Dollars and Sense: Budgeting for Emergency Services

In the current environment of not only decreasing revenues but also, in most U.S. political jurisdictions, increasing costs, governments are looking for any way to prop up their budgets. However, although some agencies are working diligently to vilify public workers, others have directed their energies toward changing the revenue side of the equation. Currently, the only emergency service that routinely bills for its services is EMS (Emergency Medical Services).

Charging for services is a mixed blessing, though, because it often subjects the service to the rules of Medicaid/Medicare and other insurance providers. Moreover, most insurance programs are based on, among other things, an anachronistic view of EMS as solely a transportation provider. However, EMS can in fact bill, at different rates, for either a BLS (basic life support) or an ALS (advanced life support) trip to the hospital.

The problem here is that the patient must actually be transported in order to bill for services. Unfortunately, though, many non-transport calls are still high-cost calls – a cardiac arrest, to use one prominent example, is the most resource-intensive, single-patient incident encountered by EMS agencies throughout the entire nation. Unfortunately, many cardiac patients are not transported anywhere by an EMS vehicle because the paramedics eventually declared them dead on the scene. Moreover, even if EMS does transport the patient, only the unit that actually carries the body can bill for the response.

Partly for that reason, other emergency providers have been looking at the possibility of billing for their services. For many years, in fact, at least some agencies have been doing just that, but usually on a limited basis. For example, hazardous materials (hazmat) teams have billed for responses to chemical spills under various state laws. In addition, some fire departments, and some EMS agencies, have been billing for responses to alarms that turn out to have been false alarms deliberately set, or otherwise unfounded for one reason or another. Also, some rescue services in “extreme wilderness” areas – where many outdoor enthusiasts go for recreation – have billed victims for their rescues. The common thread here is that there is not only a certain degree of urgency involved but also at least some level of culpability on the part of the patient or organization being billed.

Cost Recovery vs. Ethical Concerns One of the main issues in developing a plan that permits government-related agencies – whether a municipal agency or a contracted private firm – to bill for their services is that the government is usually considered, by most taxpayers, to be providing services for the common good. One of the basic principles used in defining “common good,” though, is that the government is providing services that almost any citizen might need at one time or another, but that probably would not always be immediately available, on the common market, to any and all citizens. Primarily for that reason, some local governments have been drafting legislation that would allow them to charge for certain emergency responses under the budgetary heading of “cost recovery.”

Ethical risks are another factor that must be considered in allowing emergency providers to bill for their services. In the 19th century, most U.S. fire departments routinely charged for their response services, either after the event or under some type of “subscription service” – much more common in that era than today. Here, an interesting bit of historical trivia may be worth noting: The cast-iron fire marks that are currently sold as decorations originally indicated that the houses displaying them had paid for their subscription services and were therefore entitled to a response from the local fire department. However, houses not showing the fire marks – because the owners either did not or could not pay – were allowed to burn to the ground.

Today, though, very few if any public officials and/or EMS planners would seriously consider refusing to respond to an emergency simply for lack of payment. Nonetheless, there is still an understandable temptation to prioritize responses – and, therefore, resource allocations – because of financial considerations. Further complicating this situation is that paying for the actual costs of a response to a house fire or similar incident could completely bankrupt a private citizen (or, for that matter, a relatively small private business). 

Perhaps the most important point to remember from the preceding discussion, though, is that – until and unless common homeowner’s insurance pays for the cost of an emergency response – any plan that shifts the cost from the community to the individual must be viewed very, very carefully, with particular focus on what might be considered the “culpability” factor. There may in fact be no 100 percent perfect solution to what in many communities is an extremely difficult problem, but that does not mean there is no room for at least a reasonable common-sense compromise.


For additional information on the use of Fire Insurance Marks, click on:

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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