By Emily White
The Spokesman-Review
SPOKANE, Wash. — Cindy VanValkinburgh was at work this summer when she felt her heart race and her body stiffen. She could hardly move.
When her symptoms did not let up, a co-worker helped her meet an ambulance in the parking lot. Since VanValkinburgh has insurance, she was not worried about paying for the ride to the hospital — until a $3,860 bill arrived in the mail in July.
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That ambulance ride was a bargain compared to what people will be charged for ambulance service starting Jan. 1 . Spokane Valley residents will be charged $5,404.49 for basic life support transport by American Medical Response — the privately held company responsible for 95% of all medical transports in Spokane County . People needing an ambulance inside the city of Spokane will be charged $5,275.
Those rates charged by AMR are the highest in the state.
Those charges are simply a base price and do not include additional fees for such extras as supplies, IV therapies, medication or mileage rates typically applied to ambulance bills. In Spokane Valley, AMR will charge ambulance riders $72.94 per mile, while Spokane is charged $52.49 a mile.
VanValkinburgh’s UMR United Healthcare insurance determined the ambulance service was out of network, so she has to foot the bill herself. She is still paying AMR monthly.
Spokane and Spokane Valley rates are well above those in other cities in Washington and in Idaho, some of which — including Seattle, Vancouver and Yakima — also contract with AMR.
In Seattle, AMR charges $950 for an ambulance transport and $15 for every mile traveled; AMR charges Vancouver residents $1,572.88 for basic transport and $30.77 per mile; and in Yakima, AMR charges $1,715.26 for basic transport and $49.29 per mile.
Other residents also have been surprised by the cost.
“I’ll think twice before I call an ambulance again,” said Spokane resident Kristin Foster.
After Foster passed out and started convulsing on the floor in her home this year, her boyfriend called 911. Weeks later, AMR mailed her a bill for more than $4,000.
Her insurance company, Cigna Healthcare, told her the ambulance ride was out of network. Eventually, after many calls to AMR and Cigna, Foster got 80% coverage on the ambulance ride and owed $1,000.
“I have good insurance. I haven’t had any other issues with insurance, but I’m frustrated that this is happening to me and other people who aren’t in the position that I’m in. I can pay my bill. There are people who are going to be charged $5,000 that can’t pay their bill,” Foster said.
Eastern Washington’s largest private insurer, Premera Blue Cross, has a negotiated reimbursement rate with AMR that was four times more than what AMR receives from Medicare, said Premera Blue Cross spokeswoman Amanda Landsford. In the past five years, Landsford said AMR’s charges have increased by 16.5% each year.
“For comparison, other ambulance providers have increased their charges by 5.7% each year on average,” Landsford said.
Those price increases have spurred conversations between fire chiefs in the area, who are asking the same questions: Why are ambulance rates skyrocketing? And is there anything that can be done to remove that burden from the people in Spokane County?
“I don’t know why there’s such a difference,” said Anne Raven, Spokane Fire Department’s administrative battalion chief for medical services. “I’ve been told it has to do with our payer mix, but since we are not a billing organization, that isn’t the education that I’ve ever received. I don’t pretend to understand why it is that way.”
Spokane Valley Fire Chief Frank Soto Jr calls the ambulance transport business a “black hole” because it’s expensive to operate and hard to recoup enough money from communities such as Spokane Valley to cover costs.
In Seattle, where AMR charges $950 for a basic life transport, around 68% of people being transported in AMR ambulances are covered by Medicare or Medicaid. In Spokane, 80% of people being transported in ambulances are covered by Medicare or Medicaid. Those percentages directly affect how much money AMR makes on those transports, said Paul Priest, AMR regional director. That also means that the price increase only impacts around 20% of those getting ambulance services.
“Maybe it only affects a small group of people, but I’m not convinced that it is warranted,” said Erica Johnson, an economics professor at Gonzaga University. “Inflation is still high; however, their percentage rates seemed like a big jump. It seems like they’re compensating for Medicare and Medicare rates not going up.”
That’s why Priest said AMR rates have increased dramatically over the last five years.
“When we raise the rate by $1, we make two cents,” Priest said.
In other words, AMR costs may be shifting because of low Medicare and Medicaid reimbursement rates, Landsford said.
“That discrepancy in rates exists across the health care ecosystem, not just with ambulance or ground transport contracts,” Landsford said.
Even though Raven said AMR has met response times and served Spokane well, there are things that the city is doing to try and prevent people from using an ambulance when they do not need one. Spokane has created two programs: Car50 and nurse navigation.
Car50 is a service to transport people at no cost who are seeking transport to withdrawal services, rehab or a homeless shelter. The program operates in a partnership between the city and Spokane Treatment and Recovery Services.
Nurse navigation is a program run through GMR, the parent company to AMR. When people call 911, they are asked if they want to speak with a nurse. The nurse determines what the problem is and helps solve it. Often, nurses are able to connect patients to telehealth care, urgent care or help set up a medical lift to transport the patient to urgent care. The program is for nonemergency situations, and is often used to troubleshoot a piece of medical equipment over the phone, Raven said. That way, the patient does not get a bill for services. The program is free for anyone to use.
Other areas AMR serves have developed programs that stop rates from getting too high, Priest said. Part of why Seattle’s rates are so low is because King County operates its own advanced life support paramedic ambulance service, while in Spokane County, AMR provides every ambulance service.
AMR rates are negotiated based on the level of services a market wants, Priest said.
AMR is owned by Global Medical Response, a privately held Texas company with 34,000 employees and 7,300 ambulances. It operates in all 50 states and is the largest ambulance company in the country. Among its major investors is Koch Equity Development, an arm of Koch Industries Inc., one of the largest private companies in America.
“There’s a difference between prices and costs. The costs are the same, but the prices people face for the same service is different,” said Paul Fishman, a professor in the department of health systems and population health at the University of Washington.
That’s why Fishman says he doesn’t blame AMR for raising their costs.
“I don’t blame a for-profit company for doing this, I blame political leaders for letting them do it,” Fishman said.
Out-of-pocket costs are different for consumers in King County because they use Medic One, an EMS system that trains paramedics an extra two years to provide part of the ambulance services in the county so AMR only provides basic life support services. Medic One is funded by a voter-approved levy that moves the prices of ambulance rides to property taxes so consumers aren’t charged as much, Fishman said.
“What we pay AMR for is a very small part of the entire emergency transport process,” Fishman said. "...Usually, what will happen is both AMR and Medic One or the fire department EMS will come out to a call. AMR will transport the person once they have been stabilized and cleared for transport by Medic One or EMS.”
By providing assistance to AMR, King County’s cost for services has stayed below $1,000. If Spokane County wanted to adopt a similar program, it could, if all the fire department chiefs and districts got together to figure out how to get political leaders involved.
Priest also said the cost of AMR services has increased, which also contributes to the rise in rates. He said he is willing to explore other options with fire chiefs in the county that could lower the rates.
Priest specifically mentioned the GEMT model, which is used in AMR services in California. The model would allow AMR to receive supplemental payments from the government to cover the funding gap often created when transporting Medicaid or Medicare patients.
That way, instead of people with private insurance or no insurance paying extra to cover what Medicare or Medicaid does not pay, the government does.
AMR’s monopoly over the county gives them more of an ability to raise prices, said Johnson. Competitors could bring the prices down, Johnson said.
Amy Link, from GMR public relations, attributed the new cost to price increases that have affected AMR’s ability to maintain its 60 ambulances in Spokane County.
Historically, Soto said AMR has been fair in the Valley. From 2009-24, ambulance prices did not increase by too much, Soto said. But in the past year and a half, ambulance rides in the Valley have increased in price by 412%, Soto said.
“The cost for everything for everybody has gone up. Does that justify a 412% increase? I don’t know,” Soto said.
Soto is familiar with building an ambulance transport because he created one while he was involved in the executive leadership in the Albuquerque Fire Department in New Mexico. He is already looking into solutions for Spokane Valley residents so they do not have to pay so much for ambulance services.
Soto found out about Spokane Valley’s rate increase on Dec. 8.
“Obviously, I have some concerns. I can’t share everything that I’m doing with the public; they have to trust me to see what we can do about these prices. We are working with AMR to see what we can do,” Soto said.
Spokane Valley ‘s is not the only fire department taking action. Spokane County Fire District 9 is moving forward with providing its own ambulance service starting in July.
Most of the solutions to the AMR rate problem in Spokane and the Valley would require county political leaders and fire chiefs to adopt a new system. In other words, without collaboration, rates will likely stay the same or continue to climb.
Spokane Valley Deputy Mayor Tim Hattenburg said it is certainly something he will bring up to Mayor Pam Haley and other city officials.
“I’d absolutely be interested in solutions,” Hattenburg said. "... We have to do something.”
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