# Healthcare Overhaul



## Medic2409 (Jun 29, 2012)

So, the SCOTUS has upheld the new Healthcare Law.

Not to get into the politics of it, cause what will be will be, but has anyone thought of how this might affect EMS?

I predict call volumes to rise even faster.  

Will reimbursement rates go up or down?  

Some potential side effects:

Busier crews, more BS calls, higher burnout.

But, if reimbursement goes up: potentially better pay, more ambulances and more crews.

Thoughts?


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## mycrofft (Jun 29, 2012)

Please, expand on why these will occur.

Presumably more people will have access to a primary care MD or such and not require ER visits. However, this was supposed to happen with HMO"s, and we can see where corporate greed sent that. (My spouse worked for Foundation Health, so the "greed" opinion is first-hand).


We had a knock-down drag out about "Obamacare" in an earlier thread I started.

EDIT: I predict Florida will defy the national mandate.


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## Veneficus (Jun 29, 2012)

Medic2409 said:


> So, the SCOTUS has upheld the new Healthcare Law.
> 
> Not to get into the politics of it, cause what will be will be, but has anyone thought of how this might affect EMS?
> 
> ...



I think all of these things will happen, but I do not believe that it will have anything to d with the recently upheld law. 

I am trying to find time to pour through a legal brief on it, but my schedule is full recently.


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## LondonMedic (Jun 29, 2012)

Medic2409 said:


> I predict call volumes to rise even faster.


Who will be making those calls who isn't already?


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## bigbaldguy (Jun 29, 2012)

I'm with Mycroft I suspect lower call volume for traditional EMS but a greater need of low to mid level providers. This could mean more jobs for medics and EMT's in non 911 roles. Eventually an increased scope for these folks which will hopefully require increased educational requirements like those required of providers in countries that already have healthcare systems like this in place.


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## bstone (Jun 29, 2012)

mycrofft said:


> Please, expand on why these will occur.
> 
> Presumably more people will have access to a primary care MD or such and not require ER visits. However, this was supposed to happen with HMO"s, and we can see where corporate greed sent that. (My spouse worked for Foundation Health, so the "greed" opinion is first-hand).
> 
> ...



I think that will be Louisiana instead: http://news.yahoo.com/blogs/ticket/...es-implement-obamacare-despite-152429092.html


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## bstone (Jun 29, 2012)

bigbaldguy said:


> medics and EMT's



Medics=plural of medic
EMT's="EMT is" or denotes ownership by an EMT
EMTs=plural of EMT


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## Uclabruin103 (Jun 29, 2012)

Call volume is going to increase regardless of what is going on with the health reform.  This is the first year baby boomers are starting to retire, and retirement leads to more inactivity which then causes some more health problems.  

I'm really curious to see how reimbursement changes.  I hope that it goes up and the industry as a whole gets treated a little better, but I don't foresee that happening at all.  If anything I feel that rates will go down.  More people going to the hospital for care meaning that more reimbursement is going to be needed for physicians and hospitals and less for ambulance rides.  There's only so much of the government pie to go around  I just don't see where all this magic reimbursement money is going to come from.  

I'm not too well-versed on the financial sides of things, but I for sure know that government programs do not pay anywhere near the full ambulance rate here in LA and Orange County, and I don't see that rate increasing at all.

I also think this is going to be the last breath for our Fire based EMS service if the economy doesn't turn around in the next five to ten years.  With that increased call volume we're going to have to increase staffing which means more pensions, salaries, benefits, etc.  Again, where is all this money going to come from?  

Beware the ides of March...


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## bigbaldguy (Jun 29, 2012)

bstone said:


> Medics=plural of medic
> EMT's="EMT is" or denotes ownership by an EMT
> EMTs=plural of EMT



Noted


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## Aidey (Jun 29, 2012)

bstone said:


> I think that will be Louisiana instead: http://news.yahoo.com/blogs/ticket/...es-implement-obamacare-despite-152429092.html



My bet is on Idaho.


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## Amberlamps916 (Jun 29, 2012)

More dialysis!


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## mycrofft (Jun 29, 2012)

FLorida has already been defying it. And Rush Limbaugh says he'll go expat if it goes into effect. Of course he can afford to be "self-insured".


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## CANDawg (Jun 29, 2012)

LondonMedic said:


> Who will be making those calls who isn't already?


Because a lot of people in the US are uninsured, there is a financial disincentive to contact EMS if they have a health issue. They either drive themselves to the doctor, or skip the doctor/hospital entirely. (Possibly until the issue gets worse.)

If everyone is insured, which is the goal of the legislation, that will remove the financial disincentive for most people. Theoretically, this will result in the number of EMS calls also increasing - probably to a level more in line with other nations like the US and Canada that have nationalized health care systems.


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## STXmedic (Jun 29, 2012)

dbo789 said:


> Because a lot of people in the US are uninsured, there is a financial disincentive to contact EMS if they have a health issue. They either drive themselves to the doctor, or skip the doctor/hospital entirely. (Possibly until the issue gets worse.)
> 
> If everyone is insured, which is the goal of the legislation, that will remove the financial disincentive for most people. Theoretically, this will result in the number of EMS calls also increasing - probably to a level more in line with other nations like the US and Canada that have nationalized health care systems.



I'm going to have to disagree. Financial disincentive or not, uninsured people have always loved 911. In fact, I seem to make more calls on uninsured people, than I do for the insured. EMS seems to be the "poor man's" doctor visit. They can't afford to go to the doctor, so they call us, where they don't have to pay up front, then dodge the bill later. Also, they can't afford the preventative and continuing measures, so ailments become exacerbated more frequently.

My speculation on why I seem to make more people uninsured versus insured; Insured people can afford to go to the doctor's office, get check-ups and preventative medicine, and don't have to resort to 911. These people can afford the up-front cost of these measures. I would venture to say clinics are going to be the ones to see more of a jump in business.


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## bigbaldguy (Jun 29, 2012)

dbo789 said:


> Because a lot of people in the US are uninsured, there is a financial disincentive to contact EMS if they have a health issue. They either drive themselves to the doctor, or skip the doctor/hospital entirely. (Possibly until the issue gets worse.)
> 
> If everyone is insured, which is the goal of the legislation, that will remove the financial disincentive for most people. Theoretically, this will result in the number of EMS calls also increasing - probably to a level more in line with other nations like the US and Canada that have nationalized health care systems.



Yes but the folks who don't call EMS because of the "financial disincentive" are usually the folks who are genuinely sick. So worst case we'll get the same abusers we've always had but now we might actually get some of the folks who can actually benefit from our services.
I do agree that overall call volume will more than likely increase. This increase might finally encourage EMS systems to put in programs that avoid taking people to the ER. These types of systems are already in place in the UK. Things like follow up visits from home nurses and the ability for paramedics to take patients to clinics instead of running everyone to crowded ERs. I say it might because it is the government and well let's face it they can screw anything up.


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## LondonMedic (Jun 30, 2012)

dbo789 said:


> Because a lot of people in the US are uninsured, there is a financial disincentive to contact EMS if they have a health issue. They either drive themselves to the doctor, or skip the doctor/hospital entirely. (Possibly until the issue gets worse.)


Where do these people get a doctor?


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## Veneficus (Jun 30, 2012)

LondonMedic said:


> Where do these people get a doctor?



The EMTLA law directs that persons seeking emergency care but be medically screened and stabilized. 

When a person cannot get to a PCP because of long wait or lack of funds, they go to the emergency department. 

Some via calling 911 for an emergency ambulance.

When they get to the ED, the underlying condition is often not addressed with a long term treatment plan and follow up is not possible.

It is a tremendously expensive and ineffective system.


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## LondonMedic (Jun 30, 2012)

Veneficus said:


> The EMTLA law directs that persons seeking emergency care but be medically screened and stabilized.
> 
> When a person cannot get to a PCP because of long wait or lack of funds, they go to the emergency department.
> 
> Some via calling 911 for an emergency ambulance.


DBO says these people go to a doctor but not by ambulance, does he mean they walk to the ED or do they find a PCP (I hear they're really abundant in the US)?


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## Veneficus (Jun 30, 2012)

LondonMedic said:


> DBO says these people go to a doctor but not by ambulance, does he mean they walk to the ED or do they find a PCP (I hear they're really abundant in the US)?



We refer to it as "the home boy ambulance service" when they have a friend or family member drive them to the ED.

There is a nationwide shortage of PCPs, mostly because of low compensation.

The PCPs also generally require the ability to pay upfront and only take a percentage of people on government programs, because the low reimbursement eats up all the time they could have customers that pay a reasonable amount.

The PCPs that take only government assistance usually have a very long wait (a couple years ago NEJM published the average wait for these docs was 40 days for an 8 minute appointment) 

Some PCPs refuse to take any patient who is on a government reimbursement and cannot pay cash.

Another issue is that of the working poor. They have a job, but it pays only hourly. So not only do they have to pay for the doctor (usually upfront) they also lose the income from the missed work. (Because PCPs usually work during normal business) After hours, the ED becomes the provider of choice in order to see a doctor without missing work.


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## medicsb (Jun 30, 2012)

Probably the best place to look to get an idea of how the ACA will affect EMS is to look to Massachusetts, which has a healthcare system on which the ACA is based.  Doesn't seem like much has changed there, even for EDs.


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## Fish (Jun 30, 2012)

Un-insured call 911 regardless, and then don't pay us or the hospital. There is a difference between borrowed debt and Medical Debt. And a lot fo people choose to not pay and never do, since they will never be denied treatment regardless.


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## Shishkabob (Jun 30, 2012)

On the EMS front, I see one of two things happening:


More people will have insurance, so either transport rates will go down since more transports are being reimbursed, OR transport rates will state the same even with more reimbursements, and the money will go back to the system, HOPEFULLY in the form of higher Paramedic pay!


Currently my agency collects on about 1/3 of transports.  Since about 90% of the country is to have some form of insurance, conservatively I see about 50-60% of transports being reimbursed.  More money for me?!


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## medicsb (Jun 30, 2012)

Linuss said:


> Currently my agency collects on about 1/3 of transports.  Since about 90% of the country is to have some form of insurance, conservatively I see about 50-60% of transports being reimbursed.  More money for me?!



If reimbursement increases, expect the increased revenue to be passed on to anyone but the employee.  Again, Massachusetts has a very similar set-up and I don't think anyone there has gotten increased pay due to increased reimbursement (assuming it has occurred).


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## Shishkabob (Jun 30, 2012)

medicsb said:


> If reimbursement increases, expect the increased revenue to be passed on to anyone but the employee.  Again, Massachusetts has a very similar set-up and I don't think anyone there has gotten increased pay due to increased reimbursement (assuming it has occurred).



Public/government agency.  Not like we have shareholders or send money back to the cities and their coffers. 

Hence only one of 2 things can happen:  Lower costs for transport, or money gets sent right back in to the system and its employees.


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## CANDawg (Jun 30, 2012)

Linuss said:


> Public/government agency.  Not like we have shareholders or send money back to the cities and their coffers.
> 
> Hence only one of 2 things can happen:  Lower costs for transport, or money gets sent right back in to the system and its employees.



Actually, it can easily go back into general revenue for the municipal government you work for. Unfortunately, this is more likely.


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## Shishkabob (Jun 30, 2012)

dbo789 said:


> Actually, it can easily go back into general revenue for the municipal government you work for. Unfortunately, this is more likely.



With how this agency is set up, no it can't.


Again, those 2 options I outlined are the only 2 possibilities:  Cheaper transport fees, or back in to the agency some how.


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## Aidey (Jul 1, 2012)

mycrofft said:


> Please, expand on why these will occur.
> 
> Presumably more people will have access to a primary care MD or such and not require ER visits. However, this was supposed to happen with HMO"s, and we can see where corporate greed sent that. (My spouse worked for Foundation Health, so the "greed" opinion is first-hand).
> 
> ...



Folks, we have a winner!


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## JPINFV (Jul 1, 2012)

bstone said:


> Medics=plural of medic
> EMT's="EMT is" or denotes ownership by an EMT
> EMTs=plural of EMT




This is the intertubes. Any grammar nazi posting regarding apostrophes requires the Bob the Angry Flower comic.


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## JPINFV (Jul 1, 2012)

Linuss said:


> Currently my agency collects on about 1/3 of transports.  Since about 90% of the country is to have some form of insurance, conservatively I see about 50-60% of transports being reimbursed.  More money for me?!



You're assuming that just because the rate of transports being reimbursed means that the reimbursement per transport is going to stay the same. I'm going to predict that, while more transports are going to be reimbursed, the size of the population saying, "You can't bill me, I've got a government card" is going to increase, and the reimbursement per transport is going to go down, especially government reimbursement. 

After all, why pay the taxi driver more?


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## Tigger (Jul 1, 2012)

medicsb said:


> Probably the best place to look to get an idea of how the ACA will affect EMS is to look to Massachusetts, which has a healthcare system on which the ACA is based.  Doesn't seem like much has changed there, even for EDs.



Granted I was not working before our system was implemented, but I bet anyone would be hard pressed to come up with any significant changes as a result of the passing of that legislation. MassHealth (state insurance for those without HMOs) pays by far the lowest reimbursement rate of all, including Medicare. Many of my scheduled patients use MassHealth in conjunction with an HMO or Medicare to pay for their transports and treatments, I imagine this may also occur with the ACA which may therefore increase reimbursements to private companies. Admittededly I do not have a great grasp of the system, however I've never transported any 911 patient or psych hold without insurance so it would seem that the law is working to an extent (obviously n=1 holds here).


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## DPM (Jul 1, 2012)

mycrofft said:


> FLorida has already been defying it. And Rush Limbaugh says he'll go expat if it goes into effect. Of course he can afford to be "self-insured".



And if he does he'll probably end up somewhere with public healthcare...


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## whizkid1 (Jul 3, 2012)

Not sure how it will turn out,wait and see I guess.


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## bstone (Jul 3, 2012)

whizkid1 said:


> Not sure how it will turn out,wait and see I guess.



That's not a bad attitude. This has never been done before in this country (except for in MA, so a much smaller scale) but if MA is the model then it will be a success.


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## Streetmedic7 (Jul 4, 2012)

*Cash on Delivery*

It has been discused, in my state, that an ER pt who is uninsured and doesn't have an "emergent" chief complaint plops down $250 at check in. If this goes through, uninsured "taxi rides" to the ER might drop.


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## JPINFV (Jul 4, 2012)

Streetmedic7 said:


> It has been discused, in my state, that an ER pt who is uninsured and doesn't have an "emergent" chief complaint plops down $250 at check in. If this goes through, uninsured "taxi rides" to the ER might drop.




$250 before the medical screening examination? Looks like an EMTALA violation waiting to happen.


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## Veneficus (Jul 4, 2012)

JPINFV said:


> $250 before the medical screening examination? Looks like an EMTALA violation waiting to happen.



I know some places triage people to attached fast tracks or urgent cares, so it might not exactly be a violation.

These same facilities usually charge a prior copay if the "patient" refuses to go to fast track or urgent care.


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