I'm a Paramedic for a mid sized metro area, about 1.1 million people in the metro area in the day, which the Metro Gov provides between 16 to 24 ambulances for 911 service through out the day. This is one person's view on how the first year of ACA has gone with no hard and fast data. Just a view from the front lines of medical care.
This will be long, and may not apply to your area. More after the squiggle.
Background
First off some back ground. 911 service nationally has been seeing about a 4% increase in calls each year. Many places have started "anti-911" ad campaigns to fight this along with Paramedic/RN community care (PRCC) programs. We as a society have done a very good job of getting the message out that you should call 911 to get help, we have not done a good job of getting them to determine what a 911 emergency is. (such as calling 911 because you did not get your special sauce with your chicken chunks at the drive through, or you have a low grade fever for two days.)
The PRCC is aimed at getting people diverted out of the 911 system to where they need to get the appropriate care instead of tying up the Emergency Department and Ambulances.
Our metro area in 2012 did 97,000 Calls For Service (CFS), in 2013 we saw 100,400 CFS, about a 3% increase. The state notified us that with the expansion of Medicaid in our state we should expect to see an additional 5 to 10% increase in CFS's. As of the first of the month of December we broke 98,000 calls, and with the current call rate we are expecting around 104,000 for the year. And this is on top of the 22,000 calls diverted to the PRCC, and another 15,000 diverted to the private ambulance companies. (Note, we diverted about 17,000 to the PRCC in 2013 and 9,000 in 2012 when the program started, but have no numbers on what private ambulances got in 12 and 13.)
So what is the big difference between 2013 and 2014?
More people have insurance. Now, this is a no-brainer. People are more willing to call 911 because they know they won't be charged for the service. We are seeing hospitals going on diversion twice the rate as last two years. (the health care system has been on a razors edge staffing wise for years as the for profit companies had to absorb the non-payments for care.)
The increase in use is stressing the 911 system also as hospitals go on diversion we end up slamming the ones that are not, adding to the cost of insurance when you take someone to an "out of network" hospital because theirs is on diversion. It also backs up the intake process, keeping the Ambulances at the Emergency Department longer and not on the road.
Ok, anything good happening?
But the big change is the number of people we are not marking as "Self-Pay" (which we use to joke as "No-Pay" because the bills never got paid). This should be a good thing for the service since the Metro Gov is trying to make money of this section of the 911 system and pushing us to keep costs low and billable care high.
Most governments have decided that EMS is a cash source. Billing for medical care makes some sense and their are for profit companies that provide Ambulance service that make money. So why wouldn't this opportunity to reduce taxes by direct billing for service? Well, the fact that EMS care is not profitable. At best you reduce your costs.
Take our service, in 2013 the Metro Gov budgeted $27.3 million for EMS (enough to staff a max of 27 ambulances, but not replace any equipment). The billing brought in $15.2 million that was sent right to the general fund. [to be fair, the Metro Gov did tap the capital fund to replace 5 ambulances with more than 350,000 miles on them and 2 that were destroyed in collisions - one that cost us two good people who are going to be out of work for more than a year].
This year they reduced our budget to $26.8 million, and budgeted for $14.8 million in billing. (we have a contract coming up and the thinking is they want to show how they can't pay us more because we cost too much) In the mean time we have more people with insurance using more care, and should increase the amount collected.
What is frighting is the increase in use of private ambulances to pick up 911 calls. These for profit companies charge more for the same service, and aggressively go after the billing. The Metro Gov only sends a bill twice and if not paid, writes it off. Private companies also hold the person responsible for the difference in what they billed and what the insurance company paid. For example, a in-law family member of mine took a fall and broke their leg. Called 911 and a private company was sent. The company billed $1,425 for the service, and the insurance company paid the equal to what Metro Gov charges for the same service - $950. If Metro Gov gets paid by the insurance $600, they take the $600 and that is it. This company sent mean letters and phone calls, and the insurance company argued that since my family member "chose" the private company, she has to pay the difference because she did not pre-clear the use of a non-government ambulance service and she should feel lucky they even paid what they did.
My family member was lucky, since she lived in the East side of the Metro area, the private companies are more wiling to pick up those calls. (East side is mostly white suburban areas, West side is lower income and minority areas and Medicaid prohibits going after the difference in payments.)
So nothing good has come from ACA?
No, many good things have come from it. For starters, more people have insurance and are getting medical care they use to not get or not pay for. We are sure that the billing numbers will be bigger than what the Metro Gov budgeted, even with the rumors of "redirecting bills with transport only costs" into a different accounting line. (Remember the Metro Gov has a contract negotiation coming up and needs to show how it can't afford to pay more than 140% over poverty level to EMT's. - just enough to not qualify for Medicaid)
Because of the increase in coverage, we are seeing people in less distress. The Asthmatic calls for help sooner when their inhaler does not break the attack. The diabetic calls sooner when they can't get their Blood Glucose leveled. Before they waited till it was "REALLY REALLY BAD" (RRB) but now they call when it is "just" REALLY BAD (RB). (and easier to fix. This means it cost less to treat, but we get more calls because sometimes it would fix after one more treatment, but if it did not we were doing massively invasive actions to fix.)
Personally I prefer showing up to "REALLY BAD" over the other option "REALLY REALLY BAD". I can avoid having to do drastic things like sedating the person and putting a tube down their throat to breath for them, instead give them an extra treatment, some long acting drugs and Continuous Positive Airway Pressure. Thereby avoiding a two to three day stay at the hospital. (yes, it is exciting to do the first, but the excitement is not why you stay in EMS)
We have also seen our "common" patients less. (Common meaning we get a call for them every two to three months vs our "frequent flyers" who we get a call for every two weeks to twice a day on) In once case I know it is directly due to ACA.
Patient X's Story
Patient X (PT X) had an respiratory problem that is normally treated with an inhaler or a "breathing treatment". Young (under 30), working full time at a part time job while going to college part time. PT X lived on the mixed income south end of the Metro area, and I had semi-regular contact when picking up Over Time. PT X only called when it was RRB but was so calm about it - it happened so much - that with out experience you might dismiss it as attention seeking. In February of this year, PT X showed up in my area (low income West End), because the current romantic interests lived there and it was close to the job.
I asked what insurance PT X had and got "I don't have any." A few more questions found that PT X had not applied for any, feeling that because they had a job that did not offer insurance they could not afford it. Because of no insurance they did not have an inhaler or breathing treatments. I did the whole spiel about how Medicaid had expanded to cover people like them and the KYNET also had a lot of low cost plans. Got PT X to promise to take to the registration at the hospital to get the info they had on getting signed up.
Two weeks later PT X was in my squad again, "I've got Insurance now!" But had not been to see their primary care Doc yet. Then it was three months later. "You're only seeing me because I forgot my inhaler at my house" (chose at the last minute to stay with the romantic interests who is a heavy smoker - not a good thing for either of them). This was the second Ambulance call PT X had taken since I had last seen them.
PT X had been calling about every three weeks for EMS or in the ED. Since getting insurance that has gone down to every three months or so. (Ran into them at the fast food place last month on another call and got the update)
Great, but is that going to reduce your call volume in the long run?
We hope but don't think so. While PT X is using us less, the number of people who call when it is just RB has gone up, and we have a very large number of people who suddenly have insurance for the first time and don't understand it is not a golden ticket for "faster access" to treatment. (Medicaid does not charge for Emergency Care or Regular Care) We have seen our lower priority calls increase and get demands (not requests, but demands) to be taken to the perceived better hospital across the county rather than the one just 10 blocks away. (adding a longer time the Ambulance is not free)
Whereas before they would suffer through the fever, aches, and nausea by taking over the counter medication, they now have no hesitation to call 911 for immediate care when they feel sick. (before they had to feel RRB sick because they did not want a bill)
We also have gotten more "I just want to be checked out" calls. They have fallen, or thrown up, or felt their kid was "not right". They are pretty sure everything is ok, and with out insurance would not have called but would have just kept an eye on it. But with insurance expect a medical professional to show up and check them out. Para-medicine is not regular care, we can't "just check them out" and are required by law to transport the person to an Emergency Department unless they choose not to go. (and we can't try to talk them out of it...though we do by treating them like adults and explaining as much as we can with out saying "you don't need to go")
This is why no one realistically expects to see lower call volume any time soon. Maybe over time, especially if Medicaid starts adding a small fee for Emergency Care that will redirect minor issues towards Urgent Care centers and calling the Primary Care Doc for an appointment instead of 911.
In the mean time...
We are on track to see over 104,000 CFS this year, are getting more pressure from the Metro Gov to improve our turn over and Unit Hours Utilized so revenues increase. Our West End citizens are beginning to question why they pay taxes for EMS AND get a bill when they call (or collections when it is a private company that shows up). You don't get a bill when the Fire Department shows up to put out the fire.
You can find out how things are in your city by talking to your EMS Paramedics, and asking have they seen an increase in call volume. Take a look at your EMS budget and see if they are treating EMS as a cash cow - cutting budget and increasing billing - reducing payroll costs (paying the same as private companies for 10 times the work load), shifting from Paramedics on each Ambulance to just EMT's or an EMT and First Responder - Driver. A Paramedic cost a lot more ($14 to $16 an hour) while an EMT is less ($9 to $12 an hour) and a First Responder (minimum wage to $9 an hour).
When you see your EMS shifting to EMT's and reducing the number of Paramedics, that is not a good thing for you. EMT's can only do a few things - Basic Life Support. Which is very important, but limited compared to what a Paramedic can do.
Like I wrote, this is one persons view from the front lines of health care.