FRESNO – 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 percent 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. "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.

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 taken 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."

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 taken 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 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 that 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," said Arana, who worked as a chef until five years ago.

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 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.

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 overall has grown nearly tenfold since 2008, county documents show.

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 percent of the cost, and Arana is on Medi-Cal, which pays about 42 percent 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.

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.

But 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.

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