Alto-based company. When the newcomers protested, a Palo Alto crew member responded by pointing out that the patient was on their gurney.

Well, yeah, the late arriver said, holding aloft a set of keys to the Palo Alto ambulance, which he then tossed into a bush and claimed the patient while the Palo Alto crew scrabbled to find their keys.

I confirmed this incident with a crew member of one of the ambulances as well as with other medical people.

I got a kick five years later when the film, "Mother, Jugs and Speed," came out and included a scene at a golf course where one crew tosses the other crew's keys into the rough and claims the patient. It was the one really funny part of a mostly crummy film that even its star-power stars Bill Cosby, Raquel Welch and Harvey Keitel couldn't resuscitate.

Critic Vincent Canby of the New York Times rightly described it thus: "'Mother, Jugs and Speed' is a rip-off of vulgarity, poor taste and shock, which, like guns, should be kept away from film makers who don't know how to use them. Ö"

But I've always wondered where they got the idea for the tossing of the ambulance keys into a bush.

Comments (14)

Posted by Art Kraemer, a resident of Crescent Park
on Feb 3, 2009 at 1:13 pm

If the city pays for the paramedics, why are citizens billed when their services are used? Should we be we billed if the fire department puts out a fire? Are we to be billed if we call the police to catch an intruder in our residence? Lastly, why do we hire an outside company to prepare the bills? They probably cost more than keeping the paramedics trained. Can't our large city staff handle this?
This whole area need an in-depthlook.


Posted by Kate, a resident of Downtown North
on Feb 3, 2009 at 5:26 pm

Two years ago my husband was taken from the Palo Alto Clinic Urgent Care to the Stanford ER - a distance of sixth-tenths of a mile. He did have oxygen and already had an IV in which the paramedic decided to re-do. Cost $800.00 for this trip which took less than five minutes. . Palo Alto transport 'accepts assignment' which means it can charge Medicare patients ONLY according to the Medicare payment schedule which was about $400 then. We had to pay 20%. I shudder to think what those not on Medicare have to pay. And of course, the homeless don't and can't pay anything. There is a suggestion at City Hall to increase these fees - which would especially hurt the elderly who comprise the majority of the transports.


Posted by Anonymous, a resident of Another Palo Alto neighborhood
on Feb 4, 2009 at 8:29 am

Jay,

Good piece, but perhaps you can send Gennady to report whether non-City ambulances still have the problems you found in 1971. Have the standards and rules changed? Palo Alto is the only city in Santa Clara County to opt out of the county system. Do other cities and towns have problems with the county system?

The Merc reported a couple years ago that Santa Clara and San Jose's city ambulances have been a flop.

Web Link


Posted by EMT, a resident of another community
on Feb 4, 2009 at 8:59 pm

Kate, you need to keep in mind that you're not just paying for the cost of your transport- you're paying for the cost of the SYSTEM necessary to provide it to you.

Of course, as with anything else, the ambulance service can charge anything it wants- they are completely at the mercy of medicare and other insurance providers choose to pay, which don't even cover the cost of the transport in most cases. Nevermind the system behind the transport. And then there's the homeless that you mention, and other people with no insurance and no intention of paying....


Posted by Outside Observer, a resident of another community
on Feb 4, 2009 at 10:53 pm

One of the little known perks for City employees is free paramedic transport, should they ever need it in the area served by Palo Alto.

Art Kraemer has got it right. Why should Palo Alto residents be charged for this, when they already pay with their taxes. Especially at the same time City employees, who are not Palo Alto tax payers, pay nothing.


Posted by Jake, a resident of another community
on Feb 5, 2009 at 4:33 pm

Again one needs to look at City Hall and the City Managers Ofiice.
When the PAFD started paramedic service they were not even handling 1500 emergency calls a year with one ambulance. Now the PAFD is handling near 8,000 emergency calls a year, with a whopping 1.5 ambulances. A whole .5 increase in ambulance numbers. It's only .5 because the City Manager and City Council think taking the Fire Pumper at Station 1 in busy, dense downtown PA and its 3 members and putting them on a ambulance at night is a good idea.
This means many nights there is nobody at Fire Station One. It's vacant! The Fire Pumper crew could be as far away as San Jose on the ambulance!
The residents and store owners in downtown Palo Alto have no idea that Fire Hall is empty many nights for hours. If you have a fire or medical need you will be waiting for another PA resource or one from Menlo Park (if they are able). Down town Palo Alto is at a major risk! The City Council and City Manager are gambling to save money and increase revenue on public safety!
A healthy needed program needs attention and money, not slum lord tactics. Taking every cent and not supporting a need is doomed to failure.


Posted by Member, a resident of Crescent Park
on Feb 5, 2009 at 9:57 pm

No matter who transports, there is a bill. PAFD charges less than the back up company AMR (American Medical Response).

Before AMR, there was no such thing as consistent quality EMS service which is why Palo Alto Fire went into the Paramedic business back in the 1970's. Because Palo Alto has it's own Fire Department Paramedic's, it's quality control, level of competency, and longevity exceeds private enterprise.

If anything, we should be concerned about inadequate ambulance coverage at night because the downtown fire engine is routinely out of service for hours at a time as it becomes the "back up" ambulance for the entire city. The the second ambulance shuts down at 8pm!


Posted by member, a resident of Downtown North
on Feb 5, 2009 at 10:19 pm

I've heard the same. I've also heard that when the downtown fire engine responds as an ambulance, the next closest fire station sends a fire engine. I think it means that if during that time there was a fire downtown the first two fire engines are not available?


Posted by fireman, a resident of another community
on Feb 6, 2009 at 8:43 am

Memeber. It was edited out.

2 calls and the fouth due engine is responding into downtown.


Posted by anonymous, a resident of Another Palo Alto neighborhood
on Feb 9, 2009 at 8:37 pm

Outside-
Seriously.... how many City employees do you think are transported per year? Can't be many as very few live in town. The few City employees that are transported are usually taken to the ER because of getting hurt on the job... certainly a justifiable use of City equipment and employees.


Posted by resident, a resident of Green Acres
on Feb 12, 2009 at 1:54 pm

Jay, what about the utilities billing? This is something that affects every single resident. It's strange that although natural gas prices are lower now than they were 2 years ago in 2007 the city keeps charging 2008 peak bubble prices. Could you please investigate this?

I've never ridden in an ambulance in my life...knock on wood.


Posted by Resident, a resident of South of Midtown
on Mar 11, 2009 at 7:26 pm

My partner had a TIA just last week and was taken to the Veteran's Hospital. Thank goodness he was OK but we joked afterwards that he'd taken the most expensive ride up Arastradero Road he's ever likely to take!!

I don't know how someone got a a ride for $800, that was cheap by today's prices. In fact you really have to make sure you've got a legitimate emergency to call the paramedics, and that you can pay the bill afterwards. I wonder how many non-emergency calls they get and who pays?




Posted by davey d, a resident of Midtown
on Mar 17, 2009 at 10:42 am

why don't you guys report on the fact that you have layed off 20 percent of your workforce over the past couple months?

i find this highly interesting


Posted by Alphonso, a resident of Stanford
on Apr 1, 2009 at 4:43 pm

"Art Kraemer has got it right. Why should Palo Alto residents be charged for this, when they already pay with their taxes."

No he didn't!

The concept is pretty simple - to hold down the cost of Fire the ambulance service is more or less self funded. If all of the services were free residents would have to pay higher taxes.

The users pay for the service. In most cases that means the service is covered by insurance companies. The service charges are less than a regular (AMR) ambulance would charge. An important thing to remember is you do not have to take the ambulance - it becomes a very expensive taxi ride in non-emergency situations. Also remember insurance companies may not cover an ambulance ride if you can not demonstrate an emergency situation.


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