When a La Pine medical facility calls 911 for an ambulance, the La Pine Rural Fire Protection District charges that facility, not the patient.

The fire district’s billing practice is an anomaly in Central Oregon, and the estimated $2,000 fee it charges per ambulance ride to St. Charles Bend’s emergency room has triggered a lawsuit and raised concerns among residents and medical professionals. The district’s actions could jeopardize health care in a low-income community where the life expectancy of residents is already shorter than their neighbors in Bend. Those actions could also lead to the closure of the two rural medical facilities as unaffordable fees pile up.

“It would be a tremendous step backward for our community,” said Ann Gawith, La Pine Chamber of Commerce executive director. “The people in the district need to know that ambulance service isn’t paid through their taxes.”

One La Pine health care provider fears the billing method incentivizes patients to drive to a medical facility when they’re suffering a medical emergency in order to avoid ambulance fees.

While the La Pine fire district charges the facilities that call 911, in Bend and Madras, it’s the patient’s responsibility to pay the bill, regardless of who calls for emergency help.

“The ordinance (billing practice) is not in the community’s best interest at all,” said La Pine Mayor Dan Richer. “It’s being driven by money.”

The city of 2,343 people doesn’t have any jurisdiction over this issue, Richer said. The La Pine Rural Fire Protection District is governed by its own board, which passed the ordinance allowing the unusual billing practice in 2019.

The central issue is that the fire district provides ambulance service at a loss, said Jerry Hubbard, a fire district board member whose term expires in June, in an email response. As a way to cover the costs, the board of directors at the fire district approved an ordinance in 2019 that gave the fire chief approval to impose an ambulance transport fee and a non-emergency medical fee on 911 calls he deemed not life-threatening.

The policy was changed earlier this month by the fire district board to now charge health facilities for all ambulance transport, regardless of the reason.

Suit filed

The fire district’s actions prompted the La Pine Community Health Center and St. Charles Family Care Clinic in La Pine to file a lawsuit last year disputing more than $350,000 in combined 911 initiated ambulance fees charged by the district to the clinics.

The two La Pine medical facilities allege the fire district’s fee structure is illegal because it shifts the burden of payment from the patient that received the service to the entity that made the 911 call. The lawsuit also alleges the policy gives the fire district the authority to determine if an ambulance ride was medically necessary, an action that could contradict medical professionals.

The next court hearing is May 6, according to court records.

“This is an isolated situation,” Bill Boos, Oregon Fire Chief Association second vice president. “This isn’t something that other fire departments or districts are doing in Oregon. It won’t affect anyone else.”

In some areas, the ambulance service can bill the patient the balance after an insurer pays, but in communities with a high percentage of Medicaid patients, the federal program pays anywhere from 27% to 67% of the bill and the fire district or department has to accept that payment as paid in full.

The La Pine fire district, which has two ambulances, oversees a 117 square-mile area for fire protection services and 1,000 square miles for the ambulance service district, Hubbard said in an email.

The district’s policy states a fee will be imposed directly to the medical facility, health care facility, medical office, medical clinic or hospital for all ambulance transports for patients from their facility to another. The fire chief has the discretion to interpret and apply the policy, according to the district’s policy.

Oregon law divides the state into ambulance service areas that are bid on and overseen by counties. In Deschutes County, the ambulance service area plan oversees the award of the contract to a district or department. Also under Oregon law, a patient can refuse to be transported by ambulance to an emergency department. It’s a protection offered under the law for patients who don’t have medical insurance coverage and would be responsible for the ambulance fee.

Because it’s a 30-minute drive along U.S. Highway 97 to get to St. Charles Bend’s emergency department, many folks in La Pine and the surrounding communities like Chemault and Christmas Valley buy insurance to cover the cost of airlifting or ambulance services, said Gawith who has lived in La Pine for 40 years.

Having access to medical care is important, Richer said, the La Pine mayor.

In 2020, St. Charles’s La Pine clinic called 911 95 times requesting transport from its clinic to the hospital in Bend. In 2020, the La Pine Community Health Center called 911 on behalf of patients 35 times, according to Hubbard’s email.

“Emergency medical service is an expense,” Hubbard said in an email. “Due to the high volume of ambulance transports to St. Charles ER (1,046 in 2020) the district ambulances are replaced every 2 1/2 to 3 years costing $250,000 each. The 2021 operating budget cannot afford to add additional firefighter/paramedics.”

Letters of testimony

But since 2020, the fees have been adding up against the two health centers and caused a controversy in the community that brought out more than 50 letters of testimony for and against the ordinance at a January public hearing.

“I need you to know I highly disagree with the actions that this (policy) has enlisted,” Anita Clark wrote in her testimony. “I think that a doctor is the one to determine if emergency transportation is needed. I do not think that they would call for our services if they did not think that it was absolutely necessary.”

Another who testified was Robin Lannan Adams, a retired internal medicine physician, who also launched a campaign for a seat on the fire district board.

“I first learned of this conflict between the ambulance and the medical clinics last year,” Lannan Adams said in an interview recently. “I started attending the fire board meetings to get educated, and I was shocked by the decisions made. Patients need ambulance transport. They’re not going by ambulance because they need a ride.”

La Pine residents Mark and Colleen Donzelli said in an email that their experience in the medical field in San Fransisco supports the fire district.

“We understand about the frequent flyer and the urgent care doctor not wanting to be sued so he passes the buck to the 911 service,” said Colleen Donzelli in her written testimony.

“This county has grown and the county planners have not planned for this issue.”

The Oregon Health Authority oversees and approves ambulance services and licenses ambulance agencies and vehicles, but it does not regulate billing practices, said Jonathan Modie, a health authority spokesman.

In 2020, the district transported 1,046 patients to St. Charles Bend’s emergency department, according to Hubbard.

They are transported not just from clinics, but from homes and doctors’ offices. Typically Medicare pays a flat fee for emergency and non-emergency ambulance services when the patient’s medical condition is bad enough that any other method would endanger their health.

“The district has a policy that it will never leave the citizens of La Pine without fire, emergency medical service and rescue services,” said Hubbard in an email. “Many times both ambulances are taking patients to St. Charles ER or returning to the district.”

The district’s practice concerns Oliver Tatom, a registered nurse supervisor at St. Charles Family Care and Intermediate Care in La Pine. Tatom, a former paramedic in Jefferson County, said he fears he is not getting the right care for his patients.

“I worry that if a patient is having a heart attack or stroke, I don’t want them driving or being driven to a clinic or to an emergency department,” Tatom said. “Patients with chest pains or difficulty breathing should activate 911 from their home or business for transport by ambulance under the care of a paramedic.

“Every minute counts with a heart attack,” he said. “You don’t want people getting in their car to drive to an emergency department in the midst of a medical emergency.”

Last year, the clinic saw more than 7,000 patients and referred about 700 to the emergency department at St. Charles. Only 95 of them went by ambulance from the clinic, Tatom said.

“It’s a big safety issue, and it does impact patient safety,” Lannan Adams said.

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