Making Them Pay? Patient Ability to Pay and Care Disparities in Emergency Medical Services

We investigate how patient ability to pay through insurance influences the equity of care given by Emergency Medical Service (EMS) crews following 9-1-1 calls. EMS agencies are often underfunded and rely on self-generated revenues to carry out their health mission. Revenues depend on insurance reimbursement rates that typically decrease in the following order: private insurance, Medicare, and Medicaid. Reimbursement rate differences provide strong organizational-level incentives to treat patients differently based on ability to pay, but it is unclear if such differences might impact individual-level behaviors in the absence of direct incentives. Using data from 31 states reported to the US National Emergency Medical Services Information System, we find that both private insurance and Medicare patients receive more procedures (4.6% and 1.5%) and have longer transport times (5.1% and 3.9%) than Medicaid patients. These differences reduce with call urgency but increase on busy days. Differences manifest across all agency types but particularly in larger agencies and agencies with fewer private insurance calls in the recent past. While EMS crews do not benefit directly from patient payments, our results suggest they do respond to indirect organization-level incentives when making care decisions.