[jjk166]

> The average ambulance transport costs $2,673 to provide

I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.

A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.

Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.

I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?

[justonceokay]

There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.

Is it $2600? Probably not. But I think you are low-balling pretty significantly.

Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.

[khuey]

I don't disagree with what you're saying but I want to point out that it's rather unusual for (American) ambulances to carry blood, and probably more of them should.

https://www.redcross.org/about-us/news-and-events/news/10-wa...

[FireBeyond]

Correct. The only ambulances that typically will stock blood are specialized NICU ambulances and HEMS (helicopter). Although more progressive agencies are looking more and more at part blood products.

[Spooky23]

EMTs are like veterinarians. Lovely people who get ruthlessly exploited. Benefits are garbage unless you’re a unionized public employee.

[wombat-man]

Yeah, every EMT I know was way underpaid for how crazy stressful it was. Especially considering how expensive the ride was

[jmcgough]

EMT now is often used as a stepping stone to a career with a liveable wage, like physician.

[orsorna]

This is fairly funny to me because I reckon most residents only had to do research to get in. EMT and tech experience are negative differentiators in getting into medical school, which is a shame.

[johnthescott]

years ago i lived next door to a bar popular with off duty emts. interesting, to say the least.

[michaelmrose]

Most people live in urban environments. Approaching zero are over an hour. As with most people being in urban environments most ambulance rides are in urban environments and go to the nearest hospital meaning that most rides should be under 10 minutes.

There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.

Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.

It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.

https://www.cma.ca/resources/healthcare-real/answers/healthc...

[jjk166]

Medical supply costs for transport are very small. The labor overhead costs are overhead. Insurance is included in the estimate.

A plumber charges you $200 to come to your house, it costs the plumber $20 to come to your house. The latter value is what we're discussing here.

[quickthrowman]

If I charge $163 an hour for an electricians time, the cost to my job for one hour without material is between $130-140 depending on who it is. It only costs the plumber $20 if his time is free, which it isn’t.

[jasonjayr]

TIL getting an elevator tech to just come out to look at your building's elevator is about $1600. If it's an easy fix, that's all you need to pay. If it's not, it goes up significantly....

[LanceH]

He wouldn't be much of an elevator repairman if it didn't go up considerably.

[cheesecakegood]

To be fair, if you pay the repairman, your elevator also goes up :)

[MichaelZuo]

Don’t they need to sign something legally binding, the moment they adjust even one minor internal part?

[avidiax]

I'm not going to claim that elevator malpractice isn't possible, but no elevator is designed with a single point of failure for any safety critical system, so I don't think it's easy or likely to make a mistake that would cause a safety issue.

[lazide]

A qualified elevator technician can definitely make an elevator fail dangerously spectacularly.

They wouldn’t be qualified if they couldn’t.

[_blk]

"We mark it down based on [income]".. Obviously it's profit first (I don't mind if you don't pretend that profit is a cost). It unfortunately seems cheaper to be uninsured for many cases if you're willing to pick up a phone and discuss prices and take the risk that it may not always work out (but then again dealing with insurances has its own set of annoyances and steadily rising costs).. Not a recommendation but clearly my observation.

[harmmonica]

Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.

As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.

Edit: spelling

[vineyardmike]

> I just want every medical service to have this exact type of breakdown

Check out the "No Surprises Act"

https://www.cms.gov/priorities/key-initiatives/hospital-pric...

[harmmonica]

Hi there, I’ve used this for hospitals local to me but correct me if i’m wrong but those are only the prices for services. What I’m talking about is unit economics for the service. The difference being pricing is opaque (or rather pricing alone is not transparent enough) until you know the cogs and then you can evaluate how profitable the pricing is.

edit: clarity

[consp]

Here in the Netherlands it is 877 euro for an A1 call (emergency, no delays), and 384 for B1 calls (non emergency, planable). You also get a 4.83 euro per km cost. You pay up to 375 euro if you haven't had any medical cost that year, otherwise zero.

Stand by cost are about 154 euro/hour. E.g. for sport events.

ICU transport is about 2500. All are law mandated.

The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.

[victorbjorklund]

For citizens or do you charge higher for tourists? In for example Sweden only eu citizens get the cheap price.

[zhdc1]

Seems reasonable and closer to American averages than I would have expected.

[Insanity]

+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.

[jjk166]

Replying to myself as a followup:

https://digitechcomputer.com/costs-of-ems-readiness/

Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".

[Atotalnoob]

You need more than the crew in the ambulance.

Dispatch, maintenance, janitors, HR, managers.

They also need continuous training, and that is also a large salary cost for training staff (you have to pay them and the trainer).

[kelnos]

As far as I can tell, your article is talking about total salary cost, divided by number of rides, not just the amount that the ambulance crew is being paid during an actual trip.

For that, $1500 seems pretty reasonable. In a place like the US, labor costs often dominate the total cost of many goods and services.

And remember, you have to pay the staff while they are sitting there waiting for a call that may never come. According to the OP's article, the ideal utilization is 30-50%, because you don't want a situation where there's a surge in requests and you don't have an available ambulance. So you're paying people to sit around and wait for a call, and, under normal conditions, you'll have 50-70% of that pool of people not ending up needing to take calls at all.

Also your article includes under salaries:

> Regular, overtime, vacation, and holiday pay for all EMS staff, including EMTs, paramedics, chiefs, 911 call technicians, dispatchers, and support staff

That's not just the 2-3 people on the ambulance during trips. That's a lot more people required to make the entire system work.

[cogman10]

I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.

Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.

That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.

[jjk166]

Insurance is included.

[Atotalnoob]

12k for insurance is not enough.

Normal commercial insurance is much more expensive, let alone ambulances.

And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels

[xp84]

Some of your estimates on this seem fine, but not this:

liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.

[jjk166]

The 12k per year includes medical liability insurance.

[IG_Semmelweiss]

That number looks low.

[closewith]

> A new, fully equipped ambulance is about $150k.

This is definitely not true. A base model unequipped ambulance may be in that ballpark. A fully equipped ambulance will vary wildly in cost based on clinical level but will be about $250-500k in the US.

> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Maybe for BLS or non-emergency ambulances in a low-utilisation role? For ALS/Critical Care or higher in a busy jurisdiction it's going to be significantly higher.

[tmnvix]

An interesting take on the relative differences of manufacturing (and purchasing) an ambulance in the US and China: https://www.youtube.com/watch?v=8JcCISp5S64

[somat]

It may also be telling to figure out why no startup is offering $400 ambulance rides and dominating on volume.

[userbinator]

Almost certainly regulations. Anything even vaguely medically-related tends to be very, very highly regulated.

[_carbyau_]

I for one would love to see a startup called say, "Trauma Team International" or "Docwagon"...

[keane]

Ambulnz by DocGo

[Esophagus4]

Ambulance.ai

(Shudders)

[bombcar]

You can get an ambulance for only $150k? A transit van with a few options is already $75k.

[throwaway2037]

I agree. That number is bullshit. I Googled about it. It looks like 350K to 600K USD. Also, there is wild variance in vehicle sizes and the equipment you choose to carry.

[bombcar]

At least one city I lived in it was well known that you wanted to only ask for the fire department, because they would call an ambulance company via cell directly, and that one was significantly cheaper than the one 911 would dispatch. It was also much closer to a van with a stretcher in it; the 911 ambulance was a mini hospital on wheels.

[kelnos]

This is a fine example of coming up with some "plausible" numbers to support a conclusion, but all of the "plausible" numbers are actually wildly incorrect.

A new ambulance will probably run 2-4x what you quoted. Gas/maintenance will not be comparable to a regular automobile; it will be significantly higher. Paramedic wage (though there will probably be more "cheaper" EMTs out there than paramedics) seems right, maybe a little high for some markets. $12k for liability seems shockingly low; I wouldn't be surprised if you're off by an order of magnitude.

Regarding salaries, you're not just paying for the people in the ambulance. You're paying for dispatch, operators, support staff, administration, etc. You're also paying them 24/7, not just for the times that the ambulances are actually making trips.

You also left out the cost of medical supplies and equipment, both of which need to be maintained and replaced.

[FireBeyond]

> Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.

Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.

Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).

However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.

The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.

You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).

Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.

> This is a short trip in an automobile, essentially a fancy uber ride.

That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.

> A new, fully equipped ambulance is about $150k.

Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.

> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.

Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.

> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles

For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).

This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.

[Der_Einzige]

The fact that so many people some gleeful to work as EMT despite the shit pay is just insane!

[Esophagus4]

Some of them are volunteers who do it because it’s about the calling to help their communities, not pay.

Some do it because they actually want to be firefighters but it’s helpful to be an EMT as well.

Others do it because it’s an easy entry point (in the US you only need a 3 month night course to be an EMT) in their medical career on their way to better paying jobs like MD and RN.

And yes, others are grizzled and burnt out making little money.

But mostly people do it because they want to help.

[socalgal2]

You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?

There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.

My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you

[indoorfish]

"My LLM of choice" is like when the news reporter says "confirmed by someone not authorized to speak publicly". It's not a meaningful report.

[failbuffer]

Your point about LLMs aside, I'd trust the inside source over whatever carefully baked misrepresentation the PR department doles out.

[sehansen]

Unfortunately that inside source is often coached by the PR department and are just there to say things they can't get away with saying publicly or don't want to have their exact words on record. I.e. just as much a misrepresentation as the official press releases. Or sometimes even more of a misrepresentation since nobody can actually be held accountable for their words.

[socalgal2]

It's arguably more reliable than some rando above doing napkin math and zero actual experience or evidence

[lazide]

Not in my experience. Most LLM answers are bullshit; and they almost never say they don’t know. Most people would just look at you and say ‘I don’t know’ instead of just making something up.

[jjk166]

I didn't forget the cost of insurance.

[mlsu]

Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.

[indoorfish]

IKON passes don't grow on trees you know.. Someone has to rent out in Aspen.

[bandrami]

We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).

[1] Oh, holy crap, I just got why ambulances are called that

[lazide]

The ambulance operator also gets stuck with the costs of all the ambulance rides which are never paid for - which is, statistically most - because of things like homeless folks, people giving false names, etc.

Which, notably, are so common, because it is financially ruinous to not do it.

They can’t decline transport for anyone with an emergency, regardless of ability to pay.

[Spooky23]

Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.

The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.

When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.

Air ambulance is worse.

[SoftTalker]

Nobody makes (federal) minimum wage these days. McDonalds employees make double that.

[Spooky23]

I don’t live in a red state so we have a bizarrely low minimum.

[SoftTalker]

The U.S. Federal minimum wage is $7.25/hr. Some states or localities might have higher minimums, but it's been a long time since I've seen any jobs paying that little. McDonald's here is about $15/hr to start and jobs go begging. CoL here is not the lowest but it's not like a major urban center either.

[Der_Einzige]

You haven’t been to the shithole south if you believe this.

There plenty of idiots there making 2 dollars an hour and tips and thinking they’re doing well because “at least my CoL is low!”

[kyleee]

All in cost of the employee is probably double or more of your example $23 an hour wage, just to flesh out your napkin math

[jjk166]

Which would increase the cost to $325, though I was deliberately excluding overhead.

[tbrake]

> This is a short trip in an automobile, essentially a fancy uber ride.

We need a regulatory body that can fine people for making analogies this bad

[delichon]

> We need a regulatory body that can fine people for making analogies this bad

We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.

Tsk-tsk.

[orthoxerox]

People (like the guy from the article) literally take Uber rides instead of ambulances, so they are a reasonable substitute good in many cases.

[pasquinelli]

i mean their job is transporting people.