May 18, 2012

EMS and Healthcare Reform

I have spoken on this topic a few times before and it usually sparks a lot of heated debate, as it should. So many of us are just sitting here wondering what will happen to the healthcare industry and what it means for our jobs. For me, there are just too many unknowns. I know that our system is broken, but I’m not so sure we went about the right way of fixing it. I don’t claim to have all the answers, but I think I have a pretty good idea of what works and what doesn’t. What bothers me is that people like you and me are continually left out of the decision making process. Instead we have people writing bills that have probably never seen a patient, tried to collect an insurance payment, or tried to run a private medical practice.

The talking heads continue to tell us that we need to cram trillions of federal dollars into the healthcare system in order to keep it afloat. But they never tell you why the system got to where it’s at in the first place. Medical care in the US is so expensive that most people simply can’t afford it without insurance. And many people can’t afford insurance. But have you ever sat down and looked at why it’s so damned expensive? Granted I’m no “expert” economist. I’m just a dumb-ass paramedic. But even I can see that the service I provide is expensive because nobody pays their bill.

Ambulance services can’t survive with half of their customers skipping out on the bill. We also can’t refuse service based on one’s ability to pay. I’m not saying I think we should, but it is a huge factor in the cost. Any other business in the world would call the cops if they saw someone return to their store who took something without paying. Not us. We just give them what they want and expect that they won’t pay. So how do we stay in business?

Someone has to pick up the tab for those that eat and run, and that usually falls on the insurance companies. And no, I don’t mean Medicare and Medicaid, I mean private insurance. Medicare and Medicaid walk into the restaurant and pay what they feel is fair market value and ignore the listed price on the menu. But wait, isn’t that illegal? Well, normally yes. But they’re the government and they’re here to help. The business is forced to raise their prices, which means that the people that do pay are not only paying their tab, but all the tabs of the people that didn’t pay. This nifty little technique is called “cost shifting”. It’s basically a narrowing scale that will eventually spike to the point that nobody is able to afford the cost. Think of it this way, every time the price goes up, less people will be able to afford it.

It’s arguable whether or not expanding Medicare and Medicaid benefits would help this issue. On one hand, ideally, more people would be covered by some kind of insurance which is better than nothing. But the big question is, are more people going to utilize medical services because they are now covered by government aid? If so, then it actually makes the problem worse (refer back to the restaurant analogy). Not to mention that doing so increases the national debt, which usually leads to increased taxes, which usually leads to people with less money, which then leads to less money being spent, which leads to layoffs and more people without insurance. It can make your head hurt thinking about it.

Forcing people to purchase health insurance could help solve this problem, or it could have the reverse affect. The theory behind this soon-t0-be mandate is that more people will be able to pay their medical bills, which would in return cut down on the cost of doing business. But let’s look at this from a different angle. If health insurance was affordable, most people would buy it. So do you think that some 27 year old guy working paycheck to paycheck at a dead-end job is going to be able to take a $500.00 a month hit? Probably not, so instead we hit him with a large penalty? That’s like telling me to buy an expensive sports car to avoid being charged $50,000. You would probably have to throw me in jail because you’re not getting either out of me.

So what’s the next option, forcing employers to provide health insurance? You could do that, but then the business owner would have to offset that loss somehow. And I think we both know that it would end up falling on payroll, which is usually the largest business expense. They would either have to cut wages to make up for the loss or lay off people. That doesn’t help much at all. Instead that just adds more people the uninsured pit.

This of course brings us to our next up-coming “solution”. Now we want to force health insurance companies to take all applicants regardless of their past medical history. I get the reasoning behind this, but are we really looking at the overall picture here? Health insurance companies make money by collecting your monthly premiums and hoping that you either never make a claim or do so as little as possible. They don’t want to take people with serious conditions because they know it’s a money loser from the start. It’s the same reason why auto-insurance companies don’t want drivers with bad records. It’s a losing deal. Do you think it would be fair to get in a car accident without insurance, then apply for coverage and expect them to cover your accident? What do you think a move like this is going to do your monthly premiums? Now the 27 year old guy REALLY can’t afford his coverage. I get that there is not as much of an emotional argument that goes with auto coverage, but it doesn’t change the fact that insurance companies have to stay in business in order to pay for your medical problems. Now before you come at me with torches and pitchforks, I still think that there needs to be a way for people with pre-existing conditions to get insurance. I think a good starting point would be to get more people on private insurance plans so that these companies can afford to lessen their standards. I’ll get to a broader explanation of fixing this problem later.

The next option, and in my option, the worst, is raising taxes to expand government coverage. Taking money from one person to pay for another doesn’t help the problem. Instead you take money from the people that are supposed to be supporting the economy. If you take $200.00 a month from me, you have just taken $200.00 that I would have normally spent elsewhere. This means that the movie theater, grocery store, auto shop, etc now get that much less of my money every month. Multiply by this by millions and you get a recession. Now let’s look at the opposite end of the spectrum. Lowering my taxes would not only let me keep my $200.00, but would give me more money to spend. This means that all those business now get more of my money. Multiply that by millions and you get increased demand and cash flow. This means that businesses have to hire more people in order to keep up with the demand for their product. This then translates to more jobs, which means more people with insurance benefits, paying taxes and being able to pay their medical bills. See where I’m going with this?

Now we may not be considered to be as “intelligent” as the decision makers, but even the simplest of minds can see that if a problem is caused by people not having enough money, we solve it by either getting more money to the people or making the service affordable. Now I know this doesn’t solve all our problems, but it’s a good start. We have already seen how putting money into the hands of the consumer can help, so let’s talk about how to get the cost of doing business down. Many hospitals and ambulance services operate on 40-60% of their patients actually paying their bills. So by using cost shifting, they are forced to increase their prices by that much in order to stay in business. Now imagine if everyone paid their bills. I know that’s unrealistic, but bear with me for a second. If everyone paid their bill, then the service operating with a 50% collection rate could essentially lower their prices by 50%. Sure, that’s a very simplified example, but you get the point. You might notice how I referred to the economy several times. This is because I firmly believe that fixing the economy is more than half the battle of fixing healthcare. It’s rather simple. Get more people back to working, then you will get more people being able to pay their bills.

There are of course plenty of other issues that need to be addressed like the ability to route patients to proper forms of treatment other than just the ER and the lawsuits that lead doctors to practicing defensive medicine. But for the purpose of this article, I’ll leave it here and touch on those subjects later. Like I said before, I don’t have all the answers. I could very well be dead wrong. And to be honest, I hope I am.


My Thoughts on Social Media in the Workplace

There has been a ton of press about employees getting fired or punished for “misconduct” on popular social media sites. So naturally comes the debate on:

  • Whether an employer has the right to terminate you for something you did off-duty.
  • Whether or not they should get aggressive on social media policies or embrace this as a new form of communication.
  • How we should conduct ourselves when posting on the internet.

In recent news, an EMT was fired for criticizing her boss on Facebook. While the feds ruled that the firing was illegal, I still think she could have used better judgement. This wasn’t a matter of silencing social media in EMS, it was a matter of someone trash talking their boss on Facebook and facing the consequences.

I have had many bosses over the years and I could probably write a book trash talking all of them. We all have bad things that we can say about the lovely folks in management, however it’s usually best to confine that talk to friends and family. Biting the hand that feeds you typically ends up with results like this EMT faced. In her case, a trip to federal court and a large amount of lawyers fees might just get her job back, but it’s probably not going to be a job she wants.

Working for someone that you don’t like is one thing. Working for someone that doesn’t like you is quite another. Even if she goes back to AMR, at the very least the awkwardness will be enough to make her hate her job. Regardless of what a federal judge says, she will never win that battle.

Employers and employees have a reputation to hold. We as employees don’t want the general public looking at us as being childish or immature, and employers don’t want the actions of their employees to damage their company image. It’s really not rocket science. When you work in any avenue of healthcare or public safety, you have agreed to take on a new level of responsibility, both on and off duty. Posting derogatory comments about coworkers, patients, bosses or establishments does absolutely nothing to lighten the beating that we already take in EMS.

Social media is a giant that wont be stopped, but that’s not a bad thing. It has allowed me to easily keep in touch with family and friends from across the country. It has also allowed EMS professionals like you and me to meet and share ideas with our peers around the globe. It’s a new form of communication that is literally changing the world as we know it.

I am firm believer that we should embrace it and use it to our advantage. I think that EMS and public safety professionals being able to reach out to each other and the general public is a wonderful thing. Unfortunately, as easy as it is to build relationships through social media, it’s just as easy to destroy them. Like I have said over and over, “with great power comes great responsibility”.


November 2nd, 2010

November 2nd is going to be a day that we as EMS providers and as American citizens need to have our voice heard. Many of us are unhappy with our elected officals – both Democrat and Republican – and the only way to change this is to elect people that represent you the best.

Politicians use various forms of media to bash their opponents with the hopes of winning your vote. They never offer up any plans or discuss real issues. It isn’t until they are in office that we find out what kind of representative they really are. It’s very important that we ignore the negative ads and ridiculous allegations. Do a little research on the candidates and find out who really represents your best interest. You can do this by looking at their campaign contributors, voting records, and debates.

Don’t be afraid to cross party lines or vote for 3rd party candidates. Many people argue that voting for a 3rd party is a “wasted vote”, but this couldn’t be further from the truth. Every time you vote against someone, as opposed to for someone, you have wasted your vote. The truth is, if everyone actually did the research and picked the best candidate, then all of this campaign spending would be worthless. This would also be the end of the 2-party system. Remember, the lesser of the 2 evils is still evil.

As EMS professionals, we need to pick candidates that will represent our industry. If you work in public safety, then you might want to find out what the candidates plan to do with pensions, benefits, and funding for your organization. If you work in private EMS, or even public-based EMS, then find out where the candidate stands on Medicare and Medicaid reimbursement. Everyone claims to want to “cut spending”, so find out exactly what they plan to cut. Are they planning to cut back on beautification projects or public safety jobs?

While it is extremely important that you get out to vote, it is just as important you know what you are voting for. Don’t be fooled by rhetoric, negative ads and smear campaigns. Remember that voting is your way to have your voice heard.


Cost Shifting – An EMS Fight for Survival

The ambulance company that I work for is currently under some heavy fire due to a recent rate increase request. Now I’ll be honest, it’s no small increase. I can understand peoples frustration when they hear that expensive ambulance rides are about to become more expensive. What they don’t understand, is that’s healthcare in America. At least until we come up with some real solutions.

EMS and the entire healthcare industry have been taking hits from non-payers and government programs for quite some time now. In many cases healthcare providers are getting paid by Medicare and Medicaid a measly 14 cents on the dollar. That’s insane, but it’s reality. No other industry in the world operates like that. Ford isn’t going to give you a free car if you cant pay and Chevron isn’t going to give you free gas.

Unfortunately, the people that end up paying for lost revenue are the ones that actually do pay their bills. This is usually the private insurance companies. So as the number of non-payers and government-payers goes up, so does the price. This is called cost-shifting and it sucks. But do we blame the ambulance services or the broken system? The old saying “Don’t hate the playa hate the game” couldn’t be more true in this case.

The EMS industry is in a fight for survival. It’s a losing battle and unless some serious change is made, the services we provide will become so expensive that nobody will be able to pay. So do I think services like the one I work for should be granted rate increases? Hell yes I do. I want to keep my job and I want us to keep providing the best service we possibly can. However, I also want to see we the people start working towards a permanent solution.

No single person or service can tackle this issue alone. And I’m sorry but Obamacare isn’t the answer. We need to elect people that truly understand the issues surrounding our healthcare system. Abuse, litigation, non-payers and broken government programs are killing the industry. We as EMS professionals need to be able to route patients to the most appropriate care. Hospitals shouldn’t have to treat a cut finger or deal with a sore throat. There are appropriate care facilities for those types of complaints, yet we still continue to use our resources transporting and treating them in an emergency setting.

We need to get people working so that they can pay their bills. If you fix the economy, then you are halfway to fixing healthcare. They really do go hand in hand. More people working = more people with money and insurance. More people paying their bills = lower healthcare costs. Fixing this should be #1 on the priority list.

Before I get too off track here, I need to get back to my point. Don’t get all hot and heavy when you hear about ambulance services requesting rate increases. The only difference between them and every other healthcare provider is that they have to ask to raise their prices. We are all playing the same survival game and if my predictions are correct, we will be playing it for a long time.


Big Bummer for Stockton Fire

Long story short……

Stockton City Fire recently lost their paramedic privileges due to circumstances that I still don’t fully understand. So naturally the fire officials are on TV talking about how people are going to start dying left and right because now the only paramedics responding to their calls are on ambulances.

Hmm, paramedics working on ambulances and firemen working on fire trucks. Who would have thought?

The firefighters are going to arrive on scene first, like they do 73% of the time.
-Fire Chief Ron Hittle

There are cities all over the nation that work at this same level. It’s called a tiered response and it works well. The majority of ALS care should be done while en route to the hospital. Sitting around on scene starting IV’s and pushing medications accomplishes nothing.

Don’t get me wrong, I get that there could be SOME occasions where the ambulance service is delayed arriving on scene within their required response times. But how many times is this actually going to negatively affect the patient? Cities and counties spend millions of dollars on services that can be provided at NO COST to the tax payers if it were to be contracted out to private enterprise.

I’m sure that AMR will handle this situation just fine.

http://www.ems1.com/fire-ems/articles/874010-Calif-firefighters-barred-from-ALS-responses/


Detroit EMS – Government Healthcare at It's Best

After reading about the budget shortfalls and response time issues with Detroit EMS, I am left to wonder why they haven’t considered contracting the service to a private ambulance provider? This is just another example of what happens when government is in charge of providing healthcare. Obviously Detroit’s issues go much deeper than EMS. As a matter of fact, their EMS service probably isn’t the problem at all. It’s the lack of funding and support that has put them and their citizens in this unfortunate position. Keep in mind, this is a service that not only bills the patients but receives tax dollars as well.

Had this problem come up with a private provider, they could put the contract up for bid and get someone else in who is capable of fulfilling the needs of the community. For those of you that argue that private EMS is bad because they can go out of business, then just read these articles. This sounds like a service that NEEDS to go out of service so someone can come in who isn’t subjected to cuts and do the job.

Our response time is atrocious. At any given point, day or night, consecutively for the last few months, there were no units available. That means if you call 911, it may be an hour, it may be two.

Emergency workers told Local 4 that they’re already understaffed, but come July 1, 33 more EMS positions will be eliminated.
The cause of the layoffs comes from a planned $1.8 million cut to the city budget.

Rationing care? That nonsense could never happen here!

I feel for the EMT’s, Paramedics and patients that have unfortunately been subjected to this. I really hope this gets better for them.

http://www.jems.com/article/news/budget-cuts-hit-detroit-ems

http://www.allvoices.com/contributed-news/6550028-chaos-continues-in-detroit-ems-workers-frustrated-over-lack-of-units

http://www.jems.com/video/news/detroit-ems-relying-crwon-vics


Assembly Bill AB2456 Hurts California EMS

Assembly Bill AB2456 recently passed through the state Assembly and is now making its way to the Senate floor for a vote. What does this mean to us as California EMTs and Paramedics? Well….lots of things. Some known and some unknown. The proposed bill aims to virtually eliminate local EMS agencies and give ultimate governing authority to our wonderful State EMSA. That’s right, the same agency that takes 90 days to process your license renewal, doesn’t return phone calls and takes years to complete investigations. Yep, those guys.

Mark my words, THIS WILL AFFECT YOU NEGATIVELY.

The sponsors of this bill want to see statewide protocols as opposed to the county system that we currently have in place. Sure I get the reasoning behind this, but do you really think that they are going to adopt aggressive and cutting edge protocols? No, because that would require them to fund mandatory training for the majority of the counties around the state that still play “mother may I” instead of para-medicine. Instead you would see everyone “dumbed down” to the level of the county with the tightest standards. I hope you don’t mind taking a few steps backwards because thats where we are headed.

Such a wonderful plan must come with a price right? Nobody eats for free in this world. The proposed legislation will add at least $800,000.00 to the state budget. That’s right, the budget that our legislators haven’t passed on time AGAIN. But don’t worry folks because it wont add to the current deficit. No, instead we the EMS professionals will pay for it in the form of fees tacked on to our license renewals.

The authority may develop and, after approval by the

commission pursuant to Section 1799.50, adopt a schedule of fees

to be collected from each certifying entity, and an increase in fees

pursuant to subdivision (d) of Section 1797.172, in amounts

sufficient to support the authority’s actual additional costs to

promulgate regulations pursuant to paragraph (1). The fees shall

be imposed proportionally between the certifying entities, and

through EMT-P licensure fees, based on the number of EMT-Is

and EMT-IIs Advanced EMTs certified by certifying entities and

the number of EMT-Ps licensed by the authority.

Translation: We are going to take as much of your money as we see fit.

Our current EMSA is under-staffed and under-funded. Do you really think that they are equipped to handle the task of managing EVERY agency in California? Imagine how much money it would take to hire the staff, buy the equipment, establish committees and do studies to formulate a statewide set of protocols. All of that money will come from you and me.

If you are interested, you can download and read the legislation by clicking on the link AB2456. See it for yourself.

It’s time to act

If we do nothing, this bill will pass with flying colors. Maybe we don’t have a perfect system, but lets not let the legislators in Sacramento decide what IS best for us. You can help kill this bill by calling not only your local senator, but every senator out there and voicing your opposition. It doesn’t take much time and it’s really easy. Just call them, tell them your name, zip code and the fact that you are an EMS professional and explain that you OPPOSE this bill. We have to get people from all over the state lighting up their phones to get the message through.

Follow this link for a list of all the Senators and their phone numbers. California State Senate

Please don’t let this pass. Make the calls, talk to your friends, and write letters. Lets work together to bring EMS forward, not backwards.

If you have any questions regarding this bill, you can e-mail me at sean@medicamdness.com. I will answer any questions I can in a timely manner.


Should EMS be Allowed to Carry Weapons?

A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

2nd Amendment - United States Constitution

All of us that work in EMS know that our job comes with it’s fair share of risks. I think most of us would argue that we put ourselves in harms way far more that than the average citizen. But what mechanism do we have in place to protect ourselves? …….anyone?

Every ambulance service I have worked for has strict rules against carrying weapons of any type while on duty. This includes guns, knives, pepper spray, etc. Every time I have heard these policies questioned, it is typically addressed with a general “we are not cops” statement. And they are right. We aren’t cops. We don’t enforce laws and we don’t track down bad guys. But we DO deal with the same people that law enforcement does. We run drug overdoses, assaults, homicides, suicides, etc. We find ourselves in the middle of trouble almost on a daily basis.

So back to my previous question.

What mechanism do we have in place to protect ourselves? Well for starters we have a dispatcher who decides whether or not the scene is safe to enter based off a 30 second phone call. Our next line of defense is a radio to call for help. And lastly we have the ability to run away. Criminals beware!

I’m going to come right out and say that I believe that EMS professionals should be allowed to carry concealed weapons in the name of personal defense. As a citizen the United States Constitution grants me to the right to keep and bear arms. So should my employer be allowed to deny me this right while I’m on duty?

Now I must play devils advocate for a minute. To look at this issue from an employer’s prospective, I can see where they might have issues with their employees carrying and possibly using a weapon. This opens up the doors to legal action and liability in the event that one of their employees acted inappropriately and killed someone. Employers have the right to tell us how to dress, speak, act and even cut our hair. In exchange for following these rules, we get to stay on board and receive a paycheck every 2 weeks. If we don’t like the rules, then we are free to leave at any time.

I guess where I am going with this is that while I believe that I have a right to protect self on and off duty, I don’t think that employers should be told they HAVE to allow their work force to carry weapons. Having said that, I think that liability should not be placed on an employer in the event that an EMT or Paramedic had to exercise their rights and harm someone in the name of defense. When my life is placed in danger to the point where I have to draw my weapon and kill the person who is trying to kill me, I am no longer acting as a Paramedic. I am acting as Sean Eddy. A human being that is trying to do what I can to make sure I make it home to my family. At that point I have taken all responsibility for my own actions AS A PERSON, not as a Paramedic.

Anyone disagree with me? I would love to hear your thoughts.


The pros to fire-based EMS

For those you that have been reading my blog for any amount of time, this title probably comes as a shock to you. As you know, I make it no secret that I prefer a private-based EMS system. Perhaps it’s my conservative, pro private-business background that has molded my opinion on the matter. Regardless, I have yet to publicly acknowledge that other types of systems can be beneficial. Well today the pigs are a go for take-off, because I am going to take some time to talk about the benefits of fire-based EMS.

So here it goes, my list of the “pros” to fire-based EMS.

Training

For the most part, fire crews are running less and less fire calls and more medical calls. This being the case, they typically do a lot of training for medical-related emergencies and drill often to try and keep their knowledge and skills up. This is something that many private providers have lacked for a while.

Funding

Fire departments have done a wonderful job of securing funds at the state, local and federal level for a long time. This allows for high-quality equipment, better salaries and more resources. In areas where the fire service also provides ambulance transport, they are able to bill for their services as well to increase revenue.

Selection

With high pay, good benefits and an unbeatable retirement package, fire departments have qualified applicants lining up for miles for a job opportunity. This of course allows the department to be more selective when they hire personnel.

Health and Fitness

Firefighting can be a very physically demanding line of work. So naturally, fire personnel must work hard to stay healthy and physically fit. Regular exercise is something commonly seen amongst the profession. This leads to better concentration and less chance of injury.

Non-profit

In order to write this section, I must take some time to lock my stubbornness in the other room so it doesn’t interfere….so hang in there a minute.

…..ok still there? Good, here it goes.

I will admit that there is benefit to making decisions concerning equipment purchases, in-field practices and system management when making a return on your investment isn’t a priority. This is why you will commonly see fire services take on new procedures and protocols with open arms. They don’t typically have to worry about reimbursement.

So there you have it. My list of pros to fire-based EMS.


EMS 2.0 – Be careful what you wish for

I had a great conversation with a fellow EMS blogger last night over Skype. We discussed several ways to implement changes to our “broken” ems system and how EMS 2.0 could not only fix our industry, but improve healthcare as a whole. All was good as we were fixing the world and saving lives all through the wonders of internet phone calls. This was of course, until we came to a shocking realization of what EMS 2.0 could actually mean for us as an industry. I’ll get to that in a minute.

If you have worked in EMS for any period of time, you are no stranger to 911 abuse. People using 911 to seek routine, non-emergent medical care have tied up paramedic ambulances, increased costs and delayed response times. The “you call we haul” system that we have in place decreases liability as everyone is transported to an ER physician, but it doesn’t exactly use resources efficiently. As Justin Schorr mentioned on the Happy Hour, “putting more paramedic ambulances on the street is like putting more tow trucks at a dangerous intersection. We need to fix the intersection”.

Everyone has probably heard this rant from me or any of my fellow EMS bloggers at some point in time. Regardless of the specific solution we have in mind, we can all agree that we want patients to be routed to appropriate care. Not just the ER via paramedic ambulance. One thing me and @Jeramedic discussed was the possibility of using advice nurses in conjunction with EMS dispatch to properly route these people to appropriate care. A tactic that HMO’s have been doing for years. Here is a great article on a service that has already attempted to implement such a system.

So now for the scary part.

Let’s say that one day we woke up and our dreams came true. Patients are being routed to appropriate levels of care. Paramedics have the ability to refer non-emergent patients to urgent cares, clinics, etc. Now our ALS ambulances are only being used to transport the truly ill and injured patients to the ER. Sounds great right? We have successfully decreased the workload on our EMS system. There is only one problem. What are we going to do with all those paramedics that were once responding to 12+ calls a day? If we are only transporting truly emergent patients, wouldn’t that significantly decrease the demand for paramedics? Would this leave a bunch of paramedics looking for work?

I’ll use the fire service as an example. Over the years, fire prevention and regulations have worked so well that fire departments aren’t exactly putting out fires anymore. At least not very often. They damn near prevented themselves out of jobs. Is this what we are doing to EMS?

Fire departments did a great job of overcoming this problem by integrating fire suppression with EMS response. It has done wonders for fire services around the nation. This is actually a great example of how we as EMS professionals can use EMS 2.0 to our advantage and not only advance our career, but increase demand. Programs like community-based paramedics, and advanced-care paramedics would open up a whole new world of opportunity for EMS professionals to advance in the profession. This would also be an opportunity to increase educational standards, scope of practice and improve EMS salaries. You would see EMS turn from a stepping-stone job to a life-long career.

If you haven’t had a chance to listen to Episode 88 of the EMS Garage, you should do so now. We had some great discussion on this very topic. Hopefully Justin will hijack another show in the near future so we can get further into this discussion.