(New York) - One man last year called Rural/Metro Medical Services, the region's busiest ambulance company, 313 times for a ride to a hospital. Two other people used the company's ambulances more than 180 times. Still others received rides once or more a week.
Emergency medical technicians refer to these patients as "frequent fliers," people who frequently request ambulance service simply because they can.
In many cases, the calls for an ambulance warrant an emergency response.
But some constitute abuse hospital trips for backaches, sore throats, a prescription refill, alcohol detoxification, minor bumps and bruises, or just the possibility of a hot meal.
The misuse of ambulances and 911 is a long-established problem with serious consequences.
Patients with minor ailments or other problems that don't require an ambulance limit the availability of ambulances for patients with life-threatening crises and exacerbate the strain on already crowded emergency rooms.
They also contribute to rising health costs and expose ambulance crews and the public to risks as emergency vehicles race through traffic.
More than 40 percent of the visits to emergency rooms in Western New York in 2008, whether by ambulance or other means of transportation, could be considered unnecessary, according to a recent report by Univera Healthcare.
Ambulances operate with a "you call, we haul," approach. But the misuse breeds cynicism. Emergency medical technicians don't want to waste time responding to people who use them as a taxi at 3 a.m. for a toothache.
"The entire system is broken. From the abusers to the emergency room and everyone in between," an EMT complained on a Buffalo-area Internet forum on the issue.
But like so much in health care, the problem of inappropriate ambulance use is complicated and its solution elusive.
Who wants to take legal responsibility for deciding which calls deserve an ambulance?
What do you tell callers who need assistance with a serious but not life-threatening medical or social issue that doesn't require a trip to a hospital?
The problem also reflects the success of 911, experts say. For decades, Americans have been trained since childhood to dial that number if they ever need help and they have been doing so in increasing numbers.
"The misuse of ambulances speaks to our health system. If we had a place as user-friendly as an emergency room, people would likely use it. The fix is to have more primary care and a better way to get to it," said Dr. Anthony Billittier IV, health commissioner in Erie County and medical director for the dozens of ambulance and fire services in Western New York.
Historically, patients with newly arising health problems first went to their general practitioners. No more.
Today, patients bypass their doctor more than half the time when they have an acute problem and, instead, go directly to emergency rooms or specialists, according to a recent study in the journal Health Affairs.
The new federal health reform law provides major funding to boost primary care, including $11 billion to expand community health centers and projects to promote collaborative, team-based approaches to care. But it will take years to see the results of those investments.
How much ambulance misuse exists is difficult to estimate.
Rural/Metro -- a commercial ambulance service that contracts to cover the cities of Buffalo and Niagara Falls, as well as Cheektowaga, Hamburg, East Aurora, Springville and Evans responded to 96,930 calls for an ambulance in 2009. Of those, 71,633 came through 911.
The company doesn't distinguish inappropriate calls, but it gave The News a list of 10 unidentified patients who used ambulances the most, including some of which are elderly residents transferred regularly from nursing homes to hospitals.
In 1996, Billittier and colleagues studied unnecessary ambulance use and found that, in many cases, patients said they didn't have any other way to get to the hospital. The patients who misused ambulances they tended to be poor, young adults and on Medicaid, the health program for the poor also significantly underestimated how much an ambulance ride cost.
"Whether it's abuse sort of depends on whose eyes you view this through," Billittier said.
Ambulance officials described frequent fliers as primarily a mix of poor individuals who lack adequate transportation, substance abusers, individuals who live alone, people experiencing a crisis in their lives, such as a mental health problem, and others who mistakenly view an ambulance ride as an entitlement or a way to cut in line at the hospital.
"It's a small group of people caught in a revolving door of crisis services. They are people who fall through the cracks of society," said Scott Karaszewski, Buffalo area manager at Rural/Metro.
"Others feel it's their right to call an ambulance," said Steven Pollard, communications manager.
911 abuse 'pretty low'
To make matters more complicated, the emergency medical system is not as coordinated as might be expected. It was built in an unplanned way over many years by dozens of commercial and volunteer organizations that often have competing interests, including volunteer and for-profit ambulance services, fire companies, hospitals and government agencies.
Rural/Metro does not dispatch ambulances. That job is handled by Ambulance Dispatch and Inspection, an arm of Erie County Emergency Services.
Nor does an ambulance crew diagnose patients in the field. EMTs are trained to treat every call seriously, Pollard said.
The legal and ethical dilemma for EMTs is that someone who fell isn't necessarily drunk, for instance, and a toothache is usually just a toothache, but also may signal a heart attack.
The National Fire Protection Association, which collects statistics on 911 calls to fire departments, recorded 17.1 million calls in 2009, up from 5 million in 1980. About 20 percent represent non-life-threatening situations, according to Dr. Jeff Clawson, medical director of the National Academies of Emergency Dispatch, the organization that sets standards for medical dispatch.
Of those non-life-threatening situations, about seven in 10 are emergencies that generally need an ambulance with basic support and not one staffed with more highly trained paramedics, he said. The remaining are calls that don't need emergency response and transport.
Misuse has increased, but its share of the total 911 calls has remained largely the same, meaning people are not abusing the system more today than they did in the past, said Clawson, who developed the dispatch protocols used throughout the world.
"The amount of intentional abuse of 911 is actually pretty low," he said.
The cost of inappropriate ambulance use plays a part in the debate over what to do about it.
At Rural/Metro, an advanced life-support ambulance costs private insurers $800 to $1,000 per ride, and $500 to $600 for basic life-support services, according to Jay Smith, spokesman for the Buffalo office.
For patients on Medicare, the government health program for those 65 and older, the company receives about $395 for advanced life-support calls and $333 for basic life support.
Education not effective
Rates for Medicaid patients vary by county. In Erie, Rural/Metro receives about $187 plus $2.50 per mile for advanced life support and $139 plus $2.50 per mile for basic life support. If a Medicaid recipient used a basic life support vehicle 313 times in a year, that cost taxpayers about $43,500.
Experts struggle for answers.
Education campaigns don't seem to work, according to Clawson.
In the early 1980s, Detroit allocated $3.5 million for public advertising in hopes of reducing unnecessary 911 calls that were burdening the emergency system, he said. The result: Calls increased nearly 6 percent.
"An emergency is in the eye of the beholder," he said. "We've taught the public that you call 911 for help. We didn't tell them what an emergency is because you really can't define it."
He also said the Sept. 11 attacks redirected the country's attention away from the need to fortify primary care in the United States and made it seem un-American not to send an ambulance to every call.
In the best of all worlds, Clawson said, communities would stop dispatching ambulances in knee jerk fashion and direct callers that don't require ambulances to more appropriate services, such as urgent-care centers, clinics, doctors' offices and social agencies.
A handful of cities are studying or have adopted such measures. Richmond, Va., gets mentioned as the national role model, but its experience offers faint hope.
In 2006, the city began a program in which specialized computer software, similar to what's used in England, assists 911 workers to determine if a call is higher or lower priority. Low priority calls are then referred to nurses. Two years of in-house testing had shown the system worked well enough to allay fears of lawsuits.
Richmond had hoped for enough ambulance cancellations to eliminate one ambulance crew, which would have helped offset the $140,000 annual cost of the program. That didn't happen.
Doctors and dentists refused to accept Medicaid patients and, with the lackluster economy, health clinics, urgent-care centers and social agencies limited their services. The nurses didn't have alternative places to send low-priority patients.
"It can be a great program," said Lee Ann Baker, chief administrator officer of the Richmond Ambulance Authority. "But you need resources to support it."
Now, even as other cities continue to inquire about the program, Richmond is considering whether to use the nurses in other ways, she said.