Two homeless men in Fresno have called for an ambulance an average of nearly twice a day for more than a year, racking up hundreds of thousands of dollars in costs and even more when they get to a hospital.
They are Fresno County's highest-volume ambulance users -- "frequent fliers" as they are called in the business -- and their 1,363 combined trips made up 1.34% of all American Ambulance calls in the county last year.
"I call all the time," Cesar Arana, 41, said while sitting on a bus-stop bench downtown. "I have a major problem with my liver."
Lonzel McPeters, 51, has seizures and says he grows concerned when he senses one coming on.
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"I'd be having seizures on a regular basis," said McPeters, wearing a neck brace to stabilize a broken C-7 vertebrae after a January seizure. "I call when I feel like I'm having seizures."
Because the men don't pay for the rides, the bulk of the costs is passed on to others in the form of higher insurance rates. Taxpayers pick up part of the tab through Medi-Cal and other government programs.
Some in the industry say the two are abusing the system, using it as a free taxi service. But the men, who are friends, say they're just trying to get to a hospital for treatment of their chronic illnesses.
Calling 911 when there is no emergency is a crime and there is no law saying the men must be brought to a hospital, but ambulance officials err on the side of caution. They fear liability lawsuits such as a 1979 case in which a sick man called for an ambulance, was not picked up and died.
"We do not refuse any service," said Dan Lynch, Fresno County's emergency medical services director. "If they want to go to the hospital, we will take them. It's easier to take them than to take the time to talk them out of it."
Calling in sick
In 2011, Arana called an ambulance 710 times and McPeters 653 times. In the first 41 days of 2012, they have combined for 136 calls.
Sometimes the men call an ambulance, are brought to a hospital and walk away if they have to wait too long. Then they'll call 911 for a return ride later.
Lynch's office has sent notices to the men, demanding they stop abusing the 911 system. After sending one such notice to Arana last year, Lynch said, his office got an angry phone call from Arana.
In a taped phone conversation with Lynch's office, Arana is heard saying he didn't abuse the system and threatened to call his lawyer.
"If I want to go to the hospital and call the ambulance, I will," he said. "You cannot deny me to call the ambulance."
Said Lynch: "It's defiant; it's like laughing in my face."
Arana, who worked as a chef until five years ago, said he is not trying to be defiant but trying to follow medical directions for treating his alcohol problem.
"I am trying to make sure I am doing the right thing," he said of his frequent hospital visits.
But Lynch worries that while paramedics are treating Arana or McPeters, another call might come in with a life-threatening emergency and a second ambulance will be too far away to get there in time.
In a typical ambulance call, paramedics will give patients a physical exam and check their mental state, medical history and vital signs, said Todd Valeri, American Ambulance's general manager. They'll also ask about any medications patients are taking and allergies or reactions they have with certain drugs.
After the exam, paramedics will treat, release or transport the patient.
"If the patient still wants to be transported, we will transport," Valeri said.
It takes a little more than an hour, on average, from the time paramedics are called to the time they are released for a new call, Valeri said.
The number of ambulance calls coming from the homeless has grown nearly tenfold since 2008, county documents show. The top eight "frequent fliers" among the homeless called 238 times four years ago. By 2011, that number was 2,184.
McPeters and Arana said they tell friends on the street to call for an ambulance if they feel ill, but not everyone heeds their advice.
A homeless woman who knows both men said she was upset by how they reflect upon Fresno's thousands who are homeless. She said she has watched them get in ambulances many times.
"I was hit by a car two months ago, and if I need to go to the hospital, I walk there," said the woman, who identified herself only as Mary.
A price to pay
The average ambulance ride costs American Ambulance about $400, Valeri said. If Arana and McPeters had paid for every ride they took last year, it would have cost $545,200.
McPeters is in a county medical program for the indigent -- people who have no means to pay for services -- which pays less than 3% of the cost, and Arana is on Medi-Cal, which pays about 42% of the cost.
Fresno County gives American Ambulance a flat rate of $70,000 a year for calls from the indigent. The ambulance company had 5,905 indigent calls last year, Valeri said.
That means American Ambulance got less than $12 every time it took an indigent person to a hospital.
Medi-Cal reimburses about $167 per trip, but Gov. Jerry Brown is proposing a 10% cut in those payments, Valeri said.
American Ambulance was reimbursed about $126,000 through the two taxpayer-funded programs for calls from Arana and McPeters. The net loss of more than $400,000 was made up through cost shifting, Valeri said, charging more to people with insurance and the uninsured who pay their ambulance bills.
A California family will pay $150 per month more in insurance premiums because of cost shifting for ambulance and hospital visits, said Nicole Kasabian Evans, a spokeswoman with the California Association of Health Plans in Sacramento.
That's just the beginning.
When they get to a hospital, Arana and McPeters could be examined, treated or prescribed drugs.
Community Regional Medical Center officials estimate an average trip to the emergency department with a medical evaluation is about $370. If Arana and McPeters were evaluated every time they went to a hospital, the cost would be more than $500,000.
Community Regional Medical Center, like American Ambulance, also does not refuse service.
"The reality is that many of the visits are unwarranted, but we never know," said Robyn Gonzales, associate administrator with Community Regional Medical Center in Fresno. "We have to treat them the same way every time they come in."
Liability a fear
For three years, Fresno County Emergency Medical Services officials have been trying to get frequent fliers such as Arana and McPeters to stop their constant calls but are at a loss in dealing with them, Lynch said.
In that time, the number of calls from the two men has skyrocketed from 200 in 2009 to 1,363 in 2011.
Fresno city officials, social-services agencies and hospitals have offered them bus tokens, housing, food and rehabilitation counseling, but McPeters and Arana have refused, city and county officials said.
Both men have been warned that they are abusing the 911 system. Lynch said he has sent four letters to Arana and three to McPeters. The letters are hand-delivered or sent to a known-relative's address. He said he personally talked to Arana about his calls while Arana was on a gurney going to the hospital.
"We want to show that we have gone to every possible length to advise these guys," he said.
Even though 911 abuse is a crime, it's not something that is often prosecuted locally. Fresno County District Attorney Elizabeth Egan said her office prosecutes about 10 cases of 911 abuse each year, but she couldn't determine which calls were related to ambulance, police or fire calls.
Lynch has asked Fresno County to consider policies for the ambulance service to allow American Ambulance to refuse service. The county's lawyers have not yet given him any options.
"I don't think we are going to change them," Lynch said, "so we are going to have to change the system because it is putting other people at risk."
The choices are stark, and Lynch cites a 1979 case as a cautionary tale.
At the time, the Fresno Fire Department fielded emergency calls and funneled them to several ambulance services.
George J. Kovacevich, 62, of Fresno, had emphysema and used an oxygen tank. In the five days before he died on Aug. 1, 1979, Kovacevich called the Fire Department six to eight times. The Fire Department said his calls were related to a problem with his breathing equipment and they never gave him medical aid.
Department administrators ordered a stop to service at his home and refused to send an ambulance the day his house cleaner found him unconscious on the floor of his North Ninth Street apartment. She called 911 but was told that an ambulance would not be sent.
The woman then called a relative of Kovacevich who told the Fire Department that Kovacevich was not breathing. Fifteen minutes later, an ambulance arrived, but Kovacevich was dead.
His family filed a lawsuit but lost, said his son, George J. Kovacevich Jr., a Santa Cruz lawyer.
"My dad was a tough customer. ... He would panic and call them and he wasn't always polite," he said. "But what they did was really pretty egregious. I think the conduct was really bad."
Lynch said the Kovacevich case has had long-lasting effects.
"The moral on that case is regardless of who you are, you will always get services," Lynch said. "We will always respond."
Fresno's most frequent fliers may stand alone in their overuse of ambulances. "That's certainly the most I've ever heard of in a year," said Dan Smiley, deputy director with the state Emergency Medical Services Authority in Sacramento.
Some of Lynch's fellow EMS directors in California were stunned when told of the number of times Arana and McPeters ride the ambulance.
Ross Elliott, Kern County emergency services manager, said he has callers who use the ambulance about once a day, and his office is working to identify those high users and find ways to reduce needless calls.
"These people use it because it's a convenient, free way to get around," he said. "We need to do something about it."
Elliott said one option would be a co-pay, perhaps $15 or $20, for those who overuse the system.
"There is an abuse of the system and there should be some kind of law against doing it," he said.
Around the country, programs are under way to cut into emergency room visits.
In Fort Worth, Texas, paramedics on light duty teach patients to reach service providers and find their own doctors so they don't need to call an ambulance, said Matt Zavadsky, director of operations for MedStar, the community's ambulance service.
"We had one patient who didn't know how to ride the bus, so our guy rode with him and took him to the transfer station, where they rode another bus to his doctor's office," Zavadsky said. "Now he knows which bus to get on and how to get to the doctor's office."
Among its top 54 patients, MedStar saw a 51% drop in calls, Zavadsky said.
Community Medical Centers in Fresno has a similar program that offers housing, rehabilitation counseling and links to services to assist repeat emergency room patients.
The Community Connections program has helped about 200 people find services since it began in 2009, cutting emergency room visits by helping patients get aid or finding them personal physicians, said Gonzales of Community Regional Medical Center.
The key, Gonzales said, is forging relationships with other organizations that can help people who may not know services are available.
"There is a population of patients who do game the system," she said. "But for all the people who don't want to cooperate, there are many more who do."
Fresno's homeless prevention manager, Greg Barfield, said his office and other agencies will keep working to persuade the less cooperative to change.
"There are some people who will keep telling you 'no,' " he said, "but you just have to keep the door open."