# Patient Choice



## phideux (Feb 12, 2012)

One of the agencies I work for gives the patient the choice of what hospital they want to go to. I hate it. This is the #1 abuse of the system. For the patient who really needs it, no problem, I'll take them anywhere. But the frequent fliers that know that we will take them where they want, it's ridiculous. We are their taxi service. Had one the other day, 0630 Monday morning, his hip hurt since Friday. Meets us standing at the driveway, suitcase packed and all. Walks to the ambulance, able to climb the steps with no assistance. Wants to go downtown, 45 mile ride each way, have to pass 3 other hospitals to get there, and morning traffic is starting to pick up. Has an appointment at the VA hospital around the corner from the downtown hospital later that morning. Of course quitting time is 0645. So the little bit that Medicare will reimburse us is nowhere near the 3hrs of OT each for 2 medics, plus the gas for the ambulance which gets about 8mpg. This is a daily occurrence here. Want to cut down on system abuse and save some money, put hospital choice in the hands of the medic, closest appropriate facility. Or give us a stack of taxi vouchers.
Sorry, just one of those days, rant over.:wacko:


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## akflightmedic (Feb 12, 2012)

If you are documenting properly and if your organization is submitting what you have documented, there is no way they received a penny for this transport.


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## Bluestar (Feb 12, 2012)

In the end its their choice where they go with in reason... otherwise it known as kidnapping.  There's a place up here where they want to go to the local doctors office due to no hospital in that county. They have to advise them that there insurance won't pay but they go there all the time. I agree that the system is screwed up and we all see it. I also know that taking the choice from patients can be detrimental too due to those medics and emts... we all know who they are where we are that would abuse that choice and take them somewhere close other than where they truly need to be because they want off on time.  We all would like to leave on time like normal jobs but this is the price we pay for what we do. Suck it up buttercup!!!


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## phideux (Feb 12, 2012)

It ain't the getting off on time part that bothers me. It's the waste of resources when a 911 ambulance with a large coverage area is taken out of service for 3hrs, for a person who had minor hip pain for 3 days, can walk without a limp, climb stairs, and basically just wants a ride to go to his regular doctors apt. We take this same person for a ride at least twice a month. I'm all about helping people, but this guy don't need a full ALS unit with 2 medics, he needs a taxi.


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## WolfmanHarris (Feb 12, 2012)

It used to be that the patient went to the closest "most appropriate" hospital, which for the longest time, just meant the closest unless they were a trauma patient; that was Ministry of Health policy. Enter STEMI, stroke bypass and dialysis bypass and we started bypassing more hospitals but still based on Pt. condition, not on their wishes.

Recently to help distribute patient load the reintroduced the limited ability for hospitals to go on redirect. CTAS 3-5 Patients (moderate to low acuity) but now be diverted to another hospital provided their is one within 20 mins difference in drive time. The patient now has the limited ability to provide a preference on hospital, though it cannot override the redirect and high acuity patients will still go to the closest hospital.


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## Veneficus (Feb 12, 2012)

phideux said:


> It ain't the getting off on time part that bothers me. It's the waste of resources when a 911 ambulance with a large coverage area is taken out of service for 3hrs, for a person who had minor hip pain for 3 days, can walk without a limp, climb stairs, and basically just wants a ride to go to his regular doctors apt. We take this same person for a ride at least twice a month. I'm all about helping people, but this guy don't need a full ALS unit with 2 medics, he needs a taxi.



maybe your service should spring for one if it is that much of a drain on resources?

Or at least offer him the chief's car


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## Shishkabob (Feb 12, 2012)

Talk to the higher-ups in your agency about starting a system abuser program, such as the one MedStar runs that I put in a thread just a couple of days ago.

If someone is known to abuse the system, IF a transport is warranted, they're taken to a 'home hospital'.  They can request any other hospital they want, but they won't be taken to them, ONLY to the home.  Either you go to the one offered, or you don't go.




Contrary to what some here say, it is not considered kidnapping, and I have never heard of a single person getting in legal trouble for taking a patient to a different hospital than the one they asked.  An ambulance is not a private vehicle, patients have no legal right to be in it, nor tell it where to go.  They are given a ride in it.   They USUALLY get an option as to where to go, not as a legal requirement, but as a courtesy.   Have you ever heard of a bus driver being arrested and the transportation authority being sued because someone took the bus but the bus didn't go to the location they wanted?  Yeah, doesn't happen.   They choose to go with you, they can leave at any time, therefore it's not kidnapping.  People need to quit perpetuating this fallacy.





That does NOT mean I advocate taking your problem child of a patient to the closest hospital just because.  You still need to discuss this issue with your higher-ups, and lay out a cost savings plan so they will jump on board.  If he has Medicaid, show him the number on the back of his card that gets him a free taxi.


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## jjesusfreak01 (Feb 12, 2012)

Its not kidnapping when the patient has every right to get out at any point they wish. You just make it clear that in your professional opinion they should go to the closest appropriate hospital. If they want to somewhere else, too bad. They can not get into the ambulance. If they really think they're sick, they'll go where you tell them to.


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## Veneficus (Feb 12, 2012)

Just out of curiosity,

if the patient is being managed for his long term health problems at a particular facility, from the medical standpoint, how is that not the most appropriate facility?

It sounds to me like there is too much focus on the system and not enough on the patient.

If you take this pt to the wrong facility, you are just going to create a discharge without help and then you will be going out to his place again.

It really sounds to me like there is a legit issue here on how best to serve this person.


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## DrankTheKoolaid (Feb 12, 2012)

Thankfully our LEMSA has basically put it in the hands of the provider to make the transport decision based on presentation and facility abilities with the exception of traumas. Not to say we dont take into consideration specialty needs of the patients as needed though.  And obviously if they are discharged from A and are not happy with whatever care was deemed neededby the ED MD then when whoever comes to pick them up at discharge come transport them to facility B if patient so chooses.   And if discharged and someone is able to pick them up, did they really need the first ambulance trip at all


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## medicdan (Feb 12, 2012)

On the other hand, it could be aruged that the private EMS industry treats customers not patients, especially for non-emergency transports. If you patient has a legitimate doctor's appointment a block from your destination hospital, and are unable to transport themselves, do they qualify for Chair Car (van) transport under Medicaid? If they are unable to ambulate without assistance (it sounds like they are), can they get a Certification of Medical Necessity (med nec, PMN, CMN, whatever you call it) for non-emergent trip to the VA? 

Once you take this patient out of the 911 system, where they are likely a drain, can we find other (more appropriate) approaches to their care?


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## abckidsmom (Feb 12, 2012)

I have a soapbox I get on from time to time, and here I go again:

The time to make decisions about how the system is run is NOT on the scene of a call with a patient.  It doesn't matter how many trucks are in the system, how much it costs, how much is pisses you off, or whatever.  When you (the collective, universal you) are with a patient, you are charged with the responsibility to make decisions in the best interest of the patient in front of you.  Only.

I work in a rural system in which resources are stretched thin.  This does not mean I should tell the little old person with a boring problem that she doesn't need an ambulance because there's a better call getting toned out right now.  Also doesn't mean that she goes to the absolute closest facility because the system is NUA right now.  

Look at the patient you're treating, make a transport or treatment decision that applies to that patient only, and don't think too high above your pay grade on the scene.  You can address any issues you think have come up AFTER the call, with the appropriate person.  Anything else is just inciting discontent among your coworkers.

You're part of the problem, or you're part of the solution.


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## phideux (Feb 12, 2012)

On this particular patient, he does not get treated where we transport him to. He has regular visits at a local VA clinic, which is around the corner from the ER he goes to. We do not transport to the local VA clinic because they do not have an ER. His sister also lives near the VA Clinic. When it is time for his VA clinic appointment, he will call 911 complaining of whatever. According to our rules we cannot refuse transport, and have to transport to the facility of the patients choice, as long as they do not need a specialty center(cardiac, stroke, trauma, etc). So we bite the bullet, and give him the 45 mile ride downtown. Like I said, he will meet you at the end of his driveway, with his little suitcase packed. We take him downtown, he will sign out of the ER, go to his sisters house, go to his appointment, spend a couple of days with his sister. For patients like this the VA needs to send a van, his sister needs to come pick him up, he needs to take a taxi, whatever. There has to be a better way. He just needs a ride for his monthly checkup, refill his prescriptions, and visit his sister. He's not sick, does not need 2 medics and an ALS rig. Like I said, I'm all for taking care of the patients, but for some folks there needs to be a better way. 911 shouldn't be called for regular transport to doctors appointments.


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## Shishkabob (Feb 12, 2012)

And as I said, as much as an advocate as I am to ridding the system of abusers, it has to be done the right way.  Have the discussion with your higher ups, detail the cost savings, show them the agencies who are currently doing provider refusals / system abuse no rides / at home checkups instead of transports and they'll likely listen.


When transporting him, educate him.  Ask him why he thinks it's okay to call 911 for a pre-schedule doctors appointment.  Ask him why he lacks reliable transportation and how you might be able to help.  Show him the different options he has (such as the free taxi I pointed out).




We wont fix problems if we placate people and don't call out ignorance.


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## abckidsmom (Feb 12, 2012)

phideux said:


> On this particular patient, he does not get treated where we transport him to. He has regular visits at a local VA clinic, which is around the corner from the ER he goes to. We do not transport to the local VA clinic because they do not have an ER. His sister also lives near the VA Clinic. When it is time for his VA clinic appointment, he will call 911 complaining of whatever. According to our rules we cannot refuse transport, and have to transport to the facility of the patients choice, as long as they do not need a specialty center(cardiac, stroke, trauma, etc). So we bite the bullet, and give him the 45 mile ride downtown. Like I said, he will meet you at the end of his driveway, with his little suitcase packed. We take him downtown, he will sign out of the ER, go to his sisters house, go to his appointment, spend a couple of days with his sister. For patients like this the VA needs to send a van, his sister needs to come pick him up, he needs to take a taxi, whatever. There has to be a better way. He just needs a ride for his monthly checkup, refill his prescriptions, and visit his sister. He's not sick, does not need 2 medics and an ALS rig. Like I said, I'm all for taking care of the patients, but for some folks there needs to be a better way. 911 shouldn't be called for regular transport to doctors appointments.



Talk to your system administrators, document this trend, and have your administrators make a plan with him to call a cab next time.


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## Aidey (Feb 12, 2012)

emt.dan said:


> On the other hand, it could be aruged that the private EMS industry treats customers not patients, especially for non-emergency transports. If you patient has a legitimate doctor's appointment a block from your destination hospital, and are unable to transport themselves, do they qualify for Chair Car (van) transport under Medicaid? If they are unable to ambulate without assistance (it sounds like they are), can they get a Certification of Medical Necessity (med nec, PMN, CMN, whatever you call it) for non-emergent trip to the VA?
> 
> Once you take this patient out of the 911 system, where they are likely a drain, can we find other (more appropriate) approaches to their care?




Unable to ambulate without assistance is not an automatic qualifier for medical necessity for ambulance transport. If a person's primary mode of movement is a wheelchair it is stupid to remove it to transport them another way.


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## Sasha (Feb 12, 2012)

Aidey said:


> Unable to ambulate without assistance is not an automatic qualifier for medical necessity for ambulance transport. If a person's primary mode of movement is a wheelchair it is stupid to remove it to transport them another way.



The fact they can ambulate at all means they don't meet medical necessity. They have to be bed confined. That means they are not able to be out of bed at all. No chair, no wheel chair. If they ambulate even with assistance they're not confined to a bed.


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## JPINFV (Feb 12, 2012)

Sasha said:


> The fact they can ambulate at all means they don't meet medical necessity. They have to be bed confined. That means they are not able to be out of bed at all. No chair, no wheel chair. If they ambulate even with assistance they're not confined to a bed.




No. It means they don't meet the definition of bed confined, but bed confined isn't the only valid reason for medical necessity.


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## Shishkabob (Feb 12, 2012)

Linuss' quick guide to medical necessity:

If they can walk to your ambulance, and all you do is a staring contest for the duration of the ride, they don't meet criteria for an ambulance transport.


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## Sasha (Feb 12, 2012)

JPINFV said:


> No. It means they don't meet the definition of bed confined, but bed confined isn't the only valid reason for medical necessity.



If you're basing medical necessity on bed confinement which is what it sounded like then they just disqualified medical necessity


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## Sasha (Feb 12, 2012)

Linuss said:


> Linuss' quick guide to medical necessity:
> 
> If they can walk to your ambulance, and all you do is a staring contest for the duration of the ride, they don't meet criteria for an ambulance transport.



Iso precautions. Psych transfers.


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## bigbaldguy (Feb 12, 2012)

So every patient gets punished because a few abuse the system? That's slippery slope reasoning. The problem is not your departments policy regarding patient choice the problem is the patients who abuse the system.


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## DrParasite (Feb 12, 2012)

Linuss said:


> Linuss' quick guide to medical necessity:
> 
> If they can walk to your ambulance, and all you do is a staring contest for the duration of the ride, they don't meet criteria for an ambulance transport.


While I happen to agree with you (with very few exceptions, EDPs and people who are bleeding but ambulatory), I will say that I still want to get paid for the transport, even if it isn't medically necessary.


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## epipusher (Feb 15, 2012)

It seems as though the ts needs to find a new career.


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## frdude1000 (Feb 15, 2012)

We usually give patients the option of the closest two hospitals.  The exceptions to this are when the pt. needs a specialty center, a hospital is on divert status, or there is an extenuating circumstance.  If there is a problem on hospital destination, we can radio our county wide EMS supervisor to remedy the situation.


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## johnrsemt (Feb 16, 2012)

Two problems about the OP:  one was already mentioned;  if the patients long term care is at a particular hospital then take them there.

  The other is insurance:   if you have multiple hospitals in the area; alot of insurances will NOT pay the normal amount for an out of network hospital.   Even for things like Cardiac cath:  we had a patient get transported to a hospital the EMS crew wanted to take him to instead of the in network one the same distance, but the other direction:  it ended up costing the patient almost $25,000 more for the Cath and post care:  out of pocket.   His insurance paid 50% instead of 95%.   Patient sued the EMS provider,  I haven't heard how that has turned out

    Insurances have to and will pay the in network fees for out of network if it is the difference of a large difference in time,  or a Level I  over a Level III, etc;   but they shouldn't have to pay when there is no difference except ambulance crew desire.


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## Shishkabob (Feb 16, 2012)

> :  it ended up costing the patient almost $25,000 moror the Cath and post care:  out of pocket.   His insurance paid 50% instead of 95%.   Patient sued the EMS provider,  I haven't heard how that has turned out



Hopefully the judge threw it out as a frivolous lawsuit, as that is what it is.   No one forced him to get treatment at that facility, he signed the forms. 


Anyhow I know some insurance agencies are starting to not pay for "out of network" ambulances.


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## phideux (Feb 17, 2012)

johnrsemt said:


> Two problems about the OP:  one was already mentioned;  if the patients long term care is at a particular hospital then take them there.
> 
> The other is insurance:   if you have multiple hospitals in the area; alot of insurances will NOT pay the normal amount for an out of network hospital.   Even for things like Cardiac cath:  we had a patient get transported to a hospital the EMS crew wanted to take him to instead of the in network one the same distance, but the other direction:  it ended up costing the patient almost $25,000 more for the Cath and post care:  out of pocket.   His insurance paid 50% instead of 95%.   Patient sued the EMS provider,  I haven't heard how that has turned out
> 
> Insurances have to and will pay the in network fees for out of network if it is the difference of a large difference in time,  or a Level I  over a Level III, etc;   but they shouldn't have to pay when there is no difference except ambulance crew desire.




The patients long term care is not at a hospital. It is at a clinic. We are a 911 based ambulance and cannot transport to the clinic. We can only take patients to the hospitals with an ER. When this patients monthly check-up appointment/prescription refill time rolls around he calls 911 with a minor complaint and wants to be taken to the ER around the corner from the clinic he goes to. After we take him there he will sign out, and walk around the corner to the clinic.
There are 4 transport companies in the area, plus it is a VA clinic and they have their own van, plus he has family that drives.
I don't care about the insurance or billing end of things, that is someone else's problem.
I'm all about patient care. My problem is this is a very rural station. While we take him for his non emergency call, passing 3 hospitals on the way, the rest of our area is uncovered. The next due ambulance has anywhere from a 30-90 minute response time depending on where a call comes in at.
The higher ups answer is we transport anyone and everyone with a complaint, to the hospital of their choice. No ifs, ands or buts about it.


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## johnrsemt (Feb 18, 2012)

Yea there are people who abuse the system;   I think it is Memphis that is giving out cab vouchers, paid for by the city; for people who have no need for an ambulance.   Works great for them,  wouldn't work in a rural setting due to no cabs.

   We had problems (and they still have them) where I used to work in Indy;  both 911 and private service.    They are working on them; but I don't know if they got any further along than taking care of one person/abuser at a time still.
   There was a city next to Indianapolis that there EMS would transport only to the hospital in that city;  unless the patient needed Level I type treatment;  (I remember going into their city on our private service and taking patients that were in care of their crews and taking them to the hospital of their choice; {on patient waited for 45 minutes till the city dispatcher found a private service with a truck in service to come get the patient;  the EMS crew stayed with the patient, even though if they would have transport to her hospital of choice they would have been back to their city in less than 20 minutes}).    They ran into too many lawsuits due to it; and put more units in service and started transporting to other hospitals.


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