There is an ethical component to 'payer mix'. Using a nonprofit EMS model as an example, payer mix can mean the difference between mission survival or permanently closing the doors. A particular market may have minimal entitlement payers (Medicare/Medicaid) which translates to a higher net return for each dollar billed, say $0.75 for each $1 billed. To the contrary, a market may be mostly community members relying on entitlement resources to cover healthcare. Under these circumstances, the provider (EMS in this example), must accept assignment. What this means is that the ambulance service provider must, by law, accept the reimbursement and is not authorized to balance bill. So, for example, the ambulance service provides a service (911 response) then bills Medicaid $1,000, Medicaid pays the ambulance service $280. The difference ($720) is written off as 'contractual allowance. Using this same example, the at-ready costs to provide the 911 response is $500. This equates to a per response loss of ($220). If the payer mix for the your market is mostly entitlements, and you have no other source of significant income, long term survivability is in question. Then the question becomes... what is your mission, the ethics supporting your mission. In other words, as a NFP, are there acceptable losses? What if the losses are too significant, not sustainable ('no margin no mission'). Eliminate/reduce services to this population? Optics of doing so?