I work the front lines of medical care, I’m a paramedic for a mid-sized metro area in Northern Kentucky. I started with the EMS system in 2013 just as the Affordable Care Act — “Obamacare” started to take effect.
What I saw then and what i’m seeing now show some major changes. Not all of them good by the way. (Hey, it is real life)
In 2013 a good 30% or more of my patients were “self-pay”, no insurance. Which meant we took them to the hospital ($400 to $900) and they would spend several hours there ($1,500 to $3,000) and never pay a thing. This meant that the service had to write the cost off as a loss, and so did the hospital. (there is an argument that as a tax payer provided service there should be no billing — like with fire or police)
In 2015 less than 7% system wide are “self-pay”, and in my area maybe one out of every 50 people I transport. (mostly a low income single family homes with a few converted to apartments, and a lot of vacant homes)
What this means for us is a higher number of people calling 911 for service. Better repayment rates. Less loss of money. And a bit more attention from the Metro Council.
More calls: I know, it is strange, but if you have insurance you are more likely to use it. A lot of the newer insured don’t understand when you should go to the hospital, when you should go by ambulance, or when making an appointment with your doctor is the right choice. I’ve had a person tell me that since they have insurance now, they always call the ambulance to go to the hospital, that is why they have it. Yes, that is a bit blatant, but i’ve had people call 911 because their two year old put a rubber band around their wrist and were afraid it would cause the hand to fall off.
It does not matter if they are calling for the “right” reasons or the wrong. They are calling. In 2013 around 97,000 calls for service were logged by our service (and being understaffed and underfunded, almost 5,000 calls were passed off to private ambulance services that bill more and aggressively go after payments). Prior to 2013 the growth of calls was close to the national average of 3%. In 2014 we did 105,000 (and passed off 8,000 calls). 2015 is at 112,000 now, so 114,000 is possible. (and almost 11,000 calls diverted). In short we are seeing 6 to 8% growth in calls. More if you add in the ones we don’t take but give to private companies.
However, our staffing and equipment has stayed the same. So instead of doing 8 calls in our 12 hour shifts, we are now doing 16 hour shifts and 13 calls average.
On the positive side, more of these calls are being paid by insurance...sort of. Like with any medical bill, what is billed has very little reality on what is actually charged. We bill $400 for a basic transport and care, you break your leg, the EMT’s show up and splint it and take you to the hospital. Medicaid pays $275. The service can’t go after the patient for the difference. So it is possible to be getting more payments but losing more money. Which is not what happened according to the budget...until you ask for more pay then it is. (in 2013 the billing brought in $12.3 million, 2014 $13.8 million, and 2015 looks to be close to $14.5 million. — but the budget was $23.1/$23.8/$23.7 million)
We take more people to the hospitals, and more people are going to the hospitals. One ED shared it’s numbers with the news papers a few months ago. Before 2013 an average of 10 people an hour signed in to the ED in the small hospital during the daytime. Since then they are seeing 15 to 17 an hour average per day to include the night. While they have physical beds for people to be in, they don’t have nurses or doctors to do the care. (and it takes four years to get your BSN to be a nurse).
But we are seeing more construction being done on ED’s and other parts of hospitals that only recently were planned, mostly due to the increased funding they are getting from bills being paid.
Since we as a system are bringing in more from billing, the cost to the tax payer is lower. Except it means longer response times, using older equipment, not having the most effective (expensive) drugs to use, etc. Because if you were to hire more people that would cost more, and ambulances are crazy expensive to buy, stock and maintain. (EMT’s and Paramedics are cheep, $11 to $15 an hour)
Because we are doing more calls, generating more money, and generating more complaints of being too slow, the Metro Council is looking more at us. Sadly more at “why are we not getting more money from billing than it costs to run the service?” rather than “how can we make the service to the citizens even better.”
When ever it is brought up that the EMS system has an average of under 10 min response 80% of the time and that the national standard is under 5 in 95% of the time, instead of saying “we need to add more squads in pre-positioned locations” it is “well if people would stop calling for non-emergency reasons...” True, if they would. But if your aunt had testicles she would be your uncle. The reality is we are getting those calls. Yes, there are programs that can be started to reduce non-emergency calls — public education, better call taker questions, community paramedics, visiting nurses, etc. And they should be done...not that the council is funding that either.
Council also has a vocal group that is asking why don’t they privatize the service and save the cost of all of it. Something the private companies have been pushing. And on paper they make it sound good. “you pay us $8 million to answer these calls, we get all the billing revenue, and you still come out paying less!” Yes, the government loses $14.5 million but reduced the cost by $15 million. The private company then get very aggressive with bill collection and charges higher rates and often is able to collect 10 to 20% more than government billing. As well as lowering costs by running ambulances till they fall apart, use out dated equipment, scale back protocols to the minimum, and low pay/benefits to employees. (EMT’s $10, Paramedics $12 to $14 an hour).
I blame ACA for all the attention and pressure we are getting on that front. “make sure you document throughly so we can bill for everything properly” is a common email. It is not enough to document you gave “three Nitro pills before the chest pain went away”. You have to document “1 NTG 0.4mg given with no change in pain level 7/10. 1 NTG 0.4mg given with slight change in pain level 5/10. 1 NTG 04mg given with total pain relief 0/10.” so they can bill for each of them as being documented as being medically needed.
Personally I hate that part. I signed up to do patient care, not patient billing.
Now, is ACA working? I think it is to some extent. More people have insurance and are getting medical care than before. But I think it will be some time before we start seeing chronic problems getting under control that will reduce the burden on the 911/Emergency Department system. More needs to be done to educate the public when 911 is a proper choice (and when to go to the ED). It might just be i’m paying more attention, but it feels like we have had a large increase in “stupid” 911 calls. (last two shifts — 20 something with a splinter in toe; two year old with rubber band around writs, 30 something “recent loss of mobility in legs — intoxicated”, 20 something with “infected groin”, 45 year old with split finger nail from assault, 40 something due to “bloodshot eye”, 30 something with vomiting for four days, 50 something with knee pain when going down stairs, 9 year old with fever, 60 something intoxicated unable to stand, 20 something with sore throat from screaming at (gender)friend. On top of potentially serious calls — chest pain, short of air, falls with deformity, MVC with trauma indicators, OD’s, and the GSW’s and Stabbing that are all to frequent in my ride area.)