A correspondent has drawn my attention to a report released by the Victorian Ombudsman investigating a complaint about Ambulance Victoria rendering an invoice for services where the person declined transport (Victorian Ombudsman, Investigation of a complaint about Ambulance Victoria (May 2019)).
This investigation arose from a single complaint. A not uncommon scenario: a man we call Simon is involved in an altercation, someone else calls an ambulance, he declines to go to hospital, and some time later receives a bill for $519. Simon was undoubtedly aggrieved by this. When we made enquiries into his complaint we identified what appeared to be a systemic issue: fees being charged for treatment without transport, potentially involving invoices being charged unfairly.
The circumstances of Simon’s case, and his complaint, were set out at :
On 8th January 2018 I was at the library when I was bitten, spat on, thrown to the ground, and had my wallet and car keys stolen in the carpark. The perpetrator’s partner called an ambulance for him. When the ambulance arrived, he lay on the ground and paramedics attended him. After attending him, one of the ambulance officers walked towards me, I was being questioned by police, I said “I’m ok, I will go to hospital later.” The ambulance officer walked back to the van and came back with a clipboard. She took my pulse and said “sign this”. I said “what is it?” She said “refusal of treatment form” so I signed it. I now get an invoice from a debt collection agency for $519. I feel this process was dishonest and sneaky and not appropriate for such an organisation. My complete version can be confirmed by 6 video cameras.
I did not call an ambulance, I told them I was ok. I think this is very unfair.
The Patient Care Record ():
… completed by paramedics at the scene recorded their assessment and observations of his general condition and took his history and vital signs (eg blood pressure and pulse). In terms of treatment, the PCR states ‘reassurance, wounds irrigated and cleaned.’ The PCR also notes that Simon was advised to ‘seek medical treatment’ and that he refused.
The Ombudsman decided to investigate Ambulance Victoria’s practices and reviewed 120 cases where invoices had been rendered where no ambulance transport had taken place.
An issue for the Ombudsman was whether there had been ‘treatment’ but no transport. The Department of Health said ():
…the department considers ‘treatment’ as the dispatch and arrival of an ambulance resource and includes at least the clinical assessment of a patient. Assessment is expected to include recording of observations and/or vital signs (as relevant and/or appropriate), as well as documentation of any interventions and/or other relevant information.
Cases where no treatment was required were not subject to a bill but as the Ombudsman noted ():
Logically, for a paramedic to determine that no emergency care is required (with the result that the event is non-billable) initial observations or assessments would be necessary. While such observations or assessments may amount to ‘treatment’ within the meaning of the policy [POL FCS 067 Non-Transported Patient Care Records], without further clinical care, they would arguably fall short of constituting ‘definitive treatment’ under the procedure [PRO FCS 060 Non Transported Patient Care Records – Financial Administration].
The Ombudsman was also concerned about informed consent. Ambulance Victoria (at , emphasis added) recognised that
… where the triple 000 call seeking an ambulance attendance was made by a third party who was unrelated to the patient … the patient would be unaware that a third party call was even made. By contrast other cases involve calls being made by the patient’s relative, friend or associate and in this sense consent for the ambulance to be called is reasonably implied.
Later, at , Ambulance Victoria is quoted as saying:
It is worth noting that paramedics do not engage in discussions about costs or billing with patients prior to assessment as it is not core to their clinical role and there is a risk that giving cost information would undermine their primary duty resulting in delaying treatment or a patient’s refusal of care. Paramedics as a routine ask if they can undertake a physical assessment. They do not carry out assessment where a patient is competent to refuse and does so. There is a very real risk that if a patient were required to give financial consent many assessments would not occur and serious illness or injury would go unrecognised.
AV is of the opinion that this would compromise our duty of care and lead to serious adverse events including otherwise preventable deaths.
At  the Ombudsman said ‘The High Court has recognised that ‘except in cases of emergency or necessity, all medical treatment is preceded by the patient’s choice to undergo it’. (And it’s pleasing to see that the reference for that proposition was my own book, Emergency Law (4th ed) as well as the High Court’s decision in Rogers v Whitaker (1992) 175 CLR 479). Ambulance Victoria relied on a patient’s implied consent to treatment where the patient cooperates with the paramedics taking vital signs, but this consent did not involve knowledge that the Ambulance Service would charge in excess of $500 for that service.
During the course of the inquiry, Ambulance Victoria agreed it would no longer charge where the initial call is made by an ‘unknown third party’ () and the patient refuses transport. Further Ambulance Victoria agreed not to render an invoice to each patient where it was called to a single scene but examined many potential patients (eg a house fire where each occupant of the house was assessed but no[one was transported). Rather they would split the scheduled fee between the number of patients.
The Ombudsman thought AV should go further. She said that AV should not render an invoice where ‘where the caller is known to the person, but the person did not know an ambulance was being called, or could not reasonably have consented to it’. Further there should be no charge where an ambulance was called by police to respond to injuries caused by police (such as by the use of capsicum spray or force in arrest).
The Ombudsman was of the view () that it would not be ‘unreasonable for people to be informed that an assessment, including having their vital signs taken and receiving reassurance, might cost them over $500.’
Ultimately the Ombudsman’s view was (at ) that ‘AV’s policy and practice for charging people for Treatment without Transport can result in invoices being issued that are not fair or reasonable.’ The Ombudsman made five recommendations (p. 28). They were:
Cancel the invoice issued to Simon for Treatment without Transport on 8 January 2018 and refund any other people who can provide evidence of payment in similar circumstances over the past 12 months, on the individual’s request.
Cease charging each patient for a full Treatment without Transport fee at a multi-patient event, wherever practicable splitting the charge according to the number of patients.
Cease charging a Treatment without Transport fee where the ambulance service is activated by a third party and the patient did not know an ambulance was being called, or could not have reasonably consented to it, including when an ambulance is called by police.
Revise its process for dealing with disputed invoices to ensure:
- staff are empowered to exercise discretion, and
- legislation is not misquoted.
Further to section 10(c) of the Charter of Human Rights and Responsibilities Act 2006 (Vic) note that full, free and informed consent for Treatment without Transport may include conveying relevant information about potential costs, and consider ways to adequately inform patients accordingly.
I have previously written on practices relating to ambulance charges, see
- Paying for ambulance services (October 4, 2014);
- Subtle change in the way ambulance fees are recovered in NSW (June 1, 2015);
- Paying for ambulance services in the ACT (July 16, 2018); and
- Chasing up debts for emergency ambulance services in Victoria (July 20, 2018).
It appears the Ombudsman’s report will have a significant and welcome change in this area.
My commentary relates to the attitude of Ambulance Victoria to telling people about fees and the fear that if people are told of the cost, they may decline treatment and ‘compromise our duty of care’. That is a clear example of Ambulance Victoria preferring its interests to those of its patients. If its afraid of compromising our ‘duty of care’ its afraid that it will be held to account, its seeking to ‘cover its arse’ rather than advance the interests of the patient.
In Rogers v Whitaker (1992) 175 CLR 479, Mason CJ along with Brennan Dawson, Toohey and McHugh JJ said (at ):
However, except in cases of emergency or necessity, all medical treatment is preceded by the patient’s choice to undergo it… But the choice is, in reality, meaningless unless it is made on the basis of relevant information and advice. Because the choice to be made calls for a decision by the patient on information known to the medical practitioner [or in this case, paramedic] but not to the patient, it would be illogical to hold that the amount of information to be provided by the medical practitioner [or paramedic] can be determined from the perspective of the practitioner alone… Whether a medical practitioner [or paramedic] carries out a particular form of treatment in accordance with the appropriate standard of care is a question in the resolution of which responsible professional opinion will have an influential, often a decisive, role to play; whether the patient has been given all the relevant information to choose between undergoing and not undergoing the treatment is a question of a different order. Generally speaking, it is not a question the answer to which depends upon medical [or paramedical] standards or practices. Except in those cases where there is a particular danger that the provision of all relevant information will harm an unusually nervous, disturbed or volatile patient, no special medical skill is involved in disclosing the information, including the risks attending the proposed treatment [including the risk of a bill in excess of $500]…
At  the judges said (emphasis added):
The law should recognize that a doctor has a duty to warn a patient of a material risk inherent in the proposed treatment; a risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it.
Ambulance Victoria’s comment that ‘There is a very real risk that if a patient were required to give financial consent many assessments would not occur and serious illness or injury would go unrecognised’ is to recognise that the cost is a material risk, that is it something that the patient would attach significance too. That is a reason to tell the patient, not a reason not to tell them.
Ambulance Victoria is clearly prioritising what it sees as its duty to protect patients from harm and from their own decisions (the ethical principle perhaps of beneficence) but failing to recognise the ethical principle of respecting patient autonomy. It is not the duty of Ambulance Victoria to save everyone from their own decisions but to assist people to make decisions that reflect their values and priorities (Stuart v Kirkland Veenstra  HCA 15; PBU & NJE v Mental Health Tribunal  VSC 564). A person may well cooperate with a paramedic who says ‘let me just check you over’ out of respect for the paramedic (“he or she needs to do this for his or her job, I won’t make their day complicated, I’ll cooperate”) or because it will make them go away faster if there is cooperation. That cannot be taken to be consent to receiving an bill nor is it informed consent. The person may – and is entitled to – take a very different view if they are told ‘just let me check you over, it will cost $500’. If Ambulance Victoria thinks charging people $500+ will cause them to make poor decisions then the answer is not to charge them, not to withhold information that they believe is material in the circumstances.
Further paramedics may record that a patient refused recommended transport even when that is not the case – see:
- Transport everyone or act as a professional? A question for paramedics (May 6, 2013); and
- Refusing treatment documentation (June 9, 2016).
- No adverse comments regarding paramedics following death of a woman in Ballarat, Victoria (April 3, 2017).
One can see how a patient record could be created that says ‘patient checked, and refused treatment’ rather than ‘patient checked and we all agreed nothing wrong and treatment not required’. If paramedics want to record that everyone ‘refused transport’ in order not to be criticised or asked to explain what happened if it later turns out transport was warranted, and if AV doesn’t want to tell people about fees as they may refuse transport and it later turns out transport was warranted then both are putting their interest ahead of the patient’s right to make an informed choice.
No health professional should withhold information (‘[e]xcept in those cases where there is a particular danger that the provision of all relevant information will harm an unusually nervous, disturbed or volatile patient’) on the basis that if I tell the patient all relevant information then he or she will not make a decision that I think is in their own best interests, or my best interests. If the information will affect the choice it should be given.
I note that there has also been much discussion is some ambulance services in recent months with specific regard to the interim AHPRA Paramedicine Code of Conduct (https://www.paramedicineboard.gov.au/Professional-standards/Codes-guidelines-and-policies/Code-of-conduct.aspx).
At Section 35 – Informed Consent, it states:
Fees and financial consent
a. Patients or clients should be made aware of all the fees and charges involved in a course of treatment, preferably before the health service is provided.
b. Discussion about fees should be in a manner appropriate to the professional relationship and should include discussion about the cost of all required services and general agreement about the level of treatment to be provided.
Whilst I acknowledge this could be challenging in many paramedic encounters surely the now registered paramedics have a professional obligation in addition to that of any employer to ensure that the patients have given informed consent to all aspects of their care?
Excellent post, thank you.
I’ve always thought the policy here in WA (of avoiding any discussion regarding fees and billing) to be deceptive and unprofessional. It also seems to result in many bill generated complaints that openness would avoid.
Hopefully the Ombudsman’s findings have a flow on effect to all states and territories.
I don’t actually understand how St John (WA) can charge like other ambulance services. As I’ve noted in earlier posts in jurisdictions other than WA and NT the authority to render a fee to a person who did not request the service and was not advised, in advance, is found in legislation. In the absence of legislation in WA (and NT) it has to be standard commercial principles. One can charge for a service provided but in particular for cases where there is no transport and just some ‘on scene’ assessment i would have thought St John (WA) would or should have great difficulty in enforcing their claim for payment.