Numerous media stories in the last year have highlighted the burden of ambulance fees for many Canadians.

There is the story of the Saskatchewan woman battling fatal cancer whose non-optional ambulance trips from one hospital to another amounted to more than $5,000.

There is the mom who had to call the ambulance several times when her daughter was struggling to breathe and faced almost $7,000 in fees at the time of her daughter’s death.

There is the Winnipeg man with epilepsy who racked up ambulance bills amounting to a down payment on a house.

And there are many more.

A recent CBC investigation revealed that the price patients pay for ambulances differs widely depending on where they live, ranging from $0 in the Yukon to over $500 in Manitoba. In Saskatchewan, add on fees, like per-kilometre charges can put single rides over $1000.

Should any fee be charged in the first place? Healthy Debate explores.

Ambulance services: a transportation or health service?

Most paramedicine programs opened their doors in the 1970s, and paramedics received far less training then compared to today. “In the ’60s and most of the ’70s, paramedics didn’t really exist.  It was ambulance drivers quite literally, maybe with St. John’s first aid,” says Penny Price, director of the Regional Paramedic Program of Eastern Ontario.

When the Canada Health Act was being drawn up in the early 1980s, ambulance services weren’t included as a medically necessary service because these services were still seen more as transportation than health care.

Today, however, paramedic services are much more integrated with the health system, and paramedics provide sophisticated health care at the scene and along the way to the hospital.

“More and more throughout this country, we’re becoming integrated with the health care system,” says Chris Hood executive director of the Paramedic Association of New Brunswick.  Still, the idea that paramedics provide medically necessary health care has been slow to catch on among health policy makers.

Several years ago, shortly after paramedic services had been integrated into Alberta Health Services, Price asked if the organization planned to get rid of the fees because  the services were now part of the larger health system. “I just got a blank look. I think at the time it was just too new a concept.”

The ‘inappropriate’ use justification – is it backed by evidence?

Across Canada, some policy makers argue ambulance fees reduce inappropriate use. For instance, earlier this spring, Roger Melanson, New Brunswick’s finance minister told the media that reinstating a charge would “deter inappropriate use so ambulances are available for emergency calls.” Carolyn Ziegler, public affairs officer for Alberta Health, explains the province’s $385 fee for ambulance transportation to a hospital helps ensure services are “available when they are needed the most” by reducing demand from people who don’t really need an ambulance. “There is international research to suggest that eliminating fees can increase the number of less urgent requests,” she writes in an email.

Ziegler pointed to two studies. In one, Japanese researchers asked participants whether they would call an ambulance based on various scenarios and fees. But this survey isn’t very useful, because it asks people what they would do in hypothetical situations, when they’re calm; it doesn’t look at what people actually do in real, stressful situations.

The second study looked at ambulance calls at a single facility in Queensland, Australia, where ambulance fees were abolished in 2003. The study found that arrivals by ambulance increased slightly, from around 5,150 visits in 2002 to around 5,900 visits in 2004. As ambulance users in 2004 were slightly younger and had slightly less serious health issues, on average, the authors suggested the “free” ride may have encouraged people with non-urgent issues to call the ambulance.

But other studies have found that ambulance fees don’t affect inappropriate use. Another study examining numbers from the entire state of Queensland over a longer time period found that the removal of the user charge for ambulances did not lead to a jump in calls.

In addition to the published studies, a CBC-commissioned survey of more than 2,000 Canadians released earlier this year found more than 19% said that fees had stopped them from calling an ambulance. We don’t know, however, if these decisions were made during serious emergencies or less urgent situations.

The province of New Brunswick has a history of removing and reinstating the fees (fees for many patients were removed in 2005, reinstated in 2009, removed in 2014 and reinstated again this past May). So we reached out to the government to see if they have any data on how non-urgent use of ambulances is affected by the removal of fees.

New Brunswick’s data is also inconclusive. For example, while usage increased by 4% the year before the removal of charges in 2005, it subsequently increased by 12% in the year after fees were waived. In 2009, when a $130 fee was reinstated, ambulance usage remained steady for the following four years. Then again, there was an 8% annual jump coinciding with the removal of the fee in 2014.

But Karen Scott, a communications director with the government of New Brunswick, cautions the changes may not be due to fees. Hospital closures and other service delivery changes that occurred in the province in the last decade could have influenced the fluctuations in ambulance calls. “The data is not broken down into that level of detail in order to conclusively determine the cause of an increase or decline in usage,” Scott writes.

It’s important to consider that New Brunswick doesn’t categorize calls by their level of appropriateness. So, even if the fees did lead to decreased usage, we wouldn’t know how much the growth was driven by inappropriate, versus appropriate, use.

The problem with trying to target inappropriate use

Inappropriate usage of ambulance services is an issue. Numerous Canadian and international studies have concluded that about 30% of ambulance calls were inappropriate, according to Deirdre DeJean, a postdoctoral fellow in the Department of Clinical Epidemiology and Biostatistics at McMaster University, who has summarized this research.

But there’s a reason why fees might not prevent the problem of inappropriate use. In order to be deterred by a fee, patients must know that the situation isn’t urgent. The 19 Ontario paramedics DeJean interviewed explained that a situation that a health professional sees as a non-emergency is often seen as an emergency by a patient. Patients don’t always have the medical knowledge necessary to differentiate between an emergency or non-emergency, and they’re not always aware of alternatives to ambulances.

According to Price, it’s “the extreme minority” that deliberately abuse the ambulance system – calling an ambulance to get a ride to a place near the hospital, for instance. Most of us call an ambulance when we don’t need it because we think we need it. As Price sees it, a fee isn’t likely to be a deterrent in the majority of inappropriate calls, because patients see their calls as appropriate.

Interestingly, even though Ontario has a fee for “inappropriate” use, it’s extremely rarely used – in large part because the doctors don’t think patients should be expected to know when a health problem is urgent or non-urgent. “I don’t think [the inappropriate use fee] is charged more than a couple times a year,” explains Dr. Michelle Welsford, an emergency physician at the Hamilton Health Sciences Centre in Ontario. DeJean’s research also found that doctors tend to only tick the ‘inappropriate’ box in the very rare, egregious forms of abuse.

But there’s a bigger problem with trying to use fees to stop inappropriate users from calling ambulances: it’s possible you also stop people who really need an ambulance from calling.

There are anecdotes of this happening. According to Hood, elderly people have called the ambulance saying things like: “I’ve had chest pain for three days and I’ve been trying to avoid calling an ambulance because I can’t afford it,” he says. “The longer some of these individuals experience the symptoms, the worse their disease becomes.”

Though not particularly looking at ambulance fees, the largest study on user fees in health care found that hospital user fees stopped people from accessing life-prolonging care just as often as it stopped people from accessing health services that weren’t necessary for them.

Is there a way to get rid of ambulance fees?

Aside from the ‘transportation’ designation, and the need to avoid inappropriate use, ambulance fees are justified on the basis that the system just can’t afford to cover the entire cost. To Hood, it’s a disingenuous argument. He points out the government of New Brunswick will only collect $750,000 per year out of a $110 million ambulance budget now that it has reinstated a $130 fee. “That’s pretty small potatoes,” he says, arguing the government could afford to cover the cost of the fee.

Overwhelmingly, the sources we spoke to argued that rather than charge patients, health systems should instead save money in other ways. For example, reforms to paramedic services can result in patients being directed to urgent care centres or community mental health services, when appropriate, instead of expensive emergency departments.

Such innovations are already well away in other parts of the world, and being experimented with in Canada. However, as of yet, there isn’t enough evidence to show whether these programs save money.

Following the lead of EMS reforms in the UK, Alberta has initiated programs where paramedics can treat patients on scene so a hospital visit isn’t necessary, or direct them to alternative treatment centres.

Dr. Francois Belanger, Calgary Zone medical director with Alberta Health Services, explains that for several years now, paramedics have been able to call a physician 24/7 for advice when they’re not sure if someone needs to go to the hospital.

Hood points out the new treatment and referral options for paramedics are being considered in a number of jurisdictions in Canada. “They’re clearly primary health care, and they have such huge potential to mitigate ER overcrowding and hospital bed-blocking,” he says.

Even before an ambulance is called, 911 dispatch systems can be designed to direct non-urgent callers to other services. In Alberta, a caller can be referred to a 24/7 poison control line, for example. But in most parts of Ontario, 911 responders have no choice but to send an ambulance in a health-related call.

Patient education can also help reduce inappropriate use. In Alberta, the Know Your Options service provides detailed information – including hours and locations – on alternatives to emergency rooms, such as urgent care centres.

But Price worries that such innovative  programs won’t be as successful if the fear of fees means people avoid calling an ambulance and simply show up in the emergency room.

“I don’t want people not to call a paramedic because of the fee, particularly as we become more mature, more sophisticated in the options available to paramedics,” she says.