Confusion and Disconnects in Medicine

David Langham

If we are involved in an accident, we each would want the best care possible, delivered as expeditiously as possible. There will be instances in which we will make medical care decisions for ourselves and other situations in which decisions will be made for us. It is circumstance when our decision making may not follow our personal routine.

In our day-to-day, we make decisions about consumption based upon our available resources and the price of goods and services. We act, generally, in our own best interest in those decisions (you tend to buy the car you want or like, not thinking of whether fellow Americans were employed building it). Though we are likewise consumers of medical care, there will be decisions that we will not make. One of the great challenges in our medical care system seems to be that the person needing the care (you) has become too detached from the decision making.

For example, you may purchase health insurance, or you may decline. You decide whether that product provides you value in exchange for your money. A great many do not perceive value, and thus elect not to purchase; as a result, they may later find themselves with medical bills they will not pay, and that cost is passed to the rest of society. Those who do purchase insurance may cede some or all of their choices in medical care to that insurance company. It may dictate the physician choices, testing, and care provided.

A second example is incapacity. We may, through event or disease, lack the capacity to make medical decisions. In those instances, firefighters, paramedics, doctors, and nurses may make decisions for us. In doing so, they will likely focus entirely upon the goal of alleviating our medical symptoms, and pay little or no attention to cost. Thus through contract for insurance or through circumstance, we consumers may be detached from the decisions that are normal for us in other circumstances.

An example that has been in the news recently is medical transportation. When an accident occurs, there has developed a tendency to “encourage” care. I recently heard an acquaintance recount the aftermath of a vehicle accident. The collision reportedly occurred after being stopped at a light. Neither car exhibited any damage (no scrapes, dents, scratches). However, a passing driver perceived stopped traffic and summoned authorities. When they arrived, the two drivers had exchanged insurance information and were about to depart, having concluded there was nothing to this event.

However, responding police and ambulance personnel questioned both drivers. Photographs were taken and a report generated. And, before the conversations were over my acquaintance had signed a document written in tiny print, “knowingly” waiving medical care or attention. Before signing, the ambulance crew had reportedly reminded my acquaintance repeatedly that both an ambulance ride and emergency room services would be “free.” The other driver, moments before ready to depart and forget this non-event, was instead talked into being transported to the emergency room by the ambulance crew.

At this point in recounting the story, a medical provider in the group noted that it was likely best to get a medical evaluation despite perceptions regarding lack of injury. Another in the conversation decried the crew’s repeated persuasion as unnecessary and inappropriate “pressure.” A lawyer then interjected that the crew was merely following instructions and such entreaties and forms were likely ambulance company policy. Yet another noted the company had likely been sued at some point after an accident victim learned later that injuries were more serious than perceived. Another noted that ambulances and fuel cost money, and the company only gets paid if it takes someone to the hospital. It was a lively conversation in which various perspectives, conjectures, and conclusions were voiced.

That conversation and the various perspectives came back to me when I recently read of developments in the debate of air ambulance services.

Consumer Reports article in 2017 described a Florida family, their daughter injured at home. Responding paramedics recommended an air ambulance helicopter. Over doubts of necessity, the parent was “a mom first,” and “didn’t question the decision.” Four years later, the mom struggles with a remaining invoice balance of almost $20,000. The air ambulance was not in her insurance network, and so the transport was not fully covered.

Consumer Reports says that the average air ambulance bill is $30,000. It explains that deregulation of the airline industry in the 1970s rendered states unable to regulate the cost of such services. Those law changes, though perhaps never intended to address a topic like air ambulance service, preclude states nonetheless. Regulation aimed at airlines and consumer travel constrains state regulation of air ambulance cost.

And, that regulation preclusion goes for workers’ compensation as well. Thus, there is a service in the marketplace which can (1) charge whatever it wishes, and (2) can leverage fear and uncertainty to book customers (who may or may not even be conscious). If we accept that everyone acts at all times with the highest morals and never in a self-interested manner, then perhaps that is appropriate. If we fear that human nature may pressure us differently than the highest morals suggest, then perhaps it is not.

Air ambulance services are becoming increasingly available. Consumer Reports says that the number of U.S. air ambulance providers has doubled since 2000. The industry growth is attributable to companies that offer such services for profit. Charges over $50,000 for a transport are not unheard of, whether the customer has insurance or assets, or is utterly unprepared to pay such amounts.

A trade group spokesperson quoted in the Consumer Reports article explained that companies have contracted to provide services through Medicare or Medicaid, which “pay $200 to $6,000 per transport.” Thus, companies lose money on those transports and “must collect more from people with private insurance to make up the difference.” Thus, like so much else in America, there is a socialistic process being applied by the government. Those who qualify for Medicare or Medicaid have their cost controlled by government and the rest of the consuming population is then billed more to subsidize their use of services. Socialism is a model that has attracted many acolytes over the years, but which has failed repeatedly. If everyone were “insured” by the government, and all fees were thus capped, would there be any air ambulances at all?

Despite socialism’s flaws, America long ago decided that medicine would be socialized here. There are those who support the next step in that process. They advocate that medical care is a human right and that everyone is fully entitled to a full measure of care regardless of their ability to pay, personally or through insurance. They advocate “single payer,” and wax eloquent about their high personal morals and Utopianist ideals. But, single payer has been tried, see Single Payer Lessons from Vermont. Colorado voters recently rejected single payer. The economics of socialism simply do not work, on the limited scale of single payer or the macro-scale of a country. Despite the analysis of the ambulance drivers discussed above, there is no “free” ride to the hospital nor “free” care. Everything costs, the only distinction is in who pays.

To that end, government has tried the experiment of mandating insurance coverage in the commercial market. The Obamacare plan required everyone to have health insurance, and used the federal tax enforcement of the Internal Revenue Service to make sure that they all did. The “individual mandate” was to assure that everyone paid their share. But, it somehow escaped analysis that there are Americans who do not pay taxes and do not file income tax returns. The selected enforcement vehicle did not provide uniform enforcement.

And, Obamacare neither resulted in universal coverage, nor even approached it. Years into mandatory coverage, there remained large populations of uninsured Americans when we were all finally relieved of the mandate. And, many of those who eschewed coverage all along paid no penalty, made no contribution. But, those who did have coverage almost universally received less and paid more. People who do not want insurance, it seems, will not buy it even when the cost is subsidized. The Obamacare process did not “fix” healthcare, and in the process many lost choices, lost their preferred doctor, lost their preferred insurance, and paid more. Despite this, there remain Obamacare fans even today.

When we require goods or services, we make economic decisions. If price were no object, undoubtedly we would all live in beach front mansions and drive Maseratis. We would dine on champagne and caviar, vacation on the French riviera, and our lives would be “perfect.” But, certainly that is fallacious. Everyone cannot have everything. There is not enough beach front available. Scarcity determines pricing in a capitalist market. Understand that power similarly determines access in socialistic or communistic markets. There will be always be economic choices. In capitalism consumers make them while in other systems they are made for us.

The complications that arise with medicine are difficult. First, there is a planning disconnect. Second, there is a payment disconnect. We are often called upon to make medical decisions on the spur of the moment, without planning. We may lack time for reflection and contemplation, or to consider the relative value of alternatives. And, we often have health insurance, thus the cost of services may not concern us as long as our own deductible or co-pay is affordable. Both of these disconnects may influence our decisions.

Furthermore, when we make medical choices, they are often very important or even life-critical. Our mental state at those moments may be stressed; we may have just been in an accident, received a scary diagnosis, or witnessed an injury to a loved one. Even in the best of circumstances, the most informed and careful among us may not make the most logical decisions at certain moments in our lives.

After an accident, air ambulances are offered as an alternative. A responding official, police, fire, paramedic, is offering or even recommending that service. The consumer involved (patient or family member) may be stressed, emotional or even distraught. And, there is no one among us, with a loved one in need, that does not want them to have the best and most rapid care. We will frankly be inclined to accept that recommendation, accept the air ambulance. But, should the price be disclosed? Should the price of that service should be consistent for everyone? Should they tell us if our insurance will not cover it?

The other side of the equation likewise bears consideration. Helicopters are expensive. Flight crews, paramedics, medical supplies, fuel, and maintenance all cost money. The air ambulance helicopter does not fly a schedule, and cannot be easy to budget and plan. In effect, the company’s assets and employees sit idle much of the day awaiting the chance to deploy and provide service in an urgency. In reality, we all hope they sit and wait most or all of the time; their idleness means people in the community are well and safe and do not require help.

But, as the crews and equipment wait, they are nonetheless paid. Therefore, when they are dispatched, the cost of the service will undoubtedly be expensive; more expensive than an ambulance, which in turn is similarly more expensive than taking a cab, which in turn is more than driving yourself or a neighbor to the hospital.

In a similar setting, Fox News recently reported on a family that took an infant to the emergency room after a fall from a bed. The child never lost consciousness, but was upset. The parents sought medical care from “an abundance of caution.” The hospital personnel provided a bottle of formula and the child took a brief nap. The family later received a bill for $18,836. The family was shocked. They object to the bill in light of their perception of the value of services they obtained (exam, bottle, bed).

However, this story illustrates the value that lay not in what the hospital delivered, but in what it was prepared and staffed to deliver. It is a “trauma center” and is prepared for “car accidents, mass shootings, multiple vehicle collisions” (seems a lot like simply “car accidents”), according to a hospital spokesperson. The point seemingly being that having that equipment, talent, etc. is expensive and everyone must share the cost, regardless of whether they utilize or need the services that the facility and personnel are prepared to provide. The conclusion is everyone must share, that is the definition of socialism.

Our society recognizes the value of the air ambulance. These obviously save lives. So too do ambulances save lives, as do police officers, paramedics, and fire fighters. But, the cost of many of those services, are social costs, and they have been socialized in America. Those who pay no taxes are nonetheless entitled to the protection of the police who are paid by taxes. Through that socialistic approach protection is afforded for us each. They patrol our streets, put out our fire, respond to our fall, usually without cost to us.

But, that social coverage is not always what we personally desire. We would each feel safer if we had a bodyguard assigned to us individually. But, the police do not provide that level of personal attention. There are few of them, many of us, and we each get our allotted social measure of protection, whether we contribute to the cost of it or not.

If we want more (personal bodyguard), we may obtain that at our own cost. Should the socialist analysis be applied and taxes raised to support what we each want (bodyguard) instead of what we have (police)? Our lives are protected by police and firefighters, but collectively, not individually. Because it is collective, socialist, it comes in equal measure to us all. It does not necessarily provide what we want, but what society has decided to fund. There is a persistent American disagreement between those who want to pay less for government and those who want to consume more from government. It is the friction point between socialism and capitalism.

As a society we seem unable to accept compromise in our healthcare. In healthcare, the Utopianists seek the best and the most medical care for all, regardless of their ability or willingness to pay. In healthcare, provision of some publicly-funded care (similar to some police protection) is seen by some as inhumane. They ignore the stresses on the system, and the delays in care that would invariably result, if everyone were provided everything. Alternatively, there are those who decry liability for the “good of all,” and believe that those who need or want services or goods should pay for them. And, in the midst of these two competing mindsets, we have the confusion and disconnects of our current American medical system.

The examples of air ambulance and the trauma center are revealing. The fastest, most direct, and most efficacious is what we all want for ourselves or loved ones. The cost of that is very high, and likely somewhat justifiably so as a nature of its very business model, just like the trauma center hospital. Through our use of such services, in emotionally challenging circumstances (or because we are not capable of making decisions and a helicopter is summoned for us based on the paramedic’s judgment), we may incur incredible expense, that could follow us for years.

In the end, the system and processes that we have are the result of legislative compromise. Over the years, the advocates of “pay nothing” and “pay everything” have been forced to various compromises. In various legislative and regulatory constructs, there are potentials for exploiting loopholes. Some see the deregulation act as such a loophole and decry the air ambulance company charging as they do. Others see value in the air ambulance and implicitly trust in them to make honorable decisions about necessity.

A great many believe that the system and process that we live within, the result of compromise, is flawed and antiquated. They advocate for change. But, they advocate most often from the same polar positions described above, their own personal positions. They advocate that more taxes and more “free” care will solve the dilemma or that less government involvement will. Each ignores some modicum of the reality, and their solutions seem to focus mostly on who can scream the loudest.

As yet, the screaming has not solved the complaints regarding air ambulance services. As yet, there seems no real solution at all. For now, we are locked in an ideological dispute. In all likelihood, that debate will eventually be stalled with another compromise. Whatever it is will change our consumption, expectations, or both. That compromise will enhance care for some, impair care for others. And, unfortunately, history suggests that regardless it will increase costs. Seemingly every solution in our history has increased cost.


David Langham is the Florida Deputy Chief Judge of Compensation Claims. He blogs weekly regarding system issues, regulations and decisions. He has published many articles and delivered more than 1,000 professional speeches.