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Patient Care

Dollars and Sense

Joey, a family member with whom I wasn’t on speaking terms, had a bad GI bleed a few years ago. I’m pretty sure he hated trips to the doctor as much as I do. Fortunately, Joey knew nothing about his right to consent, so I half-dragged him to the car, told him to quit complaining, tossed him in the back and tied him to his seat. We were going to the hospital whether he liked it or not.


All you champions of the sick and helpless—chill; Joey was an eight-year-old Cavalier King Charles Spaniel. He was a good dog but a bad patient, which, on a very weird level, makes us comparable. Or so I’ve been told. More importantly, Joey is going to help me make a point about customer service.


How much for that doggy in the trauma bay?


I liked the way the veterinarian and her staff treated Joey. The receptionist asked if she could give our dog a snack, then quoted a minimum charge for office visits. Next the vet introduced herself and said she’d go over the rest of the costs after Joey’s exam. That was fine with me—much better than the price gouging that sometimes follows care of two-legged patients.


That trip to the vet made me wonder why we can’t do the same for our customers—not the part about giving them biscuits when they behave; I mean discussing pricing prehospitally. The antiquated attitude that dollars shouldn’t sway treatment decisions is unrealistic in this era of sky-high deductibles. If I were a stable patient, I’d want to know about costly interventions while I still had a chance to delay or dismiss them.


I think the Affordable Care Act makes consumers more aware of healthcare costs. Suddenly, there’s a marketplace where competition forces underwriters to detail prices and services. I’m not any happier with insurance premiums than I was before the ACA, but at least I know better what I’m getting for what I’m spending.


Looking at healthcare as just another service might help us understand the importance of pricing to our patients. I certainly wouldn’t commit to home repairs, for example, without knowing the cost. My willingness to incur those charges would depend on the degree of damage. I wouldn’t want a contractor to assume I’d pay for a new roof just because of a water stain. Even a big hole in the ceiling wouldn’t change my right as a homeowner to decide what work should be done.


It’s similar in EMS, where water stains could be blood and holes are, well, holes. As medical professionals, we’re supposed to get informed consent from alert patients before taking action, no matter how routine or necessary treatment seems to us. The consequences to healthcare providers of making decisions without patients’ involvement can be unsettling and, at worst, devastating.


Deal or no deal?


I’ve been indirectly involved in one lengthy lawsuit alleging transport without consent. I don’t know how it turned out—it was still going on when I left that agency—but I remember how the adversarial process haunted the defendants. I’m not sure how well I could do my job with that sort of judgment pending.


Should prices of medical procedures be part of consent? Perhaps. According to, informed consent is “assent to permit an occurrence…that is based on a complete disclosure of facts needed to make the decision intelligently.” I don’t know if that’s the best definition of informed consent, or even the correct legal one, but it’s a good starting point for discussion.


To me, making an intelligent decision about health care often involves an awareness of the dollars involved. I’m not saying cost is the most important factor—just another consideration, like difficulty, discomfort, complications, recovery time and probability of success.


Unlike most service providers, EMS agencies don’t usually set prices according to supply and demand, because patients don’t get to pick whose ambulance will respond to their 9-1-1 calls. Without competition, the biggest advantage to knowing prices up front is the opportunity to decline a particular intervention. Some would argue it’s dangerous to give non-medical people that much discretion, but I think it would be possible to associate prices with brief, dummied-down summaries of recommended services. With a little cooperation from our employers, accessing such details wouldn’t have to be any more complicated than looking up a medication on our smartphones.


My wife, an ex-EMT, agrees costs should be a bigger factor in healthcare decisions. Like me, Helen doesn’t understand why more patients don’t ask for prices. She also says the next time I’m sick, she’s calling the vet.


Mike Rubin is a paramedic in Nashville, Tennessee and a member of EMS World’s editorial advisory board. Contact him at



Submitted byyesineedmyhead… on 04/24/2019

Great article, however I think you missed a few key differences between EMS and the vet:

1) many people have health insurance, so the amount you bill likely isn't the amount they are going to pay; this is often not the case for pets (although I have seen pet health insurance advertised)

2) you can quote the transport costs (ie, what it cost to drive Joey to the facility), but you don't know what the facility will charge. So the ambulance ride might be billed at $1000, but then they have the ER bill, the ER physician bill, the radiologist bill, and that doesn't include what happens if they need surgery or get admitted. Or if the patient has several hospitals to chose from.

But cost is often not discussed in EMS; maybe it is time to change that

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