Can you afford an ambulance in South Africa?

When a loved one is straddling the line between life and death, you won’t hesitate to call an ambulance. But once they’ve been stabilised and delivered to the nearest hospital, you’ll be faced with the bill.

The cost of an ambulance 

We find out how much an ambulance ride costs in South Africa, whether you can refuse to get into an ambulance, and who pays the bill if you’re unconscious.

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According to Denver Ramnarain, director of Quick Response Services, the National Reference Price List for Ambulance Services (NRPLAS), which was released in January 2009, is used as a guide to determine ambulance prices.

According to the Road Accident Fund Medical Tariff document, these are the fees you’re likely to pay for an ambulance in 2021.

 Source: https://www.gov.za/sites/default/files/gcis_document/202103/44252gen191.pdf

The above table distinguishes between three kinds of emergency life support: basic, intermediate, and advanced. All three are interventions used to stabilise patients until they reach the hospital. Depending on the state of the patient, emergency personnel will perform the necessary life support to ensure the safety of a patient.

Basic vs. advanced life support 

The main difference between basic and advanced life support is that the former does not include invasive treatments – in other words, a patient’s skin will not be pierced, such as with a needle or a scalpel, if they receive basic life support.

The patient will be billed according to the category their life support falls under. For example, if your lung collapses in an ambulance, and emergency personnel need to puncture your chest to re-inflate it, this will be considered advanced life support because your skin had to be pierced.

“The NRPLAS document is old, and we have adopted a 5% year-on-year increase to account for inflation, but there is no current pricing for ambulances,” says Ramnarain. 

All emergency medical service providers invoice the medical scheme if the patient is insured, or the patient directly if they do not have medical insurance cover, says Shalen Ramduth, director of operations at Netcare 911.

Lack of competition leads to higher prices

In South Africa, medical aid providers have partnered with specific private emergency companies, outsourcing them to clients to call in an emergency.

“This is anti-competitive and, if patients call a different company, insurers only pay 40 – 60% of their account as a penalty,” says Ramnarain.  

However, he explains that if you were unconscious when the call was made, the insurer will assume that someone else called and the entire account will be covered. But this needs to be motivated by the transporting ambulance service as to why the client did not follow procedure.

In any market, reducing competition leads to inflated prices. If patients are directed towards a single company, then that company will do well. But the remaining companies in the market will receive fewer clients, forcing them to increase their prices to stay afloat.

Riding an ambulance on credit

Ramnarain points out that ambulances are not financial institutions and, as such, they cannot offer patients credit.  

This means that a debt can only be charged interest on defaulting payment when it is handed over to a credit provider for collection. This increases the cost of collection, which the patient is liable for.

“I would rather allow a patient to make payment arrangements with me than have to pay collectors to retrieve money on my behalf. But patients often say they either can’t pay anything, or they didn’t call you, so they refuse to pay,” says Ramnarain.

Refusing service, and the cost of being unconscious

A patient can refuse care from anyone, regardless of whether they can afford it or not.

Ramnarain considers this an ethical dilemma. He recalls being confronted with a situation where a patient refused pain relief because he could not afford the additional cost.

“I decided to give it to him for free because I could see that he was in pain, but this is unfortunately a high-level decision that cannot be made by junior staff,” says Ramnarain.

“If a person refuses transport due to finances, it is their choice. But the onus remains on the treating medic to make sure that the person is not in a life-threatening situation,” he adds.

Ramduth agrees that all emergency medical service providers should assist with life-threatening cases, even where patients are unable to pay for the treatment received.

If they decide to wait longer than necessary and not transport a person with life-threatening injuries, this could be considered neglect, which can be reported to the Health Professionals Council of South Africa (HPCSA).

“However, this is hard to prove as the person may decide that they don’t want treatment and may not disclose that it is due to cost. Or, the medic may be acting in the best interest of the patient and they could still die,” says Ramnarain.

“Ethics is the biggest role-player and we all have vastly different moral compasses. Business is business, but people’s lives are at risk,” he insists.

On the other hand, if someone is unconscious and is taken to a government hospital, they may refuse to pay as they did not accept the terms of service.

“Here the moral responsibility lies with the patient. If they went to a private hospital, that would mean someone paid an account at the hospital and that person can sign surety for the ambulance account,” says Ramnarain.

The government not providing enough ambulances

According to the Western Cape Government’s website, no one will be refused emergency medical services based on their ability to pay for the service. 

It states that if you’re a member of a specific medical aid, you’ll be charged uniform patient fee rates agreed with the medical aids. And if you’re not, you’ll be assessed according to your income, and charged accordingly.

Ramduth points out that South Africans are protected under the National Patients’ Rights Charter, which means that they have the right to medical assistance.

“If an uninsured patient is not experiencing a life-threatening emergency, they have access to the provincial emergency services which will render stabilisation and transportation to a hospital if required, at no cost to the patient,” says Ramduth.

However, despite catering for various income groups, having a reliable service that can cater for the number of people who require the service is also important.

In December 2018, the Mail & Guardian’s centre for health journalism, calculated how many government ambulances were available in each province and they compared it to how many ought to be available.

Except for the Northern Cape, they found that none of the provinces had the requisite number of ambulances available. The Western Cape had 264 rather than 662, Gauteng had 726 rather than 1472, and Kwa-Zulu Natal had 573 rather than 1138.

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