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I work for a large county wide EMS system covering 790,000+ people in a 399 square mile area with around 250 EMT's and Paramedics.  We were warned by the State to expect some changes in our call volume, wait times at the ED, and increased paperwork due directly to implication of the ACA.

More changes are coming and more challenges to the EMS world because of ACA.  I'm holding off on making a claim of good or bad on most of them.

More details after the squiggle.  (please note these are not the opinion of the agency I work for, this is what I was told at inservice training and have seen. This is not 100% because i'm only seeing a small part and getting much from second hand.  And there is the whole changes coming as more of ACA kick's in.)

Possibly caused by ACA.

For starts, we were warned that our call volume was going to go up.  This is based of the experience of the last time the state expanded the medicaid accessibility.  When medicaid enrollment goes up, so does the use of the Emergency Department (ED) and Emergency Medical Service (EMS) system as well as medical care in general.  It is just how it is.

I work an area that is low income.  This means a majority of my patients are either uninsured or on medicaid and medicare. (many on both)  Of course I live in the area also, since EMS is notoriously low paid.  

This warning came true.  Our system did 101,000 calls last year, about 270 calls a day to the 911 service.  Between Dec 26 and Dec 31, on the days I worked, we saw an average of 250 calls a day.  Winter is our slower time.  From 1 Jan to 6 Jan, we have averaged 304 calls a day.  If this stays at this level, we will see over 110,000 calls. If it follows the pattern, we could break 115,000.

Prior to 1 Jan, we would be told to "clear the hospitals with out paperwork" about once every few days.  This means as soon as you get a patient off your stretcher to get back on the street and do your paperwork later.  Normally we have 20 min after arrival to complete the paperwork.  But if we have all the squads in the ED doing paperwork, 911 calls can't be responded to.  Since the first of the year, we have been told that two to three times a shift. (on the B shift anyways, and i've been told this is true for A shift.)

The reason is that not only are we bringing more people to the ED, but more people have been going to the ED.  "walk-in's" have increased at the ED's i've been to.  Even the ones that normally had empty rooms half the time are making us wait so they can "find a bed".  Hall beds are becoming a regular feature in many of the ED's in the last week.  (Charge Nurses HATE hall beds, and I agree also.)

Now is that due to ACA? Maybe. It could just be a bubble and we could see a reduction in 911 calls as people get treatment for their health issues.  It has only been a week.  Yet the state warned us to expect the increase and to expect that to become our normal.  This is based on past experience.

Certainly Caused by ACA.

The number of calls from doctor's offices for emergency transport.  Last year i did two calls where the person has an appointment at the doc's, shows up and the doc sends them to the ED for emergency treatment.  

I've done five this week.  In each of those cases the person made the appointment with their newly gained insurance.  Each had been feeling bad for months but had held off on getting care because they did not have insurance.  They got to the doc's office and we got called.  I "blame" ACA for that. (a good blame, but it is a direct result of ACA, otherwise they would have just gone on suffering till they suddenly collapsed and died.)

Paperwork, Paperwork…I thought were were going to be all electronic?

While the ACA requires the Bush Administrations' goal to be 100% electronic in medical records and billing, it still counts as "paperwork" to those of us filling it out.  (Bush set the goal of electronic medical records, the ACA gave authority to the DHHS to set up rules on them, and they said the goal will be met.)

On 1 Jan, I had two more tabs appear on my electronic Patient Care Report that were mandatory to fill out.  One deals with insurance, the other is additional demographics about the health history.  More mandatory tabs are coming.  At the ED the receptionist is getting four forms signed where they use to get two. Nurses are having to chart more information per patient on intake.

The law did not say "you will gather the following…" it said regulations will be established by the DHHS.  Which then made the rules to collect X and Y as mandatory collections and to submit it to them.  (Why is my patients race a mandatory collection point?  Really what does it matter?)  

But each question we have to fill out takes more of our time. Right now we have 20 min from arrival to the ED to unload the patient from the back of the squad, go to the triage nurse, give a report, get the patient registered with the Hospital, place them in a room/hall bed, clean up and sanitize the stretcher, restock the squad and complete the report.  This is doable if, IF, the triage nurse is not trying to juggle 12 different things and you had a simple case.  Yet we are told, more is on the way.

I'm willing to collect information from a person if it will help with their treatment and care and to a lesser extent billing.  But what race they are, how often they go to the doctors, how often they did not have insurance, are they aware of smoke stoppers, work history, etc?  I know a lot of "unknown" will be checked so we can close the report and get back on the road.

Challenges we know are coming but don't have details on.

The biggest will be the Accountable Care Organizations (ACOs), Medicare and Medicaid payments will be tied to these ACO's.  These are "groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare/Medicaid patients".  And the ACA requires Medicaid/Medicare providers to ensure that a person is not re-admitted with in 30 days for the same issue.  (a person with COPD - breathing problem - who gets out of a two day stay at the Hospital, gets admitted to the hospital 28 days later with another bout, could get the Hospital fined for not complying with the Outcome Based Patient Care rules.)

These ACO's will have a lot of power in deciding what treatment and care will be paid for over time. (the origin of the "death panels")  Treating a person with a chronic condition over and over in the ED is not Outcome Based Patient Care.  A better way would be to make sure they take their daily medication which would prevent their chronic issues from flaring up week after week.  But no one is suggesting that doctors be paid to make twice a week visits to these chronic patients. (talk about expensive!)

ACO's also have to ensure that medical records are transferable between area care centers. What is not clear from the regulatory side is does that include EMS?  Does ACA require the including of EMS into the ACO's?  Some say yes.  We are the front line care, the ED on wheels.  In an cardiac arrest we can do everything they can do in the ED for the first 20 min.  OBPC starts with us, determining that Patient X who just 28 days ago came out from a stay with COPD, is now having a heart attack that is presenting as a bout of COPD would help prevent fines.

Others say no EMS is not allowed to be part of the ACO's.  We have no say in how often someone calls us, our care we are allowed to provide is limited and established by the State or Region.  We already take a 10% hit to our cost for every Medicaid and Medicare transport (if they approve paying the EMS bill) because their repayment is that much less than our cost. By law we can only transport a 911 call to an ED.  So we would not be able to do anything to help OBPC.

Can EMS help lower ED usage and medical costs under ACA?

ACO's doing OBPC should lower costs with out limiting access or feeding the "death panel" lie.  I think, and many in the EMS world also, that your Paramedics and EMS systems can do more..IF we are allowed to.

A Paramedic gets paid about $15 an hour as a national average. (on the high end i've seen $25 and the low $10.  Please note i'm not talking about Firefighter/Paramedics who get FF pay)  A Registered Nurse gets about $33 an hour, between $25 and $46.  So your "average" Paramedic (actually we are all extremely above average) costs half as much to send out to check up on people.  We also have a better eye for how people are in the non-hosptial environment. (and are more likely to know where an address is as finding them at 0200 in the rain/snow is what we do)

This is called "Community Medicine".  Our 911 center could tell you the top 20 people who use 3% of our calls in a year.  Yeah, out of 750,000+ people, there are about 20 who every paramedic knows their name, medical history, drugs -prescribed and non, and address.  Ten of them would benefit from begin checked up on twice a week to keep them compliant. (IMHO, the other ten are abusing themselves and won't stop unless you strapped them to a bed 24/7/365)

ACO's should be looking to the EMS system for this rather than the higher cost RN's.

Another thing that ACO's should consider is getting laws changed so that EMS can "Treat and Release", "On Site Medical Triage", and "non emergency transport diversion".  

Treat and Release would be where the EMS provider treats the person at the site and then clears them from the need to go to the ED.  A classic example is the person with "low blood sugar".  We show up and they are having trouble responding to questions, standing, covered in sweat and can't swallow.  We start an IV, push "sugar" into them (D50) and they come back to normal.  Right now by law (in the two states I am currently licensed in and three other states i've worked in), because they had medical treatment, they have to go to the hospital ED to be cleared.  We have to do our best to get them to go.

With T&R, they could be cleaned up, IV removed, sign a document that they will follow up with their doctor and we would be back on the street.

On Site Medical Triage is a step beyond the 911 triage.  Right now, someone calls 911 and the dispatchers determine the best they can the urgency of the call and try to send the most appropriate care level to the caller. (In our system we have two levels of Ambulance: Basic which is two EMT's who can provide basic level of care, and Advanced which is at least one Paramedic and one other person often an EMT who can provide advanced level of care to include drugs and invasive treatment)

What happens is the 911 center is making a good guess based off a phone call.  They are not there.  Many times…ok, Most of the time, the caller is inflating the nature of the issue or was not clear on what they needed.  Once the Paramedic is on the site, they can better asses the situation.

Here is an example: 911 is called and dispatches an ALS crew to a Sudden onset of Shortness of Breath/Air.  We arrive and the person is laying down on the couch, smoking a cigarette.  Some quick questions and they explain they "just have not felt well", like they are out of breath if they do anything.  (And they told this to the 911 center which erred on the side of caution with the dispatching.) They have a fever, chills, runny nose, and feel tired.  It is flu season and they did not get a flu shot.

Right now, we are going to have to take this person to the ED.  By law unless they refuse to go and we can't try to talk them out of it.  So the medical cost will be an ED visit and an Ambulance transport. Neither is cheep.

OSMT would let us do a check of their vitals, assess their status and then, if warranted, turn down the request to go to the ED by ambulance. (which is what a 911 call is).  Making other arraignments for transport would be an option, such as calling a cab. Or explaining that they are not having an emergency right now, but rather a medical condition that could be treated with over the counter medication and scheduling a doctors appointment.

In line with OSMT is non emergency transport diversion.  They would go hand in hand.  Right now, a 911 call is only going to transport someone to an ED.  Not to a dialysis center, doctors office, Urgent Care Clinic, community center.  We can't take someone to a mental health center directly, they have to go to an ED.

If we could transport to other locations in a non-emergency roll, we could OSMT a person, then arrange for a diversion pick up.  Two EMTs ($9 to $12 an hour) with a van or ambulance that is set up for multiple seated patients could pick up the person in the example above, take them to the Urgent Care or Community Center as well as other people, still be on hand for any emergency with equipment.  They could take the person who is on the street, who wants to get back to being compliant with their medication directly to a mental health center. (this has had great success in North Carolina, freeing up many beds in the ED from mental health patients.)

Between 16 and 20% of all calls to 911 are actual Medical Emergencies. (based off a recent study in Maryland.  My experience says more like 10% but that is one person's view of the calls I've taken.)  80% of calls are requests for transport for medical care.  The person calling wants to receive care for non-life threatening medical issues.  This could be for sunburned legs (really happened) to really bad flu to painful productive cough.  Each one of those non-emergency calls ties up an ambulance that now can't respond.  Being able to divert to lower level of transport would save money.

Please note: i'm talking about 911 calls. Not non-Emergency Medical Transport, this is the person who needs medical supervision or care, but is not an emergency. Such as the recent hip replacement who is going from the hospital to a nursing/rehab center.  They need a stretcher with some medical support.  They are not going to hop in a car and drive over.  But most cities and states use private non-government/non-volunteer companies for this.

Over the long run, i'm expecting the following in EMS because of ACA.

First more doctors to ED calls for the next several months.
Next, more calls and fuller ED's.
Then more lectures from management about how important it is that we gather this demographic and insurance history is.
Next, more non-medical information that is mandatory to collect.
Then a better bargaining position for EMT's and Paramedics to get better pay and work conditions.

Will be able to work with ACO's and do some of what I suggested?  Don't know, I hope so.

I'm sure some people reading this will say "my state does not requirer X or Y"  And you might be right.  The Journal of Emergency Medical Service often gets great articles that advocate doing Y or X only to find out that in 29 states you would go to jail. (or lose your license for breaking the rules)

I'm sure some with think i'm making up these examples or numbers.  I will use the defense that this is what i've seen.  (Others will chime in with even worse examples they have had.  EMS is full of cases of medical WTF's)  I don't claim this is 100% correct for my area.  This i my POV from what i've seen. Take it for what that is worth.

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Comment Preferences

  •  Thank You (5+ / 0-)

    for the insight

    Power to the Peaceful!

    by misterwade on Wed Jan 08, 2014 at 11:29:53 AM PST

  •  Why is your EMS service (7+ / 0-)

    ...understaffed?

    Because that is the underlying organizational symptom that I see in your diary?

    In principle, you will see a bump as new folks have emergencies dealt with sooner.  But over time, you should see emergency cases drop as people are seen sooner and start having their conditions treated or managed.

    Redo this diary in July to give us an update as to whether that is occurring.

    The messy paperwork is intended to provide instant data for studies evaluating protocols.  I don't understand why EMS is having to do the health history that is unrelated to emergency treatment.  That sounds like something your local administration decided to do.  Surely some intake personnel could do follow-up to compete histories, couldn't they?

    50 states, 210 media market, 435 Congressional Districts, 3080 counties, 192,480 precincts

    by TarheelDem on Wed Jan 08, 2014 at 11:31:25 AM PST

    •  I've been asking the same question (2+ / 0-)
      Recommended by:
      AJayne, petral

      I think in part because the Union sucks and won't fight. (it does not help that our leadership keeps getting arrested and convicted for crimes.)

      Our management tells us that the Fire department wants to take us over to get the overtime we have.  That several of the private ambulance services want to get a piece of the pie also and are trying to get the smaller cities in the county to have them take over 911 service to "save money".

      Because of that, management wants to make nice with the Mayor and Counsel by bare-bonesing our budget and the union went along with a gutting of our pay and benefits.  The Mayor also has opposed moving to an all ALS system because of the cost and the theory that ACA is going to reduce the need for EMS.

      But they love the $15+ million our billing brings in.

      Stupid question hour starts now and ends in five minutes.

      by DrillSgtK on Wed Jan 08, 2014 at 01:19:31 PM PST

      [ Parent ]

    •  and with ACA fewer calls will be freebies (4+ / 0-)

      so in theory the EMS company should be able to hire the additional staff to meet the need.

      I suspect that word will also get around pretty quickly that insurance companies aren't willing to pay for EMS transport and ER visits for non-emergencies, and people should get themselves to the primary or an urgent care clinic instead.

      (In my only ER visit in the last 25 years, my insurance initially refused to pay on exactly that ground -- and I'd driven myself so it was just the ER cost. I won only because I had called their very own 800# nurse-line first, and she instructed me that I had to see someone that day (Sunday), not wait until Monday when the urgent care would have been open. Otherwise, they would not have covered it.

      All of this will take some time (a couple of years, not a couple of days) to sort out, and for everyone -- staff and patients alike -- to get used to the new patterns.

      •  More staffing... (1+ / 0-)
        Recommended by:
        petral

        the problem is that we can't get qualified people now.  There may be 4 people for every opening, but we can't get qualified paramedics and EMT's.  It is to the point we are running our own training program to get up to our goal staffing.  But that is very expensive and a long process, 8 months to a year.

        Ideally with increased insurance payments, even if Medicaid underpays by 10% of the cost, we would have fewer unpaid bills.  

        But like you said, insurance won't pay for non-emergency transport.  The State is now requiring services that bill to make efforts to collect.  So when medicaid refuses to cover the cost of a non-emergency run, in the past is was just written off.  Now it will go to collections and the state will attach their refunds and such.

        However, one of the arguments for why an ED bill should be covered is, "I came by Ambulance".  It is not a good one, but it is one.  A lot will depend on how the the report is written up.  

        I foresee many legal arguments about what is a reason to go to the ED.  Like below, is it acid reflux? or a cardiac event? How does the average person tell when they call 911 or drive to the ED?

        Stupid question hour starts now and ends in five minutes.

        by DrillSgtK on Wed Jan 08, 2014 at 02:27:55 PM PST

        [ Parent ]

  •  Good points about future changes needed (7+ / 0-)

    Patient education is needed.  Patients who used to have no option except the ER now need to have a walk-in provider to go to.  Those walk-in facilities are needed, and the patients need to be educated that they'll get better care there than the ER for appropriate conditions.

    The paperwork needs to be smoothed out.  It'll come.

    Better networks of in-home care is needed, such as the COPD and diabetes you describe.  This will save money.

  •  You can run into some huge problems with OSMT (5+ / 0-)

    If the EMT's judgement is wrong, you can refuse transport to someone that is having an actual emergency.

    There was a case of this in DC a few years ago when a 39 yo male was having chest pain and EMS refused transport because they thought he was just having acid reflux. He died a few hours later.
    http://www.wtop.com/...

    As much as I would love to refuse to transport our frequent flier who goes to the hospital several times a week for "heart palpitations," there's always the chance that something actually is going wrong.

    •  it is a problem. (1+ / 0-)
      Recommended by:
      petral

      Which would require some legal changes.  In the example you link to, it was not the EMS who refused to transport him.  The patient refused the transport. However the Fire Department member on the site suggested he did not need to go.  This is not currently the law in most states.  

      Actively not trying to get the person to go by ambulance is normally seen as a form of abandonment.

      However, if a person calls for chest pain, why couldn't the Paramedic run a 12 lead ECG and do a quick consult with a medical control before setting up alternative transport to a non ED site?  (the idea of a multi-seat mini-ambulance with two EMT's would fit nicely here)  Heck, at the last EMS conference I attended they had a small desk top blood lab analyzer.  Add that to an ALS ambulance and you could draw a rainbow, run it through the lab, get a reading in 10 min, and be able to make a very well informed triage call.

      But right now, if I put an ECG on someone I have to transport them, or make every effort to get them to go and bill them at ALS costs.  Once i do an ALS treatment, even sticking an ECG sticker on someone, it can't be downgraded.  This means a lot of "LOL's" - Little Old Ladies - get ALS bills for a BLS transport because they might have an underlying issue that a quick ECG ruled out.  Can't downgrade, that would be abandonment.

      Our frequent flyers could all benefit from allowing downgrading after getting an ALS check. Or clearing by Paramedics to a lower level transport - say a van or taxi to a medical care center.  You would still transport, but not with a Paramedic or an ambulance to an ED.

      Stupid question hour starts now and ends in five minutes.

      by DrillSgtK on Wed Jan 08, 2014 at 02:45:08 PM PST

      [ Parent ]

  •  My son-in-law (1+ / 0-)
    Recommended by:
    BlueMississippi

    works in the ER and told me over Christmas that they are seeing more Medicaid patients in ER seeking routine services and meds.

    He feels it is not a great use of resources.

    I hope that this changes over time as more covered patients establish regular physicans to get routine stuff dealt with.

    My hope was that the ER usage would drop over time, and save the system money.

    I almost feel like ER's should be allowed to send patients with routine illnesses  with coverage to docs instead of being required to treat them.

    The insured need to have some common sense and not abuse the ER option.

    •  However it is often the case that it is just not (4+ / 0-)

      possible to find a doctor in the area that accepts Medicaid and if the choice is between going to the ER or driving 100 miles each way to see a regular doctor then guess what, most of the time it will be the ER as most people can't afford a 200 mile round trip for every doctor's appointment.

      You have watched Faux News, now lose 2d10 SAN.

      by Throw The Bums Out on Wed Jan 08, 2014 at 12:09:33 PM PST

      [ Parent ]

      •  I was told by one newly insured... (1+ / 0-)
        Recommended by:
        petral

        that they called 911 because they could not find a doctor who took Medicaid.  As we drove by three offices with banners hanging outside saying "Now taking New Patients: Accepting Passport and WellChoice" (our medicaid programs)

        I don't get to meet people in their best situations.  No one has ever called 911 because they are having a good day.  But many times in the last 17 years of EMS, i've transported medicaid insured to the ED who have not made appointments to see their doctor. Who have not taken their children to the doctors to get their shots. Even had one parent tell me the shots were not up to date because the ED does not carry them all.

        That is not everyone, I know that.  But it is very common.  I've had people try to tell me that Medicaid Insured use the ED because it means they won't miss work like they would with an appointment with the doctor.  Yet, personal tracking for a week found that between 0800 and 2400, a ratio of 5 out of 8 medicaid insured transports per day were between 1100 and 1800.  This was in the early 2000's, and in the last week, seems about right.

        Stupid question hour starts now and ends in five minutes.

        by DrillSgtK on Wed Jan 08, 2014 at 01:14:06 PM PST

        [ Parent ]

  •  DrillSgtK - thank you for a very thougtful (6+ / 0-)

    and informative diary.

    "let's talk about that"

    by VClib on Wed Jan 08, 2014 at 12:01:16 PM PST

  •  Is it the fault of ACA (2+ / 0-)
    Recommended by:
    Sherri in TX, BlueMississippi

    or the fault of out healthcare system? Far too many people only know one way of getting healthcare . . . ERs!

    Folks having access to health insurance was not going to change that fact over night.

    If you are against sane gun regulations then by definition you support 30,000 deaths a year by firearms.

    by jsfox on Wed Jan 08, 2014 at 12:04:52 PM PST

  •  thanks (9+ / 0-)

       The one piece of information that struck me was the number of patients that are being transported from DR. office to ER.   You sited 3/week.   That would be an excellent stat to track ( if possible).

        Best wishes on the paper-work.  All new / changes in healthcare somehow require additional "paper-work", but it does tend to settle after everyone becomes familiar with the new process.

         Reading on-the-ground commentary is a great way to identify more process-improvement strategies.  

          You keep writing, we will keep reading.  

  •  New Medicaids are mostly working poor (5+ / 0-)

    which means (a) they're relatively healthy, but (b) they can't get to the doctor during the day. So one variable is whether doctors and urgent care clinics are willing to expand evening and weekend hours. A lot of the ER demand for non-emergencies is because they're the only place that's open after business hours.

    Where I am, the ERs are also on bus lines with good service. Private doctors' offices often aren't.

  •  Thank you for such a comprehensive analysis (1+ / 0-)
    Recommended by:
    petral

    I've long held that we would be wise to incorporate the experiences and opinions of those in the "first line of defense" in ANY industry into the development of processes and procedures. Your diary is proof that, indeed, we would.

  •  Terrific diary, thanks for writing, DrillSgtK. (1+ / 0-)
    Recommended by:
    petral

    I wonder if many newly insured people might just be so used to getting whatever care they have to have from the ED that they just don't think about having a regular doc to make appointments with. Perhaps they just don't think to try to make an appointment when they are well for a check-up and to get established. Will take a long time to change the thinking caused by lifetimes of unavailable medical care and abuse by insurance companies. And there are still copays and deductibles to worry about.

    The trouble ain't that there is too many fools, but that the lightning ain't distributed right. Mark Twain

    by BlueMississippi on Wed Jan 08, 2014 at 09:36:48 PM PST

    •  No co-pays on Medicaid (1+ / 0-)
      Recommended by:
      BlueMississippi

      Before the ACA we saw people in the 80% rate using the ED as their convince medical care site.  

      In 2004 or 2006, Canada had a crisis with their ED's, five to eight hour waits.  They did studies and found that 20% of the people there knew they could have gotten treatment from their primary care doctor or with over the counter medication. An additional 40% had medical issues that should have been treated through their doctor or with over the counter.

      Yet they chose the ED because it is right there.

      I know the UK has issues with this also, the National Health System has some very funny tv spots trying to educate people not to use the A&E (Accident and Emergency) Department with re-enactments of true stories - http://youtu.be/...

      I think this will be an issue that continues. EMS often calls it BS runs.

      Stupid question hour starts now and ends in five minutes.

      by DrillSgtK on Thu Jan 09, 2014 at 03:54:05 AM PST

      [ Parent ]

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