Every few years, a report comes along that doesn’t simply summarize data — it quietly begins shaping the conversation.
The recently released Emergency Ground Ambulance Costs: Trends and Policy Implications, published by the Elevance Health Policy Institute, is one of those reports. On its surface, it appears to be another thoughtful policy analysis examining ambulance charges, commercial insurance payments and patient affordability.
Many EMS leaders may skim the executive summary, nod politely and move on to the next crisis demanding their attention.
That would be a mistake.
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This report is likely to become required reading for legislative staff, state regulators, commercial insurers and policy organizations wrestling with ambulance reimbursement and balance billing. More importantly, it introduces a single number that is almost certain to take on a life of its own: “approximately 160 % of Medicare.”
If you’ve spent any time around a state capitol or Congressional hearing room, you know exactly what happens next. A simple number becomes a talking point. A talking point becomes a policy proposal. Before long, everyone begins asking why ambulance services should receive anything more than “the amount one of the nation’s largest insurers says is appropriate.”
Policy debates often become anchored around a single statistic. Once that happens, the burden shifts to everyone else to explain why the number is wrong. If we wait until reimbursement legislation is introduced to begin that conversation, we may already be arguing uphill.
The problem is that this isn’t actually what the report says. Or, perhaps more accurately, it isn’t what the report proves.
The report is well-written, professionally researched and contains useful information about one commercial insurer’s claims experience. It documents what ambulance providers charged and what Elevance paid for ground ambulance services. That data is valuable. Large insurers possess enormous claims databases that can provide meaningful insight into reimbursement trends.
But somewhere along the way, the discussion shifts from describing insurer payments, to describing ambulance costs.
That is where EMS leaders should become uncomfortable.
Imagine someone publishing a report entitled “The cost of owning a home” that carefully analyzed monthly mortgage payments, but never mentioned property taxes, homeowners’ insurance, roof replacements, HVAC failures, plumbing repairs, or the fact that your air conditioner will inevitably die during the hottest weekend of August. The mortgage payment is certainly part of the cost of owning a home — but it isn’t the whole story.
The same thing happens here.
Where the Elevance report fails to capture EMS reality
The Elevance report evaluates ambulance charges, insurer allowed amounts and payment comparisons to Medicare. It does not evaluate what it actually costs to operate an ambulance service. There are no provider cost reports, no staffing expenses, no deployment models, no readiness costs, no uncompensated care analysis, no capital replacement schedules, no financial sustainability modeling, and no discussion of the public subsidies that support many EMS systems.
That distinction may sound like accounting trivia.
It isn’t.
It is the difference between discussing what insurers pay and understanding what communities must spend to ensure that an ambulance arrives when someone calls 911.
EMS has always suffered from an identity problem. Policymakers often see an ambulance transport as a healthcare transaction. EMS professionals know it is really a public safety readiness system that occasionally generates a transport bill.
The ambulance sitting quietly in a station at 3 a.m. still costs money.
The paramedic crew covering a rural county that transports only two patients today still has to be there.
- Ambulance personnel are on-duty, ready to respond
- Dispatchers remain on duty whether the phones ring or not
- Medical directors still oversee quality improvement
- Vehicles require maintenance even when parked
- Ambulances continue depreciating
None of those expenses disappear simply because no one happened to call 911 during the last hour.
Readiness is the product.
Transport is merely the visible manifestation of that readiness.
Perhaps the most subtle assumption in the report is its repeated comparison of payments to Medicare reimbursement. Commercial payment levels are described as percentages of Medicare, with approximately 160% emerging as a suggested benchmark.
At first glance, that sounds perfectly reasonable.
Until someone asks the question the report never fully answers: “How do we know Medicare itself adequately pays for ambulance service?”
For decades, we have argued that Medicare often fails to reflect the actual costs of maintaining modern EMS systems. Congress has repeatedly acknowledged those concerns through temporary ambulance add-on payments. The Medicare Ground Ambulance Data Collection System was created specifically because policymakers recognized that they lacked reliable information about provider costs and financial sustainability.
If Medicare’s reimbursement adequacy has never been established, then saying commercial insurance should pay 160% of Medicare tells us surprisingly little. It simply tells us that commercial insurers pay more than another payer (Medicare), whose own Ground Ambulance Data Collection System found that median Medicare reimbursement was approximately 75% below the median cost of providing ambulance service.
The report also focuses exclusively on one commercial insurer’s experience.
Unfortunately, we don’t have the luxury of operating within a single payer category.
Every EMS agency simultaneously serves Medicare beneficiaries, Medicaid recipients, uninsured patients, veterans, workers’ compensation claims, automobile insurance cases and patients who ultimately never pay at all. Commercial insurance often represents one of the few payer sources capable of offsetting losses elsewhere.
Evaluating commercial reimbursement without considering the entire payer mix is a little like evaluating the financial health of an airline by examining only its first-class ticket sales.
Interesting? Absolutely. Complete? Not even close.
Another section of the report discusses the high percentage of out-of-network ambulance claims. Again, the data are interesting, but the interpretation deserves additional context. Ambulance providers do not always remain out of network because they refuse to participate. Sometimes they remain out of network because offered reimbursement rates fail to adequately cover operating costs, administrative requirements become unmanageable, governmental entities cannot practically accept proposed contract terms or reimbursement methodologies simply do not sustain service delivery.
Those are fundamentally different explanations.
One suggests providers are avoiding contracts. The other suggests insurers have built networks that providers cannot afford to join. Those are not the same conversation.
The data to back up EMS costs
None of this means our profession should dismiss the report or respond defensively. In fact, doing so would be a strategic mistake. Patients deserve protection from commercial insurer underpayments. Most EMS leaders support that goal. But protecting patients cannot come at the expense of protecting access to emergency medical care. We should resist any temptation to defend every ambulance charge or every balance bill. That debate has largely been settled in the court of public opinion.
The better argument is much simpler: Protect patients but also protect access.
Replacing patient responsibility with insurer underpayment does not solve the underlying economic problem. It merely changes who isn’t paying enough.
Fortunately, EMS enters this discussion with something it has never previously possessed: evidence.
For years, insurers had the advantage because they controlled the claims data. Ambulance organizations largely relied on anecdotes and local financial reports.
That changed with the Ground Ambulance Data Collection System.
For the first time, policymakers have access to large-scale national information describing provider costs, staffing, readiness expenses, utilization, operations, revenues, service areas and financial sustainability. The policy conversation no longer has to revolve around what insurers typically pay. It can finally focus on what it actually costs to sustain emergency medical response.
That shift represents an enormous opportunity — but only if we use it.
What EMS leaders should do now
Every ambulance organization should already be calculating its actual cost of service delivery (including readiness), its payer-specific reimbursement, its dependence on commercial insurance and the financial consequences of reducing commercial payments to any fixed percentage of Medicare. Those conversations should happen with governing boards and legislators before reimbursement legislation appears — not afterward.
The Elevance report deserves to be read. It raises legitimate questions. It contributes valuable claims information. It reflects the perspective of a sophisticated organization with enormous data resources.
It also reflects the perspective of one of the nation’s largest commercial health insurers, whose financial interests understandably include reducing reimbursement expenditures and encouraging providers to accept prevailing network rates. That doesn’t invalidate its findings. It simply reminds readers to evaluate its conclusions in the context in which they were written.
If our profession learns one lesson from this report, it should be this: The next battle over ambulance reimbursement will not be won with emotional stories or clever slogans.
It will be won with data.
For years, insurers possessed the strongest evidence because they controlled the claims data. Today, we possess something far more powerful: independent national evidence, from a national government organization, describing what it actually costs to sustain emergency medical response.
The next debate over ambulance reimbursement should not be driven solely by what one insurer pays. It should be informed by what communities must invest to ensure that when someone dials 911 on the worst day of their life, help is already on the way.
And that is a story worth telling before someone else tells it for us, which is usually either the least informed, or the one with a competing interest!
You can access the report, a detailed and executive summary of the report, and recommended actions and talking points for EMS professional at the PWW|AG Resource Hub.
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