Background: Japanese emergency medical services (EMS) can be used by anyone for free. Recently, EMS usage has increased; the increased costs and the prolonged time for ambulance transport have become recent social problems. Objective: We surveyed the willingness to pay (WTP) for resuscitation provided by EMS. Methods: In November 2011, men and women (3160) aged 20 - 59 years were asked to assume that they were experiencing a cardiopulmonary arrest (CPA), and their WTP for EMS services was assessed in the following three situations: Case A, ambulance transport alone; Case B, chest compression in addition to ambulance transport; and Case C, artificial ventilation through chest compression and intratracheal intubation, in addition to ambulance transport. We calculated the mean WTP for each case. Results: The WTP for Case A, B, and C were ¥6,696 ($65.0), ¥16,081 ($156.1), and ¥27,505 ($267.0), respectively. The WTP for Case B was significantly higher in respondents aged 40 - 59 years compared to those aged 20 - 39 years. The WTP for case B and C were significantly higher in males compared to females. WTP was significantly lower in students than it was in private employees. Although women’s intention to pay was higher than that of men, their WTP was lower than that of men. Public employees’ and students’ intention to pay was significantly lower than that of private employees. Conclusions: Our study provides information about the optimal fee for EMS, which will be useful for discussions on the feasibility of introducing a fee for EMS in Japan.
The number of dispatched ambulances in Japan has been increasing with every consecutive year. In 2016, there were 5,980,000 requests for an ambulance throughout Japan, which means that an ambulance was dispatched once every 5.3 seconds [
Although, the Japanese emergency medical services (EMS) are available, as a public service, for a person who requires ambulance transport to a medical institution urgently, approximately half of the patients who were actually transported to a hospital by ambulance had mild only symptoms [
Irrespective of the severity of symptoms, a person can take advantage of the ambulance service, without any charge, by calling 119, since the EMS provided by the fire department are run by each of the cities, towns, and villages, and the operating costs are supported by taxes and national government subsidies. However, it is becoming difficult for many local governments such as local cities, towns, and villages to secure adequate revenue owing to the decrease in tax revenue due to the increasing elderly population, decreased working-age population, and stagnant economy. Currently, the total population of Japan is declining, while it is estimated that the elderly population will increase until 2047 [
Therefore, people seem to be aware that they may have to pay for the use of ambulances in the future. The cost of operating the EMS will become a serious concern in the near future. Based on the current situation, the Ministry of Finance Japan and the Fire and Disaster Management Agency are aware of the necessity to examine the feasibility of introducing a fee for EMS [
We conducted an Internet panel survey through a company in November 2011. All respondents were registered as panel members with the company. First, to recruit the respondents for the present study, the survey company created a list by random sampling from all registers. Next, an email asking whether they were interested in participating in our survey was sent to all individuals on this list. The registration was closed when the number of respondents in each group reached the target sample size. Then, an Internet-based questionnaire using the contingent valuation approach (CVA) was filled by persons aged 20 - 59 years who were registered as panel members with the company. The respondents completed and transmitted their responses via mail. Inclusion and Exclusion criteria are shown in
The subjects were asked about their age, sex, household structure, occupation, and their history of attending a cardiopulmonary resuscitation (CPR) training course [how to perform chest compressions, how to use automated external defibrillator (AED), and how to perform artificial ventilation]. Furthermore, they were asked about the WTP in the three cases shown in
The exchange rate of the yen to US dollar in this study was, 103.0 JPY (¥) = 1.00 USD (as on September 2, 2016). Numbers with upper and lower limits of 0.5% of WTP values in all 3 cases were excluded from the calculation. The respondents who entered ¥0 into all the fields for Cases A, B, and C were not included in the calculation of the WTP, since it was judged that they had no intention to pay for the EMS. The mean WTP for each case was calculated according to sex, age category (20s - 30s and 40s - 50s), occupation, and history of attending a CPR training course.
Inclusion criteria | ü Men and women aged 20 - 59 years old who were registered with the Internet panel survey company. |
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Exclusion criteria | ü Medical workers such as physicians, nurses, and ambulance attendants. ü Respondents with unknown occupation. |
Question | Currently the costs necessary for ambulance transport and life support that are provided by the emergency services are not demanded from the user. Please specify the amount that you would pay for each case if you had to pay these costs. Please enter “0” if it is unlikely that you would pay for the costs. |
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Case A | Please assume that you had CPAa suddenly. Immediately, you would be transported to a hospital via an ambulance with ambulance attendants. However, no critical care would be provided in the ambulance and only ambulance transport to a hospital would be conducted. |
Case B | Generally, a patient with CPA is more likely to die within several minutes when no procedure is provided. However, it has been reported that the survival rate is improved when a chest compression is provided. In Case B, chest compression as critical care would be provided by ambulance attendants in the ambulance during ambulance transport. (ambulance transport and chest compression) |
Case C | On the other hand, as critical for the care for some patients with CPA, an air passage may be secured by inserting a tube into the airway directly, in combination with mechanical ventilation to deliver oxygen artificially. This procedure may improve the survival rate to some extent, although it has been reported that the rate may not be changed by the procedure, and it remains controversial. In Case C, ambulance attendants would provide critical care by mechanical ventilation, by using devices in addition to chest compression. (ambulance transport and mechanical ventilation through chest compression and intratracheal intubation) |
aCPA: Cardiopulmonary arrest.
Statistical analyses were conducted to examine the differences in WTP using a t-test or Welch’s t-test as appropriate for age category, sex, and experience of attending a CPR training course. Differences according to occupation were also analyzed. For the difference of the means among the occupations, we conducted the Kruskal-Wallis test followed by the Steel’s test for multiple comparisons, using the data of private employees as a control.
A logistic regression analysis was carried out to investigate the tendency of WTP for the use of EMS. The intention of presence or absence to pay for using EMS was the dependent variable. The independent variables included sex, age, occupation, and experience of a CPR training course. People who answered ¥0 for all three cases were classified as those who did not intend to pay for the use of EMS and those who responded to any one of the three cases were classified as those who intended to pay. JMP® version 11.2 (SAS Institute Inc., Cary, NC, USA) was used for the analyses. The level of significance was set at P < 0.05.
The response rate for the current internet survey was 32.8%; responses were received from 3160 people. Of those, 352 medical workers, such as physicians, nurses, and ambulance attendants, were excluded according to the exclusion criteria. The data of 28 subjects at the extreme top or bottom 0.5%, and 55 subjects whose occupation was unknown, were also excluded. Finally, the responses of 2725 subjects were included in the present analysis.
Category | Classification | No. of Respondents | % |
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Age category | 20 - 39 years old | 1289 | 47.3 |
40 - 59 years old | 1436 | 52.7 | |
Sex | Male | 1346 | 49.4 |
Female | 1379 | 50.6 | |
Household structure | Live alone | 444 | 16.3 |
Live with spouse | 492 | 18.1 | |
Live with spouse and children | 908 | 33.3 | |
Live with parents | 263 | 9.7 | |
Live with parents, brothers and sisters | 215 | 7.9 | |
Live with parents, spouse and children | 172 | 6.3 | |
Live with parents and children | 98 | 3.6 | |
Other | 133 | 4.9 | |
Occupation | Private employee | 1250 | 45.9 |
Public employee | 202 | 7.4 | |
Technical specialist | 16 | 0.6 | |
Self-employed people | 175 | 6.4 | |
Free-lancer | 76 | 2.8 | |
Part-time worker | 232 | 8.5 | |
Student | 89 | 3.3 | |
Housewife/Housekeeping husband | 539 | 19.8 | |
Unemployed | 146 | 5.4 | |
Experience of attending CPRa training course | No | 1551 | 56.9 |
Yes | 1174 | 43.1 | |
Intention to pay for the EMS | No | 1246 | 45.7 |
Yes | 1479 | 54.3 |
aCPR: Cardiopulmonary resuscitation.
Category | Classification | WTP | |||||
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Case Aa | Case Bb | Case Cc | |||||
JPY | (USDd) | JPY | (USD) | JPY | (USD) | ||
Age category | 20 - 39 years old | 6853 | (66.5) | 13,692 | (132.9) | 26,032 | (252.7) |
40 - 59 years old | 8733 | (84.8) | 19,719 | (191.4)* | 31,009 | (301.1) | |
Sex | Male | 9043 | (87.8) | 20,160 | (195.7) | 32,920 | (319.6) |
Female | 6672 | (64.8) | 13,655 | (132.6)† | 24,491 | (237.8)† | |
Occupation | Private employee | 9954 | (96.6) | 17,370 | (168.6) | 28,582 | (277.5) |
Public employee | 6032 | (58.6) | 11,916 | (115.7) | 20,111 | (195.3) | |
Technical specialist | 2313 | (22.5) | 9,751 | (94.7) | 16,126 | (156.6) | |
Self-employed people | 6216 | (60.4) | 19,119 | (185.6) | 41,569 | (403.6) | |
Free-lancer | 6092 | (59.1) | 18,895 | (183.4) | 23,263 | (225.9) | |
Part-time worker | 5834 | (56.6) | 22,065 | (214.2) | 33,555 | (325.8) | |
Student | 1921 | (18.7)‡ | 5713 | (55.5)‡ | 12,697 | (123.3)‡ | |
Housewife/Housekeeping husband | 6176 | (60.0) | 15,647 | (151.9) | 27,132 | (263.4) | |
Unemployed | 8706 | (84.5) | 19,500 | (189.3) | 37,360 | (362.7) | |
Experience of attending CPR training course | No | 7201 | (69.9) | 16,023 | (155.6) | 27,358 | (265.6) |
Yes | 8692 | (84.4) | 17,985 | (174.6) | 30,367 | (294.8) | |
Mean | 6696 | (65.0) | 16,081 | (156.1) | 27,505 | (267.0) |
aCase A: only ambulance transport. bCase B: chest compression and ambulance transport. cCase C: mechanical ventilation through chest compression and intratracheal intubation, and ambulance transport. dUS dollar to Japanese yen convert rate; 1 USD = 103.0 JPY as of September 2, 2016. *, †, ‡ indicate P < 0.05 (*: vs 20 -39 years old, †: vs Male, ‡: vs Private employee).
according to age category. According to occupation, the WTP was significantly lower in students as compared to that in private employees, in all cases.
Our study indicated that more than half of the respondents expressed an intention to pay for EMS. The total sum of WTP increased when it was indicated in the survey that resuscitation was needed in addition to ambulance transport. The amount of WTP for each case was significantly different between men and women. Women’s intention to pay was higher, while their payment amount for the WTP tended to be lower than that of men. This difference may be because the number of people involved in paid employment is generally smaller in women than that in men [
Independent variable | CaseAa | CaseBb | CaseCc | |||||||
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ORd | (95% CIe) | P | OR | (95% CI) | P | OR | (95% CI) | P | ||
Age | 1.008 | (1.000 - 1.017) | 0.043 | 1.009 | (1.001 - 1.017) | 0.026 | 1.008 | (1.001 - 1.016) | 0.034 | |
Sex | ||||||||||
Female | reference | reference | reference | |||||||
Male | 0.998 | (0.851 - 1.170) | 0.978 | 0.838 | (0.721 - 0.975) | 0.022 | 0.807 | (0.693 - 0.939) | 0.006 | |
Occupation | ||||||||||
Private employee | reference | reference | reference | |||||||
Public employee | 0.866 | (0.626 - 1.189) | 0.376 | 0.712 | (0.525 - 0.965) | 0.028 | 0.700 | (0.516 - 0.948) | 0.021 | |
Technical specialist | 0.787 | (0.246 - 2.181) | 0.655 | 0.902 | (0.329 - 2.472) | 0.838 | 0.815 | (0.297 - 2.235) | 0.685 | |
Self-employed people | 1.122 | (0.806 - 1.554) | 0.492 | 1.086 | (0.787 - 1.501) | 0.616 | 1.101 | (0.797 - 1.527) | 0.562 | |
Free-lancer | 0.666 | (0.389 - 1.094) | 0.114 | 0.827 | (0.517 - 1.318) | 0.425 | 0.790 | (0.495 - 1.260) | 0.321 | |
Part-time worker | 0.744 | (0.545 - 1.006) | 0.055 | 0.772 | (0.582 - 1.023) | 0.072 | 0.783 | (0.591 - 1.038) | 0.089 | |
Student | 0.232 | (0.106 - 0.449) | <0.01 | 0.486 | (0.297 - 0.778) | 0.002 | 0.553 | (0.345 - 0.874) | 0.011 | |
Housewife/ Housekeeping husband | 1.110 | (0.899 - 1.368) | 0.332 | 0.966 | (0.788 - 1.185) | 0.741 | 0.972 | (0.792 - 1.194) | 0.789 | |
Unemployed | 0.683 | (0.462 - 0.992) | 0.045 | 0.863 | (0.611 - 1.219) | 0.404 | 0.869 | (0.616 - 1.229) | 0.427 | |
Experience of attending CPRf training course | ||||||||||
No | reference | reference | reference | |||||||
Yes | 0.962 | (0.815 - 1.134) | 0.642 | 1.009 | (0.863 - 1.181) | 0.908 | 1.045 | (0.893 - 1.222) | 0.587 |
aCase A: only ambulance transport. bCase B: chest compression and ambulance transport. cCase C: mechanical ventilation through chest compression and intratracheal intubation, and ambulance transport. dodds ratio. eConfidence interval. fCardiopulmonary resuscitation.
students were less likely to express the intention to pay. It is interesting that public employees’ intention to pay for EMS was lower than that of private employees. These results may be derived from public employees’ awareness that the services should naturally be funded by public money, because EMS staff are also public employees.
Only a few studies have reported the percentage of intention to pay for EMS using questionnaires in Japan. A survey conducted in a metropolitan area showed that 63% of the respondents thought that the user of the ambulance should pay for EMS use, at least in part [
In a survey conducted in metropolitan areas in Japan, the most common WTP for the use of EMS was ¥3000 ($29.1) - ¥5000 ($48.5) [
It should be noted that various factors (such as the psychology or the social situation of the person calling for an ambulance) may influence their decision to call for an ambulance. Another survey (of the WTP by the contingent valuation approach in the situation of a myocardial infarction) revealed that the number of patients who used the EMS did not decrease even if the fee for the ambulance was high [
There are some limitations in this study. First, the study subjects were limited to persons aged 20 - 59 years, which meant that the thoughts of persons younger than 20 years and those aged 60 years or older were not included. Second, this study was a survey of the WTP, in which CPA was assumed to be an extremely serious condition. The results are likely to be different from those of the WTP for ambulance transport for patients with a disease condition that is not serious. Third, this survey was conducted as an Internet questionnaire. This may result in a selection bias of subjects. However, web surveys have recently become a common method of conducting research [
We investigated the WTP for EMS, including ambulance transport and resuscitation, by asking respondents to assume that they were experiencing CPA. The intention to pay for artificial ventilation through chest compression and intratracheal intubation (in addition to ambulance transport) was expressed by 54.3% of the respondents. Our study provides information about the fee that people are ready to pay for EMS in Japan. This information will be useful for discussions on the feasibility of introducing a fee for EMS in Japan.
Ito, Y., Akahane, M., Maeyashiki, A., Ogawa, T. and Imamura, T. (2017) Beneficiaries’ Willingness to Pay for Resuscitation Provided by Ambulance Attendants: A Survey Using the Contingent Valuation Approach. Health, 9, 1367-1377. https://doi.org/10.4236/health.2017.910100