# How will Trump effect EMS?



## ExpatMedic0 (Nov 10, 2016)

Not trying to be political here. I am just looking at this from a neutral and EMS specific standpoint. How do you think Trump being elected will affect EMS? I read an interesting article on EMS1 regarding it (link below) and one thing that was mentioned was that APA will be scraped. The APA appears to be one way that community paramedic programs where be funded for example, and also lead to reimbursement changes for many agencies.

http://www.ems1.com/ems-management/...mpaign=EMS1Member&cub_id=usr_TPB3cm65TdffwRib


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## Akulahawk (Nov 10, 2016)

The "Affordable" Care Act will likely be repealed and replaced. That won't be an overnight process and getting things right should be the primary driver when they put everything back together. In the short term, I don't think Trump will have much of an effect upon EMS. In the long run? It all depends upon what the legislators want to do and if Trump will go for it. 

I do, however, see this as an opportunity for actual stakeholders to do something the right way from the top instead of passing a new set of laws and make everyone find a way to make it work. This is an opportunity that could very easily be missed.


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## StCEMT (Nov 10, 2016)

Akulahawk said:


> This is an opportunity that could very easily be missed.


Sure is. There would be no excuse as to why *insert plan here* didn't work at this point.


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## Arovetli (Nov 10, 2016)

Honestly, nobody...and I mean NOBODY, has a clue. ACA and MACRA might be in jeopardy, putting a HUGE damper on community paramedicine. And by huge damper, if MACRA and the ACA get gutted, Medicaid block grants get gutted, CP projects will get gutted.


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## Summit (Nov 10, 2016)

Who knows... probably not a lot. 

An extreme repeal of ACA could result in some increase volume when people lose coverage that gets primary care and switch to the ER/911. But doesn't seem that likely.


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## EpiEMS (Nov 10, 2016)

ExpatMedic0 said:


> I am just looking at this from a neutral and EMS specific standpoint. How do you think Trump being elected will affect EMS?



Thanks for posting - I think this is a thoughtful question that we should all be asking.

ACA repeal/replace seems possible. Given that we have evidence suggesting that Medicaid coverage may even increase ER usage, I'd posit that insurance status and ER/911 EMS usage are related - but the correlation between coverage status and use is not necessarily in the direction we'd posit (i.e. we would expect that people with insurance seek care before a PCP manageable problem worsens to become an ED-needed problem, but in actuality, they may use the ER more from the outset).

Regulatory rules being rolled back is possible, but the bureaucracy is slow (and so is Congress). So we may see some longer-term effects, it would be hard to imagine any effects in, say, the first 100 days (though I could very well be wrong).

About the rest - labor force size, taxes, etc., I'd need to do a nice thinking session to really puzzle through it.


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## Arovetli (Nov 10, 2016)

Epi- wasnt there some data showing Medicaid was working at managing long term care better than other options? It's been a year or so since I last checked so idk.


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## EpiEMS (Nov 10, 2016)

Arovetli said:


> Epi- wasnt there some data showing Medicaid was working at managing long term care better than other options? It's been a year or so since I last checked so idk.
> 
> 
> Sent from my iPhone using Tapatalk



Could certainly be. I've seen data saying that Medicaid is more efficient - but that isn't necessarily a complete accounting, if you will, because Medicaid is a more than a bit more liberal with payments (albeit lower ones) than private insurers are. I found some interesting research on dual-eligibles, but I didn't find anything on Medicaid managing LTC better than others.

KFF has a nice briefer on Medicaid-funded LTC.


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## Arovetli (Nov 10, 2016)

ExpatMedic0 said:


> Not trying to be political here. I am just looking at this from a neutral and EMS specific standpoint. How do you think Trump being elected will affect EMS? I read an interesting article on EMS1 regarding it (link below) and one thing that was mentioned was that APA will be scraped. The APA appears to be one way that community paramedic programs where be funded for example, and also lead to reimbursement changes for many agencies.
> 
> http://www.ems1.com/ems-management/...mpaign=EMS1Member&cub_id=usr_TPB3cm65TdffwRib


 
Just released:

https://assets.donaldjtrump.com/_landings/contract/O-TRU-102316-Contractv02.pdf

Fully Repeal Obamacare. *sings* it's the end of community paramedicine as we know it...yes it's the end of community paramedicine as we know...


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## EpiEMS (Nov 10, 2016)

Arovetli said:


> Fully Repeal Obamacare. *sings* it's the end of community paramedicine as we know it...yes it's the end of community paramedicine as we know...



Probably (politically) harder to do than we may think, on the face of it. ACA contains things that many people approve of or benefit from (regardless of whether the ACA is good/bad).

Community paramedicine could survive, in isolated spots, I'd wager, and some agencies (AHRQ?) may have funding for it.


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## Arovetli (Nov 10, 2016)

For sure, and I'll wager the stuff already in effect stays, but the future stuff for pop health bill payments gets canned...there's still spots where CP makes sense but not on a broad scale....


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## Arovetli (Nov 10, 2016)

There's still some big grants for rural health that could fund projects...what program am I thinking of? The FQHC thing....


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## ExpatMedic0 (Nov 10, 2016)

It's expensive transporting people to the hospital all the time. I think the CP programs have demonstrated significant healthcare savings in many systems. I would think that maybe some private insurance company's would support it.


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## NysEms2117 (Nov 10, 2016)

I have not paid much attention to his policies, however lets all remember we can take a step back. its not a dictatorship, Congress still has a ton of power, and personally i do not think will "allow radical change". Interpret this as you may.
**THIS IS MY OPINION PLEASE DO NOT TAKE THIS AS A PERSONAL ATTACK ON ANYBODY.**


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## ExpatMedic0 (Nov 10, 2016)

I believe the house and senate are all republican majority now. I am not sure how wide the divide is within the party on healthcare issues... but I guess we will see.


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## NysEms2117 (Nov 10, 2016)

ExpatMedic0 said:


> I believe the house and senate are all republican majority now. I am not sure how wide the divide is within the party on healthcare issues... but I guess we will see.


Your correct, it is a republican majority, but they still won't want to just start deleting things. They are still sensible(ish), anything with politics is a blind dart throw... To be honest, its who gets into who's pockets. Trying not to get off topic here either, however while this is a valid topic, personally i do not think anything "radical" will happen, then again i have not read descriptive articles on what he plans to do.


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## Qulevrius (Nov 10, 2016)

NysEms2117 said:


> Your correct, it is a republican majority, but they still won't want to just start deleting things. They are still sensible(ish), anything with politics is a blind dart throw... To be honest, its who gets into who's pockets. Trying not to get off topic here either, however while this is a valid topic, personally i do not think anything "radical" will happen, then again i have not read descriptive articles on what he plans to do.



Staying on the topic of CP, it simply comes down to who's gonna pay for it. Ultimately, it has little to do with ACA and a lot to do with specific budget allocated to certain population groups. Without going into too much detail, ACA was nice on paper and oh-so-much uglier in person, because it started pushing for a socialist model of healthcare in a non-socialist country.

People who ever dealt with socialism of any kind (i.e. not the armchair experts who read the theory, but those who actually experienced it) know exactly how that works - over 30% income tax, mind-boggling bureaucracy, and particularly in medicine - immediate non-threatening care, but very few accessible specialists. The biggest issue with ACA is that it is extremely prone to abuse, especially with the # of people who are either exempt of taxation due to income, receiving government subsidies or otherwise exploiting the system. Right now, it is us who's paying for their 'free' medical care and their 'free' community paramedicine. And we also have to haul them to the ER. The irony, it's very real.


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## Tigger (Nov 10, 2016)

The implementation of the ACA led to an expansion in Medicaid (and Medicare to an extent) payor groups. This year our service's payor mix was 72% Medicaid/Medicare. Our self pay is down to less than 5%. Which is great, except that Medicaid and Medicare reimburse so far below cost. So low in fact, that we actually made more money off our self pay patients by developing payment plans with them and/or sending them to collections. An increase in insurance coverage did not lead to an increase revenue for us, though that is not really an ACA issue. Medicare/caid rates were always below market value, it just hit us harder. 

As for our community paramedic program, it would not exist without the ACA. We subcontract with the regional Medicaid contractor, and they would likely not have the budget to pay us without the ACA. Though the mental health mandate that brought about our involvement is state based, the Medicaid contractor was the only entity large enough to take that on.



ExpatMedic0 said:


> It's expensive transporting people to the hospital all the time. I think the CP programs have demonstrated significant healthcare savings in many systems. I would think that maybe some private insurance company's would support it.


Readmission avoidance programs are a result (in my opinion) of the ACA. These have the potential to be the source of funding for many community paramedic programs. When the fines finally become too expensive for the healthcare networks and they need the manpower for relatively simple readmission avoidance programs, CP programs can be the answer. We have struggled with getting their buy in so far as there really isn't that much evidence of non-hospital affiliated services reducing readmission. But in my district, there is minimal to no home healthcare. We are the only healthcare provider in the area, who else will they turn to?



Qulevrius said:


> Staying on the topic of CP, it simply comes down to who's gonna pay for it. Ultimately, it has little to do with ACA and a lot to do with specific budget allocated to certain population groups. Without going into too much detail, ACA was nice on paper and oh-so-much uglier in person, because it started pushing for a socialist model of healthcare in a non-socialist country.
> 
> People who ever dealt with socialism of any kind (i.e. not the armchair experts who read the theory, but those who actually experienced it) know exactly how that works - over 30% income tax, mind-boggling bureaucracy, and particularly in medicine - immediate non-threatening care, but very few accessible specialists. The biggest issue with ACA is that it is extremely prone to abuse, especially with the # of people who are either exempt of taxation due to income, receiving government subsidies or otherwise exploiting the system. Right now, it is us who's paying for their 'free' medical care and their 'free' community paramedicine. And we also have to haul them to the ER. The irony, it's very real.



We've been paying the low income population's healthcare costs for decades. When people don't pay their bills, the costs get passed along. One way or another that's going to continue, I'd prefer if my money was used efficiently.


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## Qulevrius (Nov 10, 2016)

Tigger said:


> We've been paying the low income population's healthcare costs for decades. When people don't pay their bills, the costs get passed along. One way or another that's going to continue, I'd prefer if my money was used efficiently.



My sentiment as well. But I'd rather not have to pay too much for those who don't feel like paying for themselves.


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## Carlos Danger (Nov 10, 2016)

Tigger said:


> We've been paying the low income population's healthcare costs for decades. When people don't pay their bills, the costs get passed along. *One way or another that's going to continue,* I'd prefer if my money was used efficiently.



As a pretty staunch libertarian and fiscal grinch, this is a tough pill for me to swallow. But it is true. Many people simply will not do what they need to do to take care of themselves, and unless we are prepared to start taking ICU patients who can't pay their bill outside to be dumped in the street, or refuse to let people who obviously really need care from entering the ED without cash payment in advance, then there has to be government programs to pay for their care.

I don't know what the answer is. It certainly isn't the ACA. The ACA wasn't even truly a healthcare bill, it was a horribly irresponsible, hyper-partisan power grab that I'm not convinced was even intended to work as advertised. The biggest problem we have is that our healthcare system has gotten to monstrously complicated, and all of the new programs just add to the mishmash of programs and increase the complexity.

I don't know what Trump's healthcare plan is, or how it will affect EMS. Repealing the ACA would be a good start, but it has to be more than that. I think there have got to be lots of free-market(ish) ideas that if nothing else, would at least slow the rise of costs for a while.


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## Tigger (Nov 10, 2016)

Remi said:


> As a pretty staunch libertarian and fiscal grinch, this is a tough pill for me to swallow. But it is true. Many people simply will not do what they need to do to take care of themselves, and unless we are prepared to start taking ICU patients who can't pay their bill outside to be dumped in the street, or refuse to let people who obviously really need care from entering the ED without cash payment in advance, then there has to be government programs to pay for their care.


Even if there aren't government programs to pay, costs will still be passed on to those that do pay.

Our rates are as high as they are because we need to use private insurance payments to make up for the below market reimbursement of Medicaid/care patients. Fair and equitable? Not in the slightest.


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## Qulevrius (Nov 10, 2016)

Remi said:


> Repealing the ACA would be a good start, but it has to be more than that. I think there have got to be lots of free-market(ish) ideas that if nothing else, would at least slow the rise of costs for a while.



So, purely theoretical - and this comes off of a conversation with another member of this community - there's a direct quote:

_"Basically, it all comes down to subsidizing it => drawing a budget => deciding who's paying for it. A socialist model would be 'hey, lets raise the taxes and pay it from the haul'; this is what we have right now - people pay more and receive less, because the excess goes into paying for those who never paid and never received. A more sensible, conservative approach is to address the situation on a case-by-case basis - without going into specifics, it has to come down to promoting communal awareness, specialized education and have NPOs take care of CP (with very strict regulation and legislation)."_

Expanding on the aforesaid:

1) the educational bar and subsequently, professional requirements for EMS professionals need to be raised;
2) EMS/CP budget has to come, at least partially, from municipal authorities. Would be much better to give [deserving] EMS professionals enough incentive to draw them away from private companies and into municipal EMS, but that's day-dreaming;
3) State/Federal approved and regulated NPOs whose leadership promotes health-related awareness and whose rank & file members provide for basic healthcare needs of a target community.

That way, at least, it's a case-by-case and not a shotgun approach. Incidentally, I believe this is nearly the exact model that Harvey Hall is employing right now (barring the NPO part).


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## CatrionaEMT (Dec 6, 2016)

Frankly - nothing but good can come out of it. Socialism is a nice idea, too bad it doesn't work. The ER's are being treated like a doctors office, and health insurance costs have skyrocketed. This leaves us with people who abuse the system and/or are taking away from people that truly need the help.
I don't know a single EMT or Paramedic in my division that didn't vote for Trump. We were all heavy supporters - and know that it will help the economy, therefore helping health insurance, therefore helping ACA - helping people stop abusing. Then we can actually get back to our job and stop running as many "I stubbed my toe" calls... (although those are in number anyway).


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## EpiEMS (Dec 7, 2016)

CatrionaEMT said:


> I don't know a single EMT or Paramedic in my division that didn't vote for Trump.



Demography is destiny, as they say.

Aside from the demographics, though, I don't think we can be very confident in politicians fixing health care, one way or the other.

The ACA (with attendant Medicaid expansion) isn't to blame for heavy use, but it sure as heck didn't help - as we know from a piece of a wonderful study/natural experiment. We've committed as a society to pay for care for the indigent forever, and really put it on paper with the EMTALA for some 30 years (as an unfunded mandate). Clearly, insuring people doesn't help. Will the putative economic benefits of Mr. Trump's policy platform make things better? I give it a qualified yes. Yes insofar as that we will have more tax revenue to make good on our unfunded mandates, but no insofar as that the economy being better overall doesn't necessarily reduce overutilization of emergency services.


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## zzyzx (Dec 12, 2016)

The fox has been let into the hen house.
EMS is my least concern.


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## DrParasite (Dec 12, 2016)

CatrionaEMT said:


> Socialism is a nice idea, too bad it doesn't work.


You sure about that?  did you watch the same movie Sicko as I did?  https://en.wikipedia.org/wiki/Sicko

Communism doesn't work, but I, for one, would love to see socialized medicine actually be applied in the US.  It works in England, and many countries in Europe.  Heck, it even works in Cuba.  The ACA is a disaster, which can be blamed on liberals and those who want something for nothing, but that's another topic.  But it did provide a means for people to get health insurance, if they wanted it.

I think Trump will be good for domestic businesses, but I don't see him getting re-elected in 4 years, especially if the democrats nominate a decent trustworthy candidate (which they failed to do this time)


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## EpiEMS (Dec 12, 2016)

DrParasite said:


> Communism doesn't work, but I, for one, would love to see socialized medicine actually be applied in the US. It works in England, and many countries in Europe. Heck, it even works in Cuba.



For what it's worth, socialized medicine isn't (politically) feasible in the U.S., except for that which we already have: Medicare (arguably), Medicaid (definitely is), and taxpayer subsidization for employer-provided health insurance. However, the fundamental constraint of a socialist system is what we as a society are willing to pay for a (selfish) individual. For example, England (the NHS) has very strict limits on the kind of care (read: cost of care) that is deemed societally acceptable. Can't really do that here, politically speaking.

If you think socialized health care works for everybody in Cuba, you're sadly mistaken: You can have a great ratio of physicians to population, a great ratio of nurses to population, and really well trained staff, but since they don't have the equipment and pharmaceuticals they need, they are basically back in the pre-antibiotic era...except if they resort to the black market. The point is, free health care is not free, and when it's "free", it's often not going to be good. 



DrParasite said:


> The ACA is a disaster, which can be blamed on liberals and those who want something for nothing, but that's another topic. But it did provide a means for people to get health insurance, if they wanted it.



To give the ACA its due, I will say this: It has improved *financial* security for a subset of people. However, it has done so at too great a cost - and we know that insurance doesn't improve physical health measures or outcomes, nor does it reduce utilization of emergency services (i.e. ambulances, EMS and the ED) for non-emergent conditions. Insurance is not care.


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## Carlos Danger (Dec 12, 2016)

DrParasite said:


> You sure about that?  did you watch the same movie Sicko as I did?  https://en.wikipedia.org/wiki/Sicko
> 
> Communism doesn't work, but I, for one, would love to see socialized medicine actually be applied in the US.  It works in England, and many countries in Europe.  Heck, it even works in Cuba.  The ACA is a disaster, which can be blamed on liberals and those who want something for nothing, but that's another topic.  But it did provide a means for people to get health insurance, if they wanted it.
> 
> I think Trump will be good for domestic businesses, but I don't see him getting re-elected in 4 years, especially if the democrats nominate a decent trustworthy candidate (which they failed to do this time)



How do you know socialized medicine works in Cuba? The accounts I've read all describe long wait times, run down facilities and old equipment, and chronic shortages of both qualified providers and basic medications.

I think socialized medicine appears on the surface to work well, but is fraught with all the problems that accompany any "free" program; namely, demand that outstrips supply. From what I understand, private healthcare is a rapidly growing industry in western Europe for those who can afford it.


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## EpiEMS (Dec 12, 2016)

Remi said:


> From what I understand, private healthcare is a rapidly growing industry in western Europe for those who can afford it.



The same holds true in Canada, I'm told. Heck, for what it's worth, in Canada, "Private insurance, held by about two-thirds of Canadians, covers services excluded from public reimbursement, such as vision and dental care, prescription drugs, rehabilitation services, home care, and private rooms in hospitals."


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## Qulevrius (Dec 12, 2016)

People who never experienced socialized medicine, do not understand how it works. Basic healthcare needs are, indeed, freely accessible and if a person has something not particularly complicated (i.e. has to see a general physician), it's on a walk-in, 15-20 min wait time, basis. But once someone needs a specialist, it turns into a horror show, because - as it has been pointed out - the demand is much greater than supply, and people end up waiting months til they can get the service they need. And the only way around it is through the cracks in the system. Corruption, the hallmark of socialism - 'all animals are equal but some are more equal than others'.


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## Drwlemt (Dec 12, 2016)

Qulevrius said:


> People who never experienced socialized medicine, do not understand how it works. Basic healthcare needs are, indeed, freely accessible and if a person has something not particularly complicated (i.e. has to see a general physician), it's on a walk-in, 15-20 min wait time, basis. But once someone needs a specialist, it turns into a horror show, because - as it has been pointed out - the demand is much greater than supply, and people end up waiting months til they can get the service they need. And the only way around it is through the cracks in the system. Corruption, the hallmark of socialism - 'all animals are equal but some are more equal than others'.


Can't agree more military healthcare and now VA health care can be a nightmare depending what you need. Plenty of Ibuprofen though.


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## Qulevrius (Dec 12, 2016)

Drwlemt said:


> Can't agree more military healthcare and now VA health care can be a nightmare depending what you need. Plenty of Ibuprofen though.



Yep. Break the pill in half, 'this half is for headache, the other one is for stomach pain. Take the wrong one and you die.'


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## Carlos Danger (Dec 12, 2016)

Drwlemt said:


> Can't agree more military healthcare and now VA health care can be a nightmare depending what you need. Plenty of Ibuprofen though.



I truly can't believe how people can witness the DMV.....the IRS.....the VA......not to mention all the ways that hyper-regulation already contributes to making our "private" healthcare system such as mess.......and then actually want the government to take even _more_ control.


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## DrParasite (Dec 13, 2016)

Remi said:


> How do you know socialized medicine works in Cuba? The accounts I've read all describe long wait times, run down facilities and old equipment, and chronic shortages of both qualified providers and basic medications.
> 
> I think socialized medicine appears on the surface to work well, but is fraught with all the problems that accompany any "free" program; namely, demand that outstrips supply. From what I understand, private healthcare is a rapidly growing industry in western Europe for those who can afford it.


Actually, I know very little about Cuba's healthcare system, other than what I have been told by some Cuban friends.  Ditto Europe: my little brother lives in England, and every time I suggest he moves back to the US, he said the free healthcare is great for someone who has chronic Kidney stones, and having a baby is much cheaper than the $5000 it's going to cost me in the states with insurance.


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## DrParasite (Dec 13, 2016)

Remi said:


> I truly can't believe how people can witness the DMV.....the IRS.....the VA......not to mention all the ways that hyper-regulation already contributes to making our "private" healthcare system such as mess.......and then actually want the government to take even _more_ control.


I don't want the government to take control, per se; but I would love for the government to fund the system via taxes, so everyone contributes to the heathcare system, at least at the basic level.  No more needing to go to the ER for routine stuff, you can go to your GP.  Or an urgent care.   no need to call 911 for the "free ride," at least now the agency will get some reimbursement for it.

Are there going to be system abusers? absolutely.  Will private insurance be needed to cover the basics that aren't covered?  probably.  But our current for profit system is inherently flawed, so something needs to be done.  If you have a better idea, I'm sure people would love to hear it.


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## EpiEMS (Dec 13, 2016)

DrParasite said:


> Actually, I know very little about Cuba's healthcare system, other than what I have been told by some Cuban friends.  Ditto Europe: my little brother lives in England, and every time I suggest he moves back to the US, he said the free healthcare is great for someone who has chronic Kidney stones, and having a baby is much cheaper than the $5000 it's going to cost me in the states with insurance.



Free:






Free isn't free - it's taxes and borrowing (from future people).



DrParasite said:


> No more needing to go to the ER for routine stuff, you can go to your GP. Or an urgent care. no need to call 911 for the "free ride," at least now the agency will get some reimbursement for it.



There is no evidence that improved health insurance reduces inappropriate ER use. It does the opposite: "[T]he increase in emergency department use occurred despite Medicaid increasing access to other types and sites of care."


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## ExpatMedic0 (Dec 13, 2016)

I have worked with 20+ UK paramedics from the NHS, not one of them had anything good to say about the NHS. It's also constantly under fire in the media. On the other hand, I have worked with a good number of paramedics from Australia and they all talked positively about their system and working in EMS there. Obviously, these are all strictly subjective and anecdotal experiences but I think it's fair to say not all systems are the same just because health care is government funded. I live in Denmark right now, the healthcare system is 100% government funded, and it has pros and cons. The EMS system also has many pros and cons but is much more stream-lined in someways. I believe the U.S. is the only modern English-speaking nation  that, until very recently, had no coverage for millions of citizens. So something had to be put into place. There are pros and cons to every kind of system, but what I am concerned most about for this forum post is the U.S. and its EMS system(s) and how they will change for better or for worse with the new president, and what the rationale is behind those opinions.


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## Carlos Danger (Dec 13, 2016)

DrParasite said:


> But our current for profit system is inherently flawed, so something needs to be done.  If you have a better idea, I'm sure people would love to hear it.



Our current system is incredibly complex and contains innumerable inefficiencies.....many (if not most) of which are a direct result of or at least partially because of a heavy regulatory burden. It's always easy to blame capitalism, but considering that our current healthcare system is far from a true free market - and hasn't been for decades - that claim just can't be made. So I disagree that the profit motive can be blamed for our systems failure. There's way too much going on besides some greedy people making money.

With all that in mind, I think the best solution is for the federal government to get out of healthcare completely. Let the states run their own programs. Of course that will never happen. 

Maybe socialized medicine does work elsewhere, but I think it's pretty clear that our federal government sucks bad at it.


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## Qulevrius (Dec 13, 2016)

ExpatMedic0 said:


> I have worked with 20+ UK paramedics from the NHS, not one of them had anything good to say about the NHS. It's also constantly under fire in the media. On the other hand, I have worked with a good number of paramedics from Australia and they all talked positively about their system and working in EMS there. Obviously, these are all strictly subjective and anecdotal experiences but I think it's fair to say not all systems are the same just because health care is government funded. I live in Denmark right now, the healthcare system is 100% government funded, and it has pros and cons. The EMS system also has many pros and cons but is much more stream-lined in someways. I believe the U.S. is the only modern English-speaking nation  that, until very recently, had no coverage for millions of citizens. So something had to be put into place. There are pros and cons to every kind of system, but what I am concerned most about for this forum post is the U.S. and its EMS system(s) and how they will change for better or for worse with the new president, and what the rationale is behind those opinions.



There's really no basis for comparison between a small Northern European country with a total population of 5.5 million, with ~10% being immigrants, and a country the size of US, with its annual immigration rates. Not to mention their respective GDP and per capita, defense expenditure and other stuff. It's not a *'*what's good for the goose is good for the gander' thing, it is a 'what's good for the goose, isn't always good for the gander'.


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## Scott33 (Dec 13, 2016)

ExpatMedic0 said:


> I have worked with 20+ UK paramedics from the NHS, not one of them had anything good to say about the NHS.



My experience is the opposite. Sure, they like to whinge about their jobs (it's a British tradition) but they have suffered increasing demands over the years which are unsustainable. Several trusts have been forced to recruit from abroad (notably Australia and NZ) to fit bums on seats, due to some places losing staff quicker than they can be replaced.  

However, most UK paras I know (and I am related to one) are still pretty proud of the NHS. They may be disillusioned with their jobs, hate their management, and wish a swift death upon Jeremy Hunt (Secretary of State for Health), but most of them would be hard pushed to imagine working under a different system...least of all something like we have in the US.


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## EpiEMS (Dec 14, 2016)

Scott33 said:


> but most of them would be hard pushed to imagine working under a different system...least of all something like we have in the US.



Seems like they are better compensated than U.S. EMS providers - in part likely because they are government-employed and (often) better educated. Not to mention, they have more in the way of a career ladder - Advanced Paramedic or even the PA-like Emergency Care Practitioner.


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## Arovetli (Dec 14, 2016)

Remi said:


> How do you know socialized medicine works in Cuba? The accounts I've read all describe long wait times, run down facilities and old equipment, and chronic shortages of both qualified providers and basic medications.
> 
> I think socialized medicine appears on the surface to work well, but is fraught with all the problems that accompany any "free" program; namely, demand that outstrips supply. From what I understand, private healthcare is a rapidly growing industry in western Europe for those who can afford it.



Sounds just like good old fashioned American capitalist medicine.


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## Arovetli (Dec 14, 2016)

Let's just call a spade a spade here and cut to the chase.

It's economics.

People with money, for a variety of reasons, have access to better things than people without money have.

EMS is the front line safety net for people without money.

Unfortunately, Ain't nobody gonna pay for that. Cheap bread and circuses have been the tonic for the masses for ages.

Let them eat cake.


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## Arovetli (Dec 14, 2016)

I don't agree with it, but it's what it is. 


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## Arovetli (Dec 14, 2016)

Refer to my signature, if you'd like a modern quote on how to deal with this problem


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## Summit (Dec 14, 2016)

Arovetli said:


> EMS is the front line safety net for people without money.


No we aren't. 
We don't function that way.
We weren't designed that way.
And we are terrible at it.


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## Arovetli (Dec 14, 2016)

Summit said:


> No we aren't.
> We don't function that way.
> We weren't designed that way.
> And we are terrible at it.




Agree with the last 3 statements, not the first.

Tragedy of the Commons.


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## EpiEMS (Dec 14, 2016)

Arovetli said:


> Refer to my signature, if you'd like a modern quote on how to deal with this problem



Yep, and the ACA (i.e. Medicaid expansions) won't help. You give a mouse a cookie, and it just wants more cookies - and (probably - but I have no concrete evidence for this) a ride to the cookie factory (even if you slap a cookie fee on them).


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## Arovetli (Dec 14, 2016)

Let me put it like this. People who make big decisions in business in policy come from schools of thought steeped in game theory and behavioral economics.

You have a gigantic case of the tragedy of the commons right here. We're committed to provided free access healthcare by virtue of law, policy and of course, ethics.

Something with massively high demand is offered for free in a world of finite resources. Challenging paradox. To resolve it, do we try more broad control of the markets or back off and let the markets run loose.

Loose markets creates inequality and instability. 

Whatever shall we do?




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## EpiEMS (Dec 14, 2016)

Summit said:


> No we aren't.
> We don't function that way.
> We weren't designed that way.
> And we are terrible at it.



I would respectfully disagree - I think we should not be functioning as the safety net, nor were we designed for safety-net purposes, but we *are*, in many places, functioning as the safety net. That being said, we are bad at it!


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## Arovetli (Dec 14, 2016)

EpiEMS said:


> Demography is destiny, as they say.
> 
> Aside from the demographics, though, I don't think we can be very confident in politicians fixing health care, one way or the other.
> 
> The ACA (with attendant Medicaid expansion) isn't to blame for heavy use, but it sure as heck didn't help - as we know from a piece of a wonderful study/natural experiment. We've committed as a society to pay for care for the indigent forever, and really put it on paper with the EMTALA for some 30 years (as an unfunded mandate). Clearly, insuring people doesn't help. Will the putative economic benefits of Mr. Trump's policy platform make things better? I give it a qualified yes. Yes insofar as that we will have more tax revenue to make good on our unfunded mandates, but no insofar as that the economy being better overall doesn't necessarily reduce overutilization of emergency services.



A good bit of trump supporters lacked a college education. A good bit of EMS providers lack college educations.

It's a correlation. Don't read too much into it.


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## EpiEMS (Dec 14, 2016)

Arovetli said:


> A good bit of trump supporters lacked a college education. A good bit of EMS providers lack college educations.
> 
> It's a correlation. Don't read too much into it.



I know, I was half joking (mostly being snide) there. I do think that any expectation of a quick fix by any party (and certainly by any individual) is unrealistic.


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## Arovetli (Dec 14, 2016)

@epi I meant to quote the post you quoted not your post, sorry!


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## EpiEMS (Dec 14, 2016)

Arovetli said:


> @epi I meant to quote the post you quoted not your post, sorry!



No worries!


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## Qulevrius (Dec 14, 2016)

Arovetli said:


> A good bit of trump supporters lacked a college education. A good bit of EMS providers lack college educations.
> 
> It's a correlation. Don't read too much into it.
> 
> ...



There's no correlation there. If you really want to correlate, consider a total % of college-educated or above people, then break it down by ethnics & residency, and finally, their party affiliation.  What you just said is an ole 'all blacks voted Obama, and a good bit of them are welfare queens/gangbangers'.

But yeah, don't read too much into it.


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## Arovetli (Dec 14, 2016)

No. what I inferred was the demographics of EMS mirror the demographics of Trump voters.

And I did not, in no such way, make any references to race, gender sexuality or any other minority groups or any type of offensive imagery that you've chosen to use.


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## Qulevrius (Dec 14, 2016)

Of course you didn't. But this is formal logic vs your figurative language,  and am showing you what it looks like.


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## Arovetli (Dec 14, 2016)

Sigh.

I pointed out one thing matched another and it should not be read into in precisely the fashion you read into it.

I apologize if that was not clear.

I also pointed out that for many thousands of years the problem of poverty, social welfare, class mobility, etc. haven't been solved and were often, by leaders, neglected in quite a gregarious fashion, as evidenced by several quotes from world leaders.

I also apologize if that was not clear. I hope that clarifies.



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## Arovetli (Dec 14, 2016)

Also,

EMS is not on anyone's radar in a policy making or business sense. There's a high amount of fraud in the industry, so from a policy standpoint increasing funding exacerbates a fraud problem.

Behavioral economics of EMS are a hot mess, and having multiple services in close proximity drain resources that could be more appropriately allocated in the aggregate. Yet, much resistance to broad regionalization.

Most of the scientific literature is undoing many of the sacred cows we have built the profession on.

The ACO/MACRA models offered EMS a window to change business models / now, many uncertainties.


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## EpiEMS (Dec 14, 2016)

Arovetli said:


> There's a high amount of fraud in the industry, so from a policy standpoint increasing funding exacerbates a fraud problem.



100%. And this is one of the many things that people neglect to think about when they claim that government-run services are cheaper to run: They sure are, because there is less motivation to detect waste/abuse/misused services (or to find cheaper alternatives to [insert expensive thing here]) than private insurers (since there's no profit motive)...


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## Arovetli (Dec 14, 2016)

Look, nobody -not the government, no Donald trump nor Donald Duck- can harm or damage EMS worse that we harm and damage ourselves.

No one is coming to save us.

No one is looking out for us.

We gotta get our act together as a profession. Then we start dictating the terms for ourselves.


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## Arovetli (Dec 14, 2016)

Yep. But then you gotta balance profit motive incentives against social justice and equality. It's an unfortunately bad circle that someone should win a Nobel prize for solving.


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## Qulevrius (Dec 14, 2016)

Arovetli said:


> I also pointed out that for many thousands of years the problem of poverty, social welfare, class mobility, etc. haven't been solved and were often, by leaders, neglected in quite a gregarious fashion, as evidenced by several quotes from world leaders.



And therein lies the problem. See, the leaders are not supposed to solve these problems. The leaders are supposed to lay down a foundation for an infrastructure, so these who don't want to live in ****, can make an effort and stop living in ****. And then there's the mice vs cookies analogy. This is the very nature of difference in philosophy between capitalism and socialism.


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## Arovetli (Dec 14, 2016)

I agree with you, I would point out that as the US is a mixed economy, it's far more complicated that just left vs. right.

I will give an example: for ever percentage point the unemployment rate increases thousands of Americans die or suffer ill health.

Where's the social justice when Enron comes over for dinner, or BP wrecks the environment with an oil spill,  or poor behavior on Wall Street leads to recession?


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## Arovetli (Dec 14, 2016)

It always amazes me: 

that when a large group of people gets together and pool money to cover risk of bad health it's called private insurance.

And then when a large group of people get together and pool money to cover risk of bad health it's called socialized medicine.


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## Arovetli (Dec 14, 2016)

One is s taxpayer and one is a shareholder 

Hmmmm. A puzzler.


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## Qulevrius (Dec 14, 2016)

Arovetli said:


> I agree with you, I would point out that as the US is a mixed economy, it's far more complicated that just left vs. right.
> 
> I will give an example: for ever percentage point the unemployment rate increases thousands of Americans die or suffer ill health.
> 
> ...



Absolutely. The backstage players have no political affiliation, they just - figuratively speaking - put people behind the wheel, so they can steer it their way. Unfortunately, social justice is, for the most part, a pipe dream. So, whilst like you said, no Donald (Trump or Duck) could solve these issues, what the Donald can do is try and present an alternative business model to the backstage players. And him being the successful, experienced businessman he is, plus his apparent lack of interest in political lobbying, could tip the scales. We'll see.


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## Qulevrius (Dec 14, 2016)

Arovetli said:


> It always amazes me:
> 
> that when a large group of people gets together and pool money to cover risk of bad health it's called private insurance.
> 
> ...



The former is by choice, the latter is forced. Not really a puzzler. Quality of care provided/received applies.


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## Arovetli (Dec 14, 2016)

Do you really have choice?

A few big private insurers and one big government all up in bed together.

There's a word for that kind of system. Oh, right. Fascism.


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## Summit (Dec 14, 2016)

Arovetli said:


> A few big private insurers and one big government all up in bed together.
> 
> There's a word for that kind of system. Oh, right. Fascism.



That is not what Fascism is. Fascism is a form of totalitarianism.

Perhaps you meant a Corporate semi-Oligarchy resulting from governmental regulatory morass and corrupt lobbying?


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## Arovetli (Dec 14, 2016)

More multi factorial than totalitarianism alone.

Make America Great Again.


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## Qulevrius (Dec 14, 2016)

Arovetli said:


> Do you really have choice?
> 
> A few big private insurers and one big government all up in bed together.
> 
> ...



Yes, you do. You can choose to pay for your healthcare insurance, or you can choose not to. With ACA, there's no choice and we're penalized if we don't do their bidding.

And I don't think you really understand what Fascism is.


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## EpiEMS (Dec 14, 2016)

Arovetli said:


> We gotta get our act together as a profession. Then we start dictating the terms for ourselves.



Is this something that reduced/increased Federal involvement in EMS could help/hurt?


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## Arovetli (Dec 14, 2016)

Qulevrius said:


> Yes, you do. You can choose to pay for your healthcare insurance, or you can choose not to. With ACA, there's no choice and we're penalized if we don't do their bidding.
> 
> And I don't think you really understand what Fascism is.



Why the automatic leap to me not understanding a concept?

You've presented a binary choice as an alternative to mandatory health insurance. Instead of choosing one thing I can choose two. You get better options at Sue Bells Home Town Buffett.




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## Arovetli (Dec 14, 2016)

EpiEMS said:


> Is this something that reduced/increased Federal involvement in EMS could help/hurt?



I'm of the school of thought that we're all better off if we pool resources and work together.

That frightens many people.

Hypothetical:

I was elected president.

Name for me one reason why I should put resources and increase debt to find EMS? What will I get for my money, so to speak, that I'm not already getting?




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## Qulevrius (Dec 14, 2016)

Arovetli said:


> Why the automatic leap to me not understanding a concept?
> 
> You've presented a binary choice as an alternative to mandatory health insurance. Instead of choosing one thing I can choose two. You get better options at Sue Bells Home Town Buffett.
> 
> ...



Because you're making unsupported statements. Once again, this isn't an exercise in colourful rhetoric; you can't just throw fancy words around and expect people to take it for face value. And no, you really cannot choose two in this particular case - people who already *chose* their healthcare plan before ACA came into play, are now *forced* to pay twice. Only so these mice who couldn't or wouldn't choose before, can have their own little cookie.

You seem to take a particular liking for communist/libertarian ideas (this is me extrapolating from your previous posts), so here's a quote for you: 'Freedom Lies In The Recognition Of Necessity'. I don't recognize any necessity to financially support people who won't do it themselves, am I free to choose/not to choose ?


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## EpiEMS (Dec 14, 2016)

Arovetli said:


> Name for me one reason why I should put resources and increase debt to find EMS? What will I get for my money, so to speak, that I'm not already getting?



Well, that's a fair point. I would say that, hopefully, we could help to reduce preventable deaths, cut down on ER usage (community paramedics doing catheter changes, for example), and spend less on unnecessary transports (e.g. replace BLS IFT with wheelchair vans where possible). But yes, I do see your point - there is not a *clear-cut* benefit/savings unless you have knowledge of what EMS can do.


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## Qulevrius (Dec 14, 2016)

EpiEMS said:


> Well, that's a fair point. I would say that, hopefully, we could help to reduce preventable deaths, cut down on ER usage (community paramedics doing catheter changes, for example), and spend less on unnecessary transports (e.g. replace BLS IFT with wheelchair vans where possible). But yes, I do see your point - there is not a *clear-cut* benefit/savings unless you have knowledge of what EMS can do.



Just to expand on this - let's pretend for a moment that we actually want to treat the disorder, instead of addressing the symptoms. What is the nature for the state EMS is in these days ? Is it the overwhelming amount of BS calls that put a strain on the system ? The incredibly low entry level requirements ? The lack of funding or infrastructure ? Can it be possibly related to the healthcare system and if so, in what way ? Finally, what's the prophylactic ?

I mean, we can ***** and moan all we want, but it always addresses some specific issue and I don't think we see the forest for the trees. Plus, if this exchange of ideas could yield anything worth an effort, we could always sum it up and fwd it to NAEMT.


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## Carlos Danger (Dec 14, 2016)

Arovetli said:


> I'm of the school of thought that we're all better off if we pool resources and work together.
> 
> That frightens many people.



I don't think there is any evidence that people are "frightened" by the idea of pooling resources and working together. Consider the near universal voluntary participation in things like various types of insurance plans, shopping co-ops, and mutual funds. Consider the fact that for all our faults, Americans are the most charitable folks on earth, by no small margin.

What people don't like is being forced to contribute their hard-earned money towards things that they may even not feel are important (or to contribute financially to programs that other participants don't have to contribute to), especially when such programs are always run by incompetent bureaucrats.


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## Arovetli (Dec 14, 2016)

Versus greedy CEOs?


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## Arovetli (Dec 14, 2016)

Qulevrius said:


> Because you're making unsupported statements. Once again, this isn't an exercise in colourful rhetoric; you can't just throw fancy words around and expect people to take it for face value. And no, you really cannot choose two in this particular case - people who already *chose* their healthcare plan before ACA came into play, are now *forced* to pay twice. Only so these mice who couldn't or wouldn't choose before, can have their own little cookie.
> 
> You seem to take a particular liking for communist/libertarian ideas (this is me extrapolating from your previous posts), so here's a quote for you: 'Freedom Lies In The Recognition Of Necessity'. I don't recognize any necessity to financially support people who won't do it themselves, am I free to choose/not to choose ?



I take a fancy in spirited debate and the presentation of all sides. I'm happy to play devils advocate if it helps readers to see both sides and choose which suits them.

What fancy words did I throw around that you take objection to?


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## Qulevrius (Dec 14, 2016)

Ha. Sorry mate, I'm not playing this game with you. If you cannot be arsed to re-read your/mine priors, we have nothing to discuss.


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## Arovetli (Dec 14, 2016)

I tell you what. This is a great discussion. Let's keep it going.

It's been a really busy day and to be honest I've kind of lost track of the convo, so maybe we can start over with this:

I'll adopt the position that:

EMS hurts itself far worse than a president or government might, due to lack of national cohesive leadership, organization, buy in of the rank and file, technician level training standards, fraud, lack of representation in acadamia, etc.

Pooling of resources and allocation at the Federal government is not a bad thing 

Mixed economic models seem to work best



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## EpiEMS (Dec 14, 2016)

Qulevrius said:


> Just to expand on this - let's pretend for a moment that we actually want to treat the disorder, instead of addressing the symptoms.



Sadly, I feel like we don't even have good enough data on the problems to even start addressing symptoms. All I've got is comparative EMS systems and assumptions that things that hold elsewhere (i.e. the rest of healthcare) would hold for EMS. Research is #1 on my agenda.


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## Arovetli (Dec 14, 2016)

Qulevrius said:


> Ha. Sorry mate, I'm not playing this game with you. If you cannot be arsed to re-read your/mine priors, we have nothing to discuss.



Ok. Have a great night. All the best.


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## ExpatMedic0 (Dec 15, 2016)

I am not claiming to be a businessman, but looking at the current system strictly as a business model, isn't it financially dismal, outdated, and inefficient? Customer calls for an ambulance - ambulance shows up - ambulance takes the customer to the emergency department of the hospital - the customer is treated by an emergency doctor and released. Let's face it, a significant portion of these people doesn't even need an emergency ambulance. Many of these bills go unpaid or are reimbursed at terrible rates

1. Dispatch could have criteria to refuse an ambulance regardless of what the customer wants and directly help schedule them an appointment with their primary care provider in some cases.
2. An ambulance shows up and finds no life-threatening emergency, refuses to transport patient regardless of what they want.
3. Instead of going to the emergency department by ambulance, they go to their primary care provider or are scheduled to have a community paramedic integrated into their care or are tied into the appropriate channels of the healthcare system some other way.

People who truly are having an emergency, would, of course, go through the current system.

The obvious issues here are the liability, education, and reimbursement/funding models...


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## EpiEMS (Dec 15, 2016)

ExpatMedic0 said:


> 1. Dispatch could have criteria to refuse an ambulance regardless of what the customer wants and directly help schedule them an appointment with their primary care provider in some cases.
> 2. An ambulance shows up and finds no life-threatening emergency, refuses to transport patient regardless of what they want.
> 3. Instead of going to the emergency department by ambulance, they go to their primary care provider or are scheduled to have a community paramedic integrated into their care or are tied into the appropriate channels of the healthcare system some other way.
> 
> ...



It genuinely seems like other countries have at least gotten part of this right. The UK, for example, with all their problems, at least has more treat-and-release and telephone triaging, I'm given to understand.

For what it's worth, I think EMS in the U.S. is generally put together in a terrible ad-hoc fashion not aligned to what the actual needs are...so I think what you're getting at is much more rational, especially for a municipal or government provision (or subcontracted out to a private organization by a government agency but not at a "payment for transport" type of rate, more like at a "fee for providing EMS response plus performance incentives for appropriate provision of service").


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## DrParasite (Dec 15, 2016)

ExpatMedic0 said:


> I am not claiming to be a businessman, but looking at the current system strictly as a business model, isn't it financially dismal, outdated, and inefficient? Customer calls for an ambulance - ambulance shows up - ambulance takes the customer to the emergency department of the hospital - the customer is treated by an emergency doctor and released. Let's face it, a significant portion of these people doesn't even need an emergency ambulance. Many of these bills go unpaid or are reimbursed at terrible rates
> 
> 1. Dispatch could have criteria to refuse an ambulance regardless of what the customer wants and directly help schedule them an appointment with their primary care provider in some cases.
> 2. An ambulance shows up and finds no life-threatening emergency, refuses to transport patient regardless of what they want.
> ...


In a perfect word, you are 100% correct.  But you hit on the 3 obvious issues: Liability, education (which I don't think is as bad as people make it out to be, but I digress), and funding.

How many dispatch agencies want to be on the front page of the paper as the agency that refused the ambulance on a person who died?  The fact that they would have died regardless is irrelevant, as is the fact that despite calling for a hangnail, the person experienced a completed unrelated cardiac issue 2 days afterwards.

Ditto the ambulance, person A call for an ambulance, for a boil, gets denied transport, and then while walking to the cab, gets hit by a car and dies.  Family's lawsuit get quoted in the newspaper: if the ambulance hadn't refused to transport my loved one, he would still be alive!!

How do you get funding for your community paramedicine program?  It doesn't generate any revenue, but it does keep people out of the ER and prevent them from being transported by EMS, so those entities are losing out of the billable activities.  

Don't get me wrong, I completely agree with what you are saying, but without a completely system overhaul, including a stable funding source, I don't see anything happening.  Too many people are ok with business as usual, because it serves their own selfinterests


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## ExpatMedic0 (Dec 15, 2016)

I agree, and yes a complete system overall would be needed. However, we might get just that. Love it or hate it, the ACA was a big change. I think with the incoming administration some components of the healthcare system are going to change for better or for worse, including the ACA. If it was to change any liability and reimbursement issues which affect EMS, we could see monumental changes.


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## Tigger (Dec 15, 2016)

DrParasite said:


> How do you get funding for your community paramedicine program?  It doesn't generate any revenue, but it does keep people out of the ER and prevent them from being transported by EMS, so those entities are losing out of the billable activities.


As an aside our community paramedic program actually turns a small profit and we do bill patients who use it. It does save downstream costs so it is in local health networks interest to pay us for our services to save them money later.


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## EpiEMS (Dec 15, 2016)

Tigger said:


> local health networks interest to pay us for our services to save them money later.


And also Medicaid, Medicare, and insurers (one day)!


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## ExpatMedic0 (Dec 15, 2016)

Interesting, not much info here but could effect things in the right direction http://www.jems.com/articles/news/2...l&utm_source=facebook.com&utm_campaign=buffer


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## EpiEMS (Dec 15, 2016)

ExpatMedic0 said:


> Interesting, not much info here but could effect things in the right direction http://www.jems.com/articles/news/2...l&utm_source=facebook.com&utm_campaign=buffer



Plausible - I  just don't know if the AAA's incentives are truly aligned with the incentives of prehospital care providers individually/as clinicians.


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## Tigger (Dec 16, 2016)

EpiEMS said:


> Plausible - I  just don't know if the AAA's incentives are truly aligned with the incentives of prehospital care providers individually/as clinicians.


They are a start. My chief does a lot of work with them working on rate confirm and also sits on our state's Medicaid rate review committee. Realistically we are going to be a reimbursement based service for a while (which is bad), so reimbursement reform is sorrily needed.


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## EpiEMS (Dec 16, 2016)

Tigger said:


> They are a start. My chief does a lot of work with them working on rate confirm and also sits on our state's Medicaid rate review committee. Realistically we are going to be a reimbursement based service for a while (which is bad), so reimbursement reform is sorrily needed.



That's a fair point - I don't want to totally dismiss them. But I will say that we should be cautious - they have stakes in the existing (transport based) system.

Reimbursement reform is definitely something to look at as a temporizing measure.


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## Tigger (Dec 16, 2016)

EpiEMS said:


> That's a fair point - I don't want to totally dismiss them. But I will say that we should be cautious - they have stakes in the existing (transport based) system.
> 
> Reimbursement reform is definitely something to look at as a temporizing measure.


Sure, but we will always transport people, no matter the service model. Maybe less people, but that need is not going away.


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## ExpatMedic0 (Dec 16, 2016)

EMS is the gatekeeper to the healthcare system in many ways in many systems around the world, it could be in the u.s. also, but reimbursement and funding is definitely something that would need to change.


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## EpiEMS (Dec 16, 2016)

Tigger said:


> Sure, but we will always transport people, no matter the service model. Maybe less people, but that need is not going away.



Certainly true! That being said, transport is a type of treatment, just like splinting or defibrillation. Thus, should we not be billing by the procedure or by the ICD (as determined by the receiving facility) like every other type of practitioner?


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## Tigger (Dec 16, 2016)

EpiEMS said:


> Certainly true! That being said, transport is a type of treatment, just like splinting or defibrillation. Thus, should we not be billing by the procedure or by the ICD (as determined by the receiving facility) like every other type of practitioner?


Yes, which is why the AAAs initiative is important. We are a transport benefit and not a provider benefit and that prevents us from billing for what we do.


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## ExpatMedic0 (Dec 16, 2016)

Exactly, I don't know all the details but it sounds like a step in the right direction


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## EpiEMS (Dec 16, 2016)

Tigger said:


> Yes, which is why the AAAs initiative is important. We are a transport benefit and not a provider benefit and that prevents us from billing for what we do.



Giving it a closer read, it seems like (at a high level) a decent proposal...I will have to spend some more time on it!


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## ExpatMedic0 (Dec 16, 2016)

One of my paramedic lab instructors was double digit certification number from Washington state. She said when she started  in EMS, she arrived to car accidents and loaded as many people as possible in the back and got paid "per head" like a commission. I remember laughing and thinking how old school that was... But the sad truth is reimbursement is often still transport based...


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## NomadicMedic (Dec 16, 2016)

Hell, when I started in EMS in the late 80s, we would still transport four people in the ambulance to dialysis in one trip. One on the stretcher, three on the bench, EMT would sit in the airway seat. 

We did the same thing with intoxicated individuals. Roll into the downtown area, scoop up three or four and make one run to the hospital detox. 

 No vital signs, no assessment. A small 3 x 5 "trip ticket" that would get the simple narrative, "patient conscious and alert, sat on bench seat, transported to ____ without incident." 

I don't know how we got away with that…


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## Carlos Danger (Dec 16, 2016)

DEmedic said:


> Hell, when I started in EMS in the late 80s, we would still transport four people in the ambulance to dialysis in one trip. One on the stretcher, three on the bench, EMT would sit in the airway seat.
> 
> We did the same thing with intoxicated individuals. Roll into the downtown area, scoop up three or four and make one run to the hospital detox.
> 
> ...



I once transported 4 patients from an MVC in one ambulance. Two were "ALS" (got an IV).

I loved mid-90's EMS.


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## akflightmedic (Dec 16, 2016)

Medicaid and Medicare fraud like a mofo...old school!


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## Tigger (Dec 16, 2016)

DEmedic said:


> Hell, when I started in EMS in the late 80s, we would still transport four people in the ambulance to dialysis in one trip. One on the stretcher, three on the bench, EMT would sit in the airway seat.
> 
> We did the same thing with intoxicated individuals. Roll into the downtown area, scoop up three or four and make one run to the hospital detox.
> 
> ...


We can still transport multiple drunks to detox at once. We have to write PCRs on them, but if I get the van out, they can take more than one at once and it's just an 8x11 form. Detox is  "non-medical" though. And we can't bill if we transport there, because transport benefit!


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## EpiEMS (Dec 16, 2016)

Most I've transported was two...and I had another EMT in the back with me - in retrospect, I am a lucky guy. Two clearly BLS patients, mind you.
(Fly car medic kindly drove - I could have had Fire drive, but they don't drive so nicely).


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## NomadicMedic (Dec 16, 2016)

Now, if we have two patients at a minor MVA it means two trucks out of service. We have a "one patient per truck" policy.


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## akflightmedic (Dec 16, 2016)

I transported 5 a few times....

But it was during a disaster and/or evacuation.


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## captaindepth (Dec 16, 2016)

We transport numerous patients in one ambulance pretty frequently, usually they are all simple complaints and easy to manage. I have been on minor MVCs where we transport 2 or 3 patients and complete another  couple refusals on scene. Nothing like racking up 5+ PCRs on one call.


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## DrParasite (Dec 16, 2016)

Remi said:


> I once transported 4 patients from an MVC in one ambulance. Two were "ALS" (got an IV).
> 
> I loved mid-90's EMS.


I remember taking 5 people: 2 were backboarded, 1 in the CPR seat, one in the captains chair, and one in the front seat next to my partner.  I was standing leaning against the cabinet while we drove the 15 minutes to the ER. looking back, it probably wasn't one of my best decisions.


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## Carlos Danger (Dec 17, 2016)

DrParasite said:


> I remember taking 5 people: 2 were backboarded, 1 in the CPR seat, one in the captains chair, and one in the front seat next to my partner.  I was standing leaning against the cabinet while we drove the 15 minutes to the ER. looking back, it probably wasn't one of my best decisions.



In my case transporting 4 wasn't my choice. The city was slammed and the crash happened at rush hour. No one was injured beyond bumps and bruises, but fire had talked everyone into going "to get checked out". It was a 10 minute drive to the ED and would have taken longer than that for another ambulance to get on scene. Dispatch didn't want me waiting on scene until the other ambulance got there, so my supervisor called me, confirmed that nobody was sick, and told me to take all 4. It wasn't at all uncommon at the time for us to transport two, so while 4 was quite a stretch it didn't seem like the most outrageous idea. I had two backboarded (one on the stretcher, one on the bench seat), one seated on the airway seat, and one in the front seat. I wrote run sheets and gave report on each one. I did start IV's on the two who were backboarded, making them "ALS" patients. Maybe that was just to show off a little.


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## luke_31 (Dec 17, 2016)

I've had up to six in the back of my truck before, but we typically will load as many as can fit if nobody is seriously sick or injured.  Still had to call another unit for more patients who collapsed further down the road and we couldn't move to their location to get to them.  All of those patients got IVs and were given fluids, morale of that story was heat and humidity at night was still too high for a ruck march.


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## RocketMedic (Dec 21, 2016)

I've done 5 out of a CO poisoning. Both of my O2 trees, both of my portables, and our vent in CPAP @ 5 on 100% FiO2.


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