A province-wide qualitative study on emergency medical services (EMS) in Alberta was initiated to better understand the extent to which patient billing influences EMS performance. After completing lengthy interviews with 108 EMS-related subjects it was learned through qualitative research methods that billing patients for EMS treatment (ambulatory care) has subtle or determined influences on EMS providers' emergency actions. Furthermore the act of billing patients can and does have an impact on patient care. It often leads to patients and/or their representatives refusing treatment and transportation. Testimony indicates that the final result can be and is troublesome to, patient outcomes. The findings support the generalization that in Alberta the patient's responsibility to pay for needed EMS treatment can be a major obstacle for inclusive injury control.