May 21, 2012

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Privatizing Detroit EMS

February 10, 2012 By 29 Comments

The City of Detroit has been facing some serious financial issues over recent years, and now they are faced with running out of cash before their fiscal year is over. It’s a pretty big deal. I’m not exactly sure how they got into this situation, but if I had to make a guess, I would say they spent more money than they took in (as if there’s any other way?). One of the major side effects from their financial woes is a horribly broken EMS system. Ambulances sitting idle because they can’t afford to fix them, response times to critical calls exceeding an hour in some cases, poor employee morale, and a bad working environment are just a few problems that the public can see.

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With the state jumping in to fix the problem, city officials now have some serious changes to make. Privatizing the EMS system is now on the table as a big possibility. Personally, I think it should have been on the table a long time ago, but that’s neither here nor there at this point. The talking heads at City Hall say it will save money while the union heads say it will cost the city money. So which is it?

There are a lot of details I don’t know about Detroit’s EMS system so I can only speculate based on some assumptions, so if I’m wrong about something, please feel free to correct me.

It’s pretty obvious at this point that Detroit EMS operates at a loss. This isn’t much of a surprise to me given the unemployment rate in Detroit and the fact that 911 simply isn’t a money-making enterprise. It’s very rare to find an EMS system that actually makes money on 911 calls alone. Where the money is usually made is event standbys and inter-facility transfers. Most private ambulance services use both to offset their losses from the 911 calls.

I’m not sure if Detroit EMS runs inter-facility or just 911, but I’m going to assume they only run 911. If I’m correct, then it is going to be virtually impossible for any service – whether it be public or private – to operate without a subsidy. So what can they do? Well 2 viable options exist. They can either pay a private service a fixed subsidy to run the 911 calls, or they can pay them no subsidy and give them exclusive rights to the inter-facility transfers and 911 calls. Personally, I think the second option is better at this point.

They can set performance requirements as a condition of the contract. These might include response times, minimum staffing, complaint resolution, etc. The service that wins the bid is required to operate within their budget and meet the requirements of the contract. I have seen this type of exclusive operating contract work very well in several areas, including a few that I have personally worked in. Where things usually go wrong, is when the city decides to start over-regulating the ambulance service to the point that they can’t afford to operate without a subsidy. At that point your right back to square one.

If the City of Detroit goes through with this decision, then my advice to the city is this:

Pick a good company with a good reputation. There are plenty of them out there. Give that company exclusive rights to all emergency and non-emergency responses within the city limits. Set reasonable requirements and hold them to it. After you do all that, stay the hell out of their way. Don’t start trying to fix something that isn’t broke.

I’m sure plenty people will disagree with me on privatization, but we do know that the public system isn’t working for them. The city has proven itself incapable of keeping a balanced budget, so why not wash their hands of it and allow someone else to manage the EMS operations? I really hope the best for the EMT’s and Paramedics working in Detroit. We’ll see what happens in the next couple months.


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It’s all about the provider

October 10, 2011 By Leave a Comment

I have spent the overwhelming majority of my career working in the private, for-profit sector of healthcare. I got my feet wet working at a radiology clinic while I went to EMT school at night. I worked there for about 2 years before I finally landed my first EMS job at a very small “mom-and-pop” ambulance service about an hour north of town. I worked there part-time and stayed full-time at the radiology-clinic for about 2 years before landing a full-time job at the large metropolitan ambulance service. Nearly 7 years later I parted ways with that job and am now working at a non-profit children’s hospital and a small, rural, non-profit ambulance service.

Many things have changed throughout my journey. My work setting has changed dramatically several times, but what has remained consistent is me. Sure, I have certainly grown and matured throughout my career, but my work ethic, professionalism and level of care has pretty much stayed the same.

In every setting I have seen exceptional care-givers and I have seen exceptionally bad care-givers. Every place I worked at had their strengths and weaknesses. Sometimes I agreed with their practices, and other times I didn’t. Over the years I have developed an opinion on what I feel is the “best” way to run an EMS system, and I know that there are plenty of people out there that disagree and most likely have equal – if not better – ideas than I do. I know that I’m never going to be 100% right, and neither will anyone else. What remains the same, is that we both care enough about the profession to share ideas and try to improve the industry.

One thing that has really stuck with me, was something my boss said to me before leaving my job at the metropolitan ambulance service: “No matter where you end up, don’t ever lower your standards”. I didn’t fully grasp what he was saying until I started both of my new jobs recently. During classroom orientation at the hospital, I quickly learned that the management practices are much different than what I’m used to. Not in a good or bad way, just different. Once I got onto the floor and started training, the human factor set in. Both places offer plenty of training resources, good protocols, and top-of-the-line equipment. And just like both places, there are those who choose to take advantage of it, and those that don’t. Most people care about the quality of care that they provide, but unfortunately, some people just do enough to stay out of trouble and bring home a check.

Now let’s look at the other side of the coin. The small, rural ambulance service I work for reminds me a lot of my first EMS job. Both companies don’t have the resources of the large hospitals or the metropolitan EMS systems. They may not have bleeding-edge technology, but their equipment is good, functions well and serves it’s purpose when caring for patients. Most of the EMT’s and Paramedics working on the trucks (a new term I picked up working out here in Texas) use the long transport times and limited resources as an opportunity to improve their skills and actually do some real hands-on patient care. And of course, there are the few that choose to use the setting as an excuse for “not being able to do their job”. Once again, completely different settings, essentially the same people working.

I guess where I’m going with this, is that it doesn’t matter what setting you work in. Whether it be fire-based, private-based, non-profit, 3rd-service, or volunteer, the decision to provide quality patient care is up to you.

Good patient care isn’t measured by your protocols or resources. It’s measured by compassion, competence, and the willingness to do what’s right for the patient. It doesn’t matter if you show up in a brand-new ambulance with all the latest equipment and aggressive protocols, or if your on the side of the road in your private vehicle with nothing but a first-aid kit. You can still provide quality care to the best of your abilities.

So, back to the previous statement about “not lowering your standards”. It doesn’t matter what system you work in, the decision to provide quality care is yours. Just because a service doesn’t require you to attend airway training doesn’t mean you shouldn’t practice on a dummy frequently. Your service might be very conservative on the amount of medications and procedures that are allowed in your protocols, but that doesn’t mean you can’t do a thorough assessment and treat your patients to the best of your ability. The same goes for appearance. You should always present yourself in a professional manner, regardless of the mandatory dress code or lack thereof. You may be able to get away with wearing a worn-out, faded uniform – hell, it may be all that’s available to you – but that shouldn’t stop you from ironing it every day and at least looking like you give a damn about your job.

If there is one thing that I have learned throughout my years in healthcare, it’s that management simply cannot force good or bad patient care. They can certainly influence it one way or the other, but the final decision rests with the provider on the ground.


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At least it sounded like a good idea….

March 2, 2011 By 1 Comment

http://www.jems.com/article/news/california-city-becomes-first

As I was doing my daily read of the most recent EMS-related news headlines, I stumbled across this interesting article. To be honest I was taken back at first, because I have always wondered why all of the cities around the OC / LA area insist on responding so many paramedics to every call. The fact that they run ALS engines isn’t what gets me, it’s the fact they use private ambulances for transport and FORBID them from providing any ALS care. This of course requires a fire-medic to ride in to the hospital and have the engine or squad follow them to pick them up at the ER. Maybe I’m just ignorant, but it seems like they are doubling their work.

To me it seems that it would make more sense for the fire department to just provide the ambulance transport themselves. Staff a paramedic who doesn’t split his/her role with any other function on the ambulance and an EMT to drive. I will never be convinced that having 4 paramedics treating 1 patient is a good idea.

This particular article is intriguing because for the first time (that I have seen), they actually want to get away from their current system and let a private ambulance staffed with a single paramedic and EMT handle the patient care. While I typically endorse this kind of change, I think the city and county need to be fair to the tax-payers. Chances are, the citizens pay some form of tax to pay for the paramedic service that is currently in place. While such a move will certainly save money, it kinda screws the tax payers. If they go ahead with a switch to private-level service, then they either need to remove that tax, or reduce it accordingly. The whole purpose of contracting to a private pay-for-service model, is the savings in tax dollars to the public, not the general fund.

I thought that this was actually a viable option until I read that the city doesn’t attempt to collect on uninsured parties, and they would expect the private service to do the same. I can say with 100% certainty that this kind of policy WILL NOT WORK without government subsidies. If they are expecting that some private company is going to come in and willingly operate at a loss, then they have another thing coming.

I personally don’t think that such a change is going to happen without some fierce resistance. I applaud their ability to think outside of the box, but I have my doubts that they will actually make this happen.


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When you can't beat them, go around them

February 2, 2011 By 2 Comments

This kind of stuff irritates me, and it happens all the time.

http://www.jems.com/article/news/more-worries-over-florida-coun

If you haven’t been following this story, you should. The North Naples Fire District had their ability to provide ALS on-scene care revoked by the local medical director because of poor performance and their training not meeting his standards. OK, maybe there is more to the story then what the media tells us, but this sounds pretty simple to me. It’s his license. Either provide care and train to his standards, or don’t provide care.

I would think that the department would have taken this message and headed straight for the classroom. Instead, they spent their time raising their voices and eventually found a way to provide ALS service by bypassing the local medical-control system. Nope, let’s not fix the problem, we’ll just find a medical director who will let us do what we want.

I would be interested to hear what the people of that community have to say.


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Privatization of Fire?

September 16, 2010 By Leave a Comment

It looks like Omaha Nebraska is considering taking steps towards switching to a private-based fire service. It’s been a while since I have heard this topic. It’s not uncommon to hear of communities switching to private ambulance service, but privatizing the fire service is something that I rarely hear about.

I’m usually all for private ambulance service as it saves tax dollars and is staffed with paramedics who don’t have their duties divided between fire fighting and medicine. I’m not really sure how a private fire service would work. I’m assuming they would rely on billing insurance companies for structure fires but what about everything else? Would they receive subsidies? If so would that defeat the purpose of switching to a private-based system?

This truly is a topic that I know nothing about. I’m really interested to learn more. If anyone has any experience working with private-based fire, please let me know. I would love to hear all about it.

http://www.omaha.com/article/20100908/NEWS01/709089874/1003154


Filed Under: News, Opinion Tagged With: ,

The pros to private-based EMS

June 7, 2010 By 1 Comment

After my last post in regards to “fire-based EMS“, I got a few e-mails starting with “what the hell dude?” So I decided to make a post defending my real position on private-based EMS. As most of you know, I work in and favor a private-based single-medic EMS system. My last post was written to make a point that other systems do have their benefits. So here is my rundown on why I prefer a private-based EMS system.

Cost

Private-based EMS is the most cost-effective solution for any municipality. Ambulance companies operate at no cost to the tax-payers unless they actually use the service. In times of financial hardship, it just makes sense.

Contracts

Exclusive operating contracts comes with requirements that must be met in order to continue providing service. These include response time compliance, complaint resolution, QA programs, community service programs and in some cases, minimum staffing. There is a good argument that there is actually more oversight for private companies than public services.

Single Medic

Private ambulances typically run 1 medic per ambulance. This means that each medic does more skills, has more responsibility and runs more calls on their own. For skills like intubation, paramedics need to be performing it as frequently as they can. I do realize that single-medic systems are not unique to private-based EMS, but it is more common amongst those types of systems.

Single Function

One of the biggest reasons that I prefer a private-based ambulance service, is that paramedics employed by these companies are only working as medics. Their roles are not split up by other jobs like firefighting or law enforcement. On top of that, I don’t think that being a firefighter should be a prerequisite to being a paramedic in a 911 system.

I have a few articles out there arguing for private-based EMS systems. If you are interested, check them out.

privates-to-the-rescue

two-paramedics-are-not-always-better-than-one

Private EMS – The Stepchildren of public safety


Filed Under: Opinion Tagged With: ,

The pros to fire-based EMS

June 2, 2010 By 4 Comments

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.


Filed Under: Opinion, Politics Tagged With: , ,

Don't get your hoses in a knot

February 1, 2010 By 8 Comments

Lately I have participated in many discussions regarding fire-based EMS. As we all know, there are very good arguments to both sides as to whether EMS should be run exclusively by the fire department. So rather than argue about whether or not it should be done, I am going to express my opinion on how fire-based EMS should be run.

Having worked in a single-medic service for my entire career, I tend to favor that type of system. I truly believe that 1-2 paramedics for each call is really all you need. Any more than that and you are just wasting resources. At minimum 1 paramedic on the ambulance would be sufficient. Depending on ambulance availability I suppose having a medic on the engine would be beneficial too. You can refer to my article “Two paramedics are not always better than one” for more on that subject.

I believe that the paramedics assigned to ambulance duty should play a single-function roll. It is very difficult to keep up your skills as a paramedic if your job responsibilities are split between patient care and firefighting. I also say this because I don’t believe that paramedics should have to become firefighters in order to practice in a 911 system.

One big problem with having multiple paramedics on scene is establishing who is in charge. It needs to be made very clear in writing who runs the show. I feel that this responsibility should be given to the transporting paramedic. If they are going to care for this patient all the way to the hospital and have to answer to the doctors and nursing staff, then they should have the final say in how the patient will be cared for.

Being the conservative that I am, I don’t really believe in “special taxes”. Having said that, I do believe that if a community wants to vote to impose such taxes to provide fire-based EMS services, then more power to them. If a special tax is imposed to provide the service, then the department should not be billing the patients. Departments that tax and bill their patients are just asking to be shut down and replaced by a private ambulance service who collects no tax dollars.

I truly do believe that efficient and effective service can be provide by fire-based, third service or private-based EMS, it’s just a matter of doing it right.


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