It’s both. It can take a while to be triaged if you walk into the local emergency department. The ambulance can call ahead and the ED can prepare to admit you.
I’ve had three ambulance interactions where patient and/or hospital choice came into play:
- In 1988, I was hit by a semi while bicycling across the Cooper River in Charleston. I was pretty jacked up, but I was lucid. The ambulance crew asked me if I had a preference on where to go. I said no, but that they should be aware that I was in the Navy. Their response was “oh… well… Medical University of South Carolina is closer… and they have a trauma unit… yeah, that’s the ticket… (I could be misremembering the last bit)”. I don’t know whether they were worried about the distance, about not getting paid by the Navy, or about the abysmal patient survival record that Navy hospitals had in those days. Regardless, they presented me with a choice, but then took me to MUSC on their own judgement (where I received spectacular care BTW).
- In the mid-90s, I hit a crack in the pavement while biking in the north Chicago suburbs and smacked my head hard. Some folks who lived near the crash called an ambulance. The crew asked if I wanted to go to the hospital and I said no. Somebody called me a taxi and I went home and proceeded to puke my guts up with a concussion… it also turned out that I had a fractured radius. This led me to question the wisdom of letting the patient choose when they literally have bean damage.
- About seven years ago, my wife called an ambulance when I said I felt off and was going to look up symptoms on the internet (yes, she’s the smart one in the relationship). The ambulance came and had me in the back, in front of our house, while the paramedic negotiated with dispatch over whether to take me to the neighborhood hospital a half mile away or across town to the cardiac center (where she wanted to go). They ultimately approved the latter and they wheeled me in only a couple of minutes before I arrested the first time. The cardiac center was much better equipped to treat me, but the long delay in going anywhere was pretty disturbing, given how badly things went in such a short time.
Thanks for the example - especially the second one. That was part of my issue with the original poll and discussion. It stated that the party had suffered a serious injury, but would be fine if treated quickly. In general, although that’s not always the case, a serious injury -to me- implies some form of accident, whether it be a vehicular, or falling equipment/machinery/boxes, or something else.
In those sorts of cases, I personally always worry that the first response from the person injured (which could be me, my wife, or someone I’m responsible for) is going to focus on the obvious injuries which may be minor but visually dramatic and meanwhile miss something as or more serious that isn’t as obvious. I mean I’m sure there are enough examples IRL of such things to keep ambulance chasers in whiskey and beer, but it doesn’t come up as often in the news, or at least, not compared to clickbaity issues like leaving equipment inside of people.
In my wilderness first aid class, the instructor said that people with hypothermia often don’t realize how impaired they are, and will refuse aid because “I’m okay, i don’t need help”. He suggested following them so that if they lose consciousness you can render aid. (You can’t do anything to a conscious adult without their consent, but unconscious people are legally presumed to consent to emergency medical care.)
People with trauma can be quite lucid, though. A friend shattered her femur and refused pain killers because she knew she had important decisions to make.
Just because someone was in an accident doesn’t mean they’ve lost their ability to consent and make decisions about their care.
Did the crew ask if you’d hit your head, and advised you on the importance of being seen if you’ve had a concussion? I feel like that’s usually the first two questions medical professionals ask people with traumatic injuries, “did you hit your head? Did you lose consciousness?”
I honestly don’t remember. As I recall, they made pretty clear that I should go to the ER, but I had dinner guests coming over(!) (one of whom was an RN and royally pissed with me when she found out).
A guy I know (a real asshole) was speeding in heavy rain and rolled his car. He wasn’t seat-belted. Someone called 911. He regained consciousness in the ambulance just as it started moving.
He insisted that he was fine. The ambulance stopped and let him out. Police hadn’t arrived yet. He ran for a while to get away from the car and eventually made his way home. He had a broken arm, cuts and bruises, and a concussion. He reported his car stolen in the morning and eventually got someone to drive him to the hospital.
No repercussions whatsoever. I know what happened because he bragged about it to me.
I think they had to let him out if he insisted, otherwise it’s kidnapping. But they could have filed a report that they’d pulled him from the car. Lucky for him they didn’t bother.
I agree with this. Once you accept the help of an ambulance or EMT, you need to accept their process. I am not trained like they are, and if they think my injury is serious enough to be taken to an ER, then I need to be able to accept their decision. They may call more than one hospital to ensure there is available capacity, etc., but they should not at all be considering my insurance in their decision-making, same with the ER. Yeah, the system is messed up, but the ambulance/EMT job should be very narrow and constrained to just preserving/stabilizing life/limb and getting me to more stable/capable care, not futzing with thoughts about my insurance. If I cannot accept their process, I should not call for their help.
And not to take away the concern from the OP scenario, but if you were taken to an out of network hospital in an emergency situation, and your insurance made a fuss about coverage, I beleive you can appeal that and likely win, with documentation, on the grounds that the ambulance/EMT had to take you there to preserve life and/or limb (“I was not presented with a choice”).
I fear you are wrong.
I mean, this goes into “the US healthcare system is fucked up”, but i think you are wildly optimistic here.
I had a scan read by an out-of-network person when i was pregnant. At first i denied that the guy had treated me at all, since i hadn’t seen any men at any stage of the care for my pregnancy. But they explained that while he hadn’t done the scan, he had interpreted it.
The hospital messed up. It’s not as if i had any choice who they sent the scan to.
I ultimately got them to drop the charge, because i was prepared to fight over it, and it wasn’t all that much money, and it had actually been a mistake on their part. But my understanding was that legally they were in the right and i actually did owe them the money.
Actually, that might not be true any longer. Just last year, the “no surprises” act was passed, and i think it protects you from out-of-network costs in exactly this situation:
But i believe this story predates the bill.
Having a scan read by a back office staff is not at all like a life-threatening situation where time is critical, but I think the process is the same as what you had to do - you need to be prepared to fight your insurance if they try to screw you over. I beleive under the ACA insurance companies cannot charge you more for an ER visit to a non-network hospital. But, I agree the system can still be manipulated by insurance to cause consumers problems, even with the "No Surprises Act. I do not want to derail the thread here more by questioning the premise of the OP.
The real medical ethics issue here is that you HAVE to choose a different hospital in an emergency depending on your insurance or go bankrupt…
It wasn’t the insurance trying to screw me, fwiw. They were clear about what they’d cover, and the fault was on the part of the hospital for sending an out-of-network guy to read the scans. (My insurance had a similar name to insurance that would have paid for him.) Well, and also on the part of our crazy system that invites “networks” and wildly disparate pricing.
And the “process” was just being willing to be difficult enough that the hospital decided to write off the loss instead of fighting it. My guess is that the out-of-network reimbursement they could get was greater than what they would have gotten if they’d given it to a bill collector.
Anyway, I’m pretty sure that the woman in the hypothetical could have been right about one choice being financially crippling.
I totally agree.
Yes. And that changes everything.
IMO if we had a sane system, the ethical decisions would be “pick best care pronto”.
But given that we do not have a sane system in the USA the actual medical emergency decision-making process must incorporate that insanity and financial considerations just as much as the decision process in a rural environment differs from that in an urban environment due to the wildly different distances to, and features of, the hospital and clinic care immediately available.
To do otherwise is to close our eyes to one of the largest features of the decision landscape, and make decisions based on the remaining faulty subset.
But, in an emergency situation, I dont think you need to worry about choosing your in-network hospital - if you have insurance, they are supposed to cover emergency care at any ER you are taken to, under ACA rules AIUI. Now, if you need to be admitted to the hospital, that’s a different story, and you should be appraised of your options after you are stabilized. But if you have insurance, you are supposed to be covered for ER care.
And sadly, i suspect that even with the new 2022 law meant to protect you in this situation, it does matter, more often than not. And I’m glad my mom convinced the EMTs to take her to the hospital that cost her less.
I’m pretty sure emergency care is always in-network here in the United States. At least if you have insurance.
Didn’t used to be but is now by law. Provided your insurer decides your emergency was emergent enough.
Right. If you want a choice, you call a taxi or an uber. There are private ambulance services, so i guess you could use one of them. But then, is it really an emergency?
Also, my medical insurance covers me at a non- Kaiser ER. I think the co-pay might be a bit higher. Of course, I would be moved to a Kaiser facility as soon as it was safe…
Are we really sure that most medical insurances will not cover you at a non-covered facility, in the case of a true emergency?
In CA, that is the law-
https://www.dmhc.ca.gov/healthcareincalifornia/getthebestcare/emergencyandurgentcare.aspx
Health plans must cover emergency care, even if you do not go to a hospital in your plan’s network. Any emergency room must treat you until you are well enough to be moved to a hospital in your health plan’s network. Your plan must also cover emergency care when you travel outside of your plan’s service area.
Yeah, that’s what I thought.
The person afraid to call an ambulance has no way of knowing whether their insurance will consider that they had a true emergency. Maybe it really is only heartburn. Maybe that horrible abdominal pain will result only in being sent back home from the hospital with no diagnosis, or with a diagnosis of something that would have cleared up on its own.
And I wasn’t even thinking only of that issue. I was thinking also of people who don’t go to the doctor at all, let alone in an ambulance, despite worrying symptoms; and those who don’t take needed medications because of the cost.
And there are people who have no insurance.
The law, at least in California cited above, says that “it is an emergency if you reasonably believe that it is an emergency.” Has nothing to do with the actual diagnosis.