TSUKUBA, Ibaraki Prefecture—A man in his 60s who fell hard on his left shoulder in Tokyo managed to board a train that took him to the nearest station to his home here early the following morning.

By then, the pain in his shoulder became so severe that he could barely move. With no station attendants around, he called the emergency 119 number and took an ambulance to a hospital.

A doctor told him he had a broken shoulder that might require surgery.

However, adding to his pain was a surprise charge in his medical bill: 7,700 yen ($50) for ambulance services.

Ibaraki last year became Japan’s first prefecture to charge patients in “non-emergency” condition for ambulance rides. Such conditions are determined by doctors.

In Japan, ambulances, operated by fire departments of local governments, are basically free of charge.

But advocates of ambulance billings say the increasing trend of people with minor injuries or ailments using ambulances has squeezed the resources of emergency care providers, making it difficult for patients in true emergencies to receive treatment in a timely manner.

“Lives that can be saved might not be saved in this situation,” a prefectural official said, explaining why Ibaraki Prefecture adopted the billing setup in December.

Ambulances were dispatched more than 140,000 times in the prefecture in 2023, a record high for Ibaraki.

In recent years, more than 60 percent of patients summoning ambulances were taken to 22 large medical facilities in the prefecture with teams capable of providing emergency care.

But nearly half of cases were considered “mild” by doctors, according to the prefecture’s medical policy section.

One patient called an ambulance after “blood oozed from a cut in the fingertip on the right hand.”

Another patient who had a “cold for three days” summoned an ambulance at the “insistence of a family member.”

The prefecture’s new rule seems to have curbed the number of ambulance rides.

Ambulances were dispatched 35,491 times between June and August, down 8.3 percent from the same period in 2024.

The prefecture also saw a 19-percent decline in ambulance patients who did not require admittance to hospitals.

In the five nearby prefectures that provide free ambulance services, the numbers were more or less the same during the three-month period year on year.

Fukushima Prefecture saw a rise of 0.6 percent, while Tochigi, Gunma, Saitama and Chiba prefectures posted drops of 0.5 to 4.0 percent.

Between June and August in Ibaraki Prefecture, 20,707 patients were taken to 22 hospitals that can charge fees for ambulance rides.

Of these patients, 673, or 3.3 percent, were billed.

Most of them, or 55, complained about stomachaches, followed by 47 who experienced dizziness or unsteadiness, and 45 who had bruises.

A prefectural official said about the billing system, “It has produced a certain effect in easing the strain on the emergency medical care system and guiding people toward the appropriate use of the ambulance service.”

But some health experts are concerned that potential ambulance bills may discourage seriously ill patients from seeking urgent care.

Hiroyuki Yokota, head of the Japan Foundation for Emergency Medicine, noted that for some people, summoning an ambulance is the only way they can get emergency treatment.

“Residents living in mountainous communities will not be able to receive emergency care unless they turn to an ambulance,” he said. “Some people might end up with deteriorating medical conditions as they refrain from calling an ambulance.”

The 22 hospitals in Ibaraki Prefecture charge between 1,100 yen and 13,200 yen for ambulance transport.

Skeptics question whether the hospitals are making impartial decisions about charging for ambulance rides.

The prefecture’s guidelines on ambulance transport lists 12 symptoms that should not be evaluated as urgent.

Minor cuts are “clearly not urgent cases” while slight fevers or bruises should be deemed “less urgent cases,” according to the guidelines.

But the brochure does not have an entry on bone fractures.

The Tsukuba man with the broken shoulder in July said he was surprised his injury was considered minor.

People who are unsure about whether to call for an ambulance are urged to call the hotline #7119 for 15-year-olds or order and #8000 for 14-year-olds and younger.

“It was my first time to experience a bone fracture and call an ambulance due to the extraordinary pain,” the Tsukuba man said.

In response to his inquiry, a prefectural official explained that an experts’ assessment on whether a person is at a “life-threatening risk” determines whether an ambulance charge is applied or not.

But the man said he was unconvinced by the official’s explanation.

“I cannot thank the hospital enough for providing emergency care, but charging me for the ambulance transport does not feel right,” he said. “The decision should be made by taking into account the circumstances of individual cases.”

The hospital that treated him declined to comment, citing the protection of his privacy.