# HEMS usage, what do you in the field think about this?



## jgmedic (May 13, 2019)

Hey guys, So i work as a FAE-Medic for a very rural fire district in San Diego County. We have a minimum ground transport of 50-60min by ground to the closest receiving, 1.5 hr to STEMI, over 2 to trauma/Stroke. We obviously fly anything critical, but my question is this. How do you guys feel when you get flights for so-called borderline patients. The managers at the HEMS companies tell us to always use them, but i know that's most likely profit driven. We have flown patients with resolving neuro symptoms or traumas that meet criteria but really don't have major injuries or even symptomatic presumed cardiac chest pain. Pt's that in the city would not go to code to the ED, but out here get a helicopter. I guess what I want to know is how do you flight crews see these patients in terms of necessity or are we just over triaging.


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## DrParasite (May 13, 2019)

From a HEMS management perspective:
you already paid for the jet fuel to get you to the scene, are currently paying for crews salaries, might as well take the patient to the hospital

from a ground crew perspective:
the patient might have an issue that requires rapid transport.  a few minutes might not matter, but comparing 2 hours for a stroke patient, who can be at the ER in 30 by air?  which is better for the patient?

HEMS is definitely over used, but the time to talk about bordering patients is not when the chopper is on the ground to pick up a patient.


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## DesertMedic66 (May 13, 2019)

It’s all a judgement call from the ground crews. We aren’t likely to question your judgement. Usually if we are requested for something borderline it means the providers aren’t the most comfortable with that specific issue and hopefully we are.


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## GMCmedic (May 13, 2019)

2 things I keep in mind when I go on flights. 

1. The ground provider either recognizes the need for critical care capabilities, time sensitive emergency, or doesnt feel comfortable. If one of those conditions exists, the patient is likely better off with us. 

2. Regardless if the flight is unnecessary, I still get paid to ride in a helicopter today, and that is pretty awesome.


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## Tigger (May 13, 2019)

How do we think patients, families, and payors feel about the cost of unnecessary flights? 

It's quite common here for flight to land only to leave without the patient because it turned out they were not that serious. Working in BFE means long transports come with the territory.


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## GMCmedic (May 13, 2019)

Tigger said:


> How do we think patients, families, and payors feel about the cost of unnecessary flights?
> 
> It's quite common here for flight to land only to leave without the patient because it turned out they were not that serious. Working in BFE means long transports come with the territory.


Supposedly my company does not bill blatantly unnecessary flights, or so they say.

As a patient advocate, the last thing I want is for patients to be bombarded with high bills. As a provider being requested by another provider, I don't mind the work.


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## VFlutter (May 13, 2019)

A lot of HEMS companies use requests, not necessarily transports, as a metric for a helicopters profitability  so in that sense request the helicopter whenever you think it may be necessary and cancel if you deem them not needed. As a HEMS provider I do not encourage unnecessary transports as it really does not help anyone as they are not likely to reimbursed and may result in a patient getting a bill. Having said that, if a ground provider is requesting transport it is really unlikely the HEMS crew would refuse unless it is blatantly inappropriate.


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## VentMonkey (May 13, 2019)

Kind of as an aside, (in my area at least) I have seen ground crews get so laser focused on “time savings” as the sole reason for helicopter utilization. This can be equally as frustrating.

While I agree that over-triage is a thing that exists, from the “boots on the ground”—or in this case—the air, it’s almost always beyond most flight teams job descriptions to openly question, or second guess what it is that caused the ground crews requests for launch.

The last thread that I created kind of touches on your initial question, @jgmedic.

And while I’m sure further research and/ or implications may be required, it’s not such a far fetched idea or tool to both help mitigate over utilization, and assist in simplifying provider judgment.

I just wish that the AMPT triage score somehow adopted non-traumatic criteria. Though, I suppose for most ground providers cardiac and neuro cases are a typical no-brainer.

That said, and circling back to my opening remark, there are a plethora of reasons and ailments that may stump many field providers that would hopefully benefit from both higher-level providers, and/ or prompt recognition for rapid transport.


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## Tigger (May 14, 2019)

BLS fire launches helicopters for everything around these parts, and while the helicopter will usually beat the ALS ambulance (AMR or paid fire districts), they won't load if they are confident that the patient can go by ground, which I certainly appreciate. I do feel for them when they get yelled at by EMTs and EMRs for not immediately taking the "time sensitive" patient. It's a training issue combined with the flight programs frequent encouragement to have them come to most any scene.


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## jgmedic (May 14, 2019)

@VentMonkey, that's kind of what prompted me to start this thread. Of my 15 years in Fire/EMS, its only the last 3 I've been rural and had significant HEMS usage. Our Chief hates having our one ALS ambo out of district, so he encourages us to fly people. That being said, this is a mostly low income area and we're not looking to bankrupt anyone. Plus our medics relish the opportunity to get out of town and into an actual city. So not wanting to transport isn't an issue. I was just curious because I voiced concern once to a Reach crew and their response was to always call them, that they want all the calls they can get.


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## DesertMedic66 (May 14, 2019)

jgmedic said:


> @VentMonkey, that's kind of what prompted me to start this thread. Of my 15 years in Fire/EMS, its only the last 3 I've been rural and had significant HEMS usage. Our Chief hates having our one ALS ambo out of district, so he encourages us to fly people. That being said, this is a mostly low income area and we're not looking to bankrupt anyone. Plus our medics relish the opportunity to get out of town and into an actual city. So not wanting to transport isn't an issue. I was just curious because I voiced concern once to a Reach crew and their response was to always call them, that they want all the calls they can get.


That is pretty much going to be the answer of all HEMS management since it is all about call volume. For my company we have the option and are encouraged to do an airborne stand-by for major calls without being officially dispatched out. The thought process is that ground crews are more likely to use us if we only have a 5 minute ETA air are overhead instead of a 30 minute ETA.


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## Peak (May 14, 2019)

Tigger said:


> BLS fire launches helicopters for everything around these parts, and while the helicopter will usually beat the ALS ambulance (AMR or paid fire districts), they won't load if they are confident that the patient can go by ground, which I certainly appreciate. I do feel for them when they get yelled at by EMTs and EMRs for not immediately taking the "time sensitive" patient. It's a training issue combined with the flight programs frequent encouragement to have them come to most any scene.



To be fair, I think that mostly developed because of how long it takes AMR to respond to the more rural areas of their contract.


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## CANMAN (May 14, 2019)

GMCmedic said:


> Supposedly my company does not bill blatantly unnecessary flights, or so they say.
> 
> As a patient advocate, the last thing I want is for patients to be bombarded with high bills. As a provider being requested by another provider, I don't mind the work.



Your company is lying to you..... SOMEONE is getting a bill. HEMS programs aren't typically in the game to give away free Jet A (unless it's coming out of a PR allowance or something). Whether they're getting any reimbursement for those medically unnecessary flights is the question, with the answer likely being no. But at some point the cost to launch etc. will be passed onto someone.

I see it often in my current program unfortunately on IFT flights, and it absolutely bothers me. The fact we will get spun up by dispatch for an IFT NSTEMI w/o chest pain because they're going to the cath lab and the MD wants them on the table for example is really frustrating. I'm many years past the coolness factor of flying, and actually care about if something that is totally appropriate to go via ALS ground ambulance gets billed as a rotor wing flight plus mileage and the patient gets a HEMS bill (regardless of how little it may be) vs. a ground ALS ambulance bill which would absolutely be less. There is a huge system problem. In some cases yes out of hospital time is solid reasoning, but PLENTY of patients who are flown can stand the ALS ground trip to whatever they need to go for evaluation/service. Often times patients who come in post trauma for mechanism type referral will lay in a trauma bay for hours awaiting consults if they're stable, even if something is found on workup like a fracture, neuro issue, etc. So with that being said I don't always agree with flying the "mechanism trauma patient" because you're 90 minutes away from a trauma center.


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## VFlutter (May 14, 2019)

jgmedic said:


> @VentMonkey That being said, this is a mostly low income area and we're not looking to bankrupt anyone.



Low income usually is medicare/medicaid which means they can not be billed and the company is under reimbursed. Uninsured people are usually not the ones getting huge bills, it are those who have private insurance and are caught in the middle of a claim rejection and appeal.


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## Tigger (May 16, 2019)

Peak said:


> To be fair, I think that mostly developed because of how long it takes AMR to respond to the more rural areas of their contract.


But what do you expect when you're 35+ miles from the absolute edge of the city limits? Nobody pays a dime to subsidize the rural ambulance service here aside from a few fire districts that allow ambulances to reside in their stations rent free.


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## Peak (May 16, 2019)

Tigger said:


> But what do you expect when you're 35+ miles from the absolute edge of the city limits? Nobody pays a dime to subsidize the rural ambulance service here aside from a few fire districts that allow ambulances to reside in their stations rent free.


I'm not saying that it is only AMRs fault, the reality is that they run a business and that in order to keep out of the red they can't just put ambulances all over the rural response areas in their contract.

That region, in my personal opinion, is filled with a constituency who's primary motive is to not pay taxes. There have been many opportunities to change the healthcare environment but for many reasons it continues to fall through. Ironically historically it has also been the or one of the highest percentage of medicaid, underinsured, and uninsured population in the state; I don't understand how so many people vote for politics that hurt them.

There have been many times that fire could have taken over EMS or contracted through someone else but it never happened. A little bit more money from AMR and fire is pacified again for a bit.

I liked back when central was the city hospital. There are fewer and fewer safety net hospitals around the country, and the city sold out to the U. The former CEO got a massive golden paracute and the actual staff lost their pensions (they could work elsewhere in the city, but where are that many techs, RTs, nurses, and so on really going to go). I won't say that the quality was as good, but I actually got to meet up with a trauma nurse who just left there and they way she described it there hasn't seemed to be that much change brought in from the U. Main was definetly the nicer hosptial (at at the time in my opinion a better trauma service), but if they needed something and couldn't pay central would still take care of them.

It still continues. They city approved for the new hospital to be built on the north side of town where there are already a hospital that offers inpatient pediatrics, not to mention that both peds hospital systems have pediatric EDs and inpatient care less than 45 miles to the north. Meanwhile there is essentially no pediatric specialty care in the rest of the southern half of the state.

Since they wanted to push the protocols for fire closer to AMR they stripped down the scope of practice for the AMR medics. Fire takes more and more money from AMR only worsening the budget tightening. 

Back on topic flight is massively overused, but realistically 80% of the volume is transfers anyway. I don't actually care as much about the 911 calls, for the most part you have under trained first responders who are uncomfortable and think that they are doing the best thing for the patient. 

Most of the transfers the sending facility should have known better, but what do you do when the facility basically has dumped the patient on you and you are already there? Leave and come back with the CCT bus? Tell them to take it BLS or ALS ground?

We do education but in so many ways we set up the EMS system for failure. I was amazed when I watched our HEMS primary teams' medical director lecture at a conference and it was amazing the number of ER physicians who truely don't understand the difference in scope between EMTs, Paramedics, and the critical care teams and what form of transport is actually appropriate. How can I expect a rural EMR or EMT who sees maybe a handful of calls in a year to make the same decision?


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## DrParasite (May 16, 2019)

Tigger said:


> But what do you expect when you're 35+ miles from the absolute edge of the city limits? Nobody pays a dime to subsidize the rural ambulance service here aside from a few fire districts that allow ambulances to reside in their stations rent free.


Well, that's what happens when you live 35 miles from the edge of the city limits.  You would be amazing how many people from the cities move to the sticks, because it's cheaper and they don't have to pay city taxes, yet will complain when they don't get the same level of service as they did (such as an ambulance or fire truck right around the corner) when they were inside the city.  You can't expect the same level of service without having to pay for it.....

The real question is, how many of these patients are really time sensitive?  The golden hour has been debunked, most chest pain calls aren't actual MIs that are going directly to the cath lab, etc, so how many of these patients are truly time sensitive, where they will suffer a long term permanent negative outcome if they aren't transported by helicopter?  

If a person chooses to live in the rural areas, that is their choice.  The system should provide services to them, but if you aren't paying for city services, it is unreasonable to provide city level services in the rural areas.  and if you get hit with a large bill because a helicopter was appropriate to transport  you for a time sensitive condition, well, that's the gamble you take when you live in the rural areas and need appropriate medical care.


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## johnrsemt (May 20, 2019)

50-60 minutes to small hospitals  must be nice;  my PT job is 110 miles to small hospital  130 to everything else.

We are lucky to get a bird:  my last 2 shifts I ground transported an Acute MI, and a multi system trauma from an ATV wreck.  Too windy to get a helicopter.  Both cases the ED nurses argued that we had to divert to a closer hospital; I asked them both if they had ideas; cause there was nothing closer, (trauma I said nothing closer that wouldn't kill the patient).


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## Carlos Danger (May 21, 2019)

Peak said:


> That region, in my personal opinion, is filled with a constituency who's primary motive is to not pay taxes. There have been many opportunities to change the healthcare environment but for many reasons it continues to fall through. Ironically historically it has also been the or one of the highest percentage of medicaid, underinsured, and uninsured population in the state; I don't understand how so many people vote for politics that hurt them.



You are implying that a very complex problem (the cost and availability of healthcare) can be solved if we just vote for the right politicians and agree to pay more in taxes. Countless politicians have said "just vote for me and give me some more tax revenue, and I'll solve your problems" and it never ever works that way. Considering that government spending on healthcare is positively correlated with increased cost of healthcare and that it's been that way for a long time, and the fact that the federal government bears direct responsibility for many of the problems in healthcare delivery (especially the healthcare insurance industry), I think it's time to stop painting those who are skeptical of more government involvement as being obstructionist. There are lots and lots of problems with our healthcare industry, but right at the top of the list of issues is massive amounts of crony capitalism (essentially collusion between politicians, private insurers, health systems, and physician's lobbies), along with simple over-regulation.  You don't fix the problem of too much government involvement with MORE government involvement. 

OP, the HEMS industry is an absolute hot mess. Some of it is the fault of the players (the programs themselves encouraging the EMS agencies to call them for anything and still citing the "golden hour"), and some of it is the fault of larger trend in healthcare. But your questions and concerns are not the least bit unique.


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## Peak (May 21, 2019)

Remi said:


> You are implying that a very complex problem (the cost and availability of healthcare) can be solved if we just vote for the right politicians and agree to pay more in taxes. Countless politicians have said "just vote for me and give me some more tax revenue, and I'll solve your problems" and it never ever works that way. Considering that government spending on healthcare is positively correlated with increased cost of healthcare and that it's been that way for a long time, and the fact that the federal government bears direct responsibility for many of the problems in healthcare delivery (especially the healthcare insurance industry), I think it's time to stop painting those who are skeptical of more government involvement as being obstructionist. There are lots and lots of problems with our healthcare industry, but right at the top of the list of issues is massive amounts of crony capitalism (essentially collusion between politicians, private insurers, health systems, and physician's lobbies), along with simple over-regulation.  You don't fix the problem of too much government involvement with MORE government involvement.
> 
> OP, the HEMS industry is an absolute hot mess. Some of it is the fault of the players (the programs themselves encouraging the EMS agencies to call them for anything and still citing the "golden hour"), and some of it is the fault of larger trend in healthcare. But your questions and concerns are not the least bit unique.



I'm not going to go into any general political statements, nor did I intend for my statement to be taken as one. 

That area in particular is a disaster and I absolutely think the politics there contributes to it. The prioritization of the city council, mayors, county, and voters definitely at a minimum keeps putting fuel into the fire, although they were probably the spark and a good dose of accelerant as well. 

I don't know if you are actually familiar with the area of reference. I suspect that if you were you might be a little less eager to assume my politics are about being liberal rather than a statement of the corruption and mismanagement.


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## Carlos Danger (May 21, 2019)

Peak said:


> I'm not going to go into any general political statements, nor did I intend for my statement to be taken as one.
> 
> That area in particular is a disaster and I absolutely think the politics there contributes to it. The prioritization of the city council, mayors, county, and voters definitely at a minimum keeps putting fuel into the fire, although they were probably the spark and a good dose of accelerant as well.
> 
> I don't know if you are actually familiar with the area of reference. I suspect that if you were you might be a little less eager to assume my politics are about being liberal rather than a statement of the corruption and mismanagement.



I didn't assume your politics - you made it clear in your first post that you think that simply being willing to pay higher taxes would improve the healthcare system in the area in question. I also don't need to know anything about this specific area, because that strategy has never worked anywhere. Witness the current state of our healthcare system. More state and federal money spent on healthcare = higher healthcare costs. Notwithstanding the fact that at the county level - especially a rural, poor county - the money simply doesn't exist to make much impact. 

Unfortunately, it is impossible to talk about healthcare economics without also talking politics, because with nearly 50% of all healthcare dollars spent coming from some sort of federal program, and with the insurance and hospital industries being absolutely strangled by federal regulation, the two things are practically synonymous these days. It is time people wake up and stop insisting that we double down on policies that very clearly don't work.


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## RocketMedic (Jun 3, 2019)

*Raises hand*

Hi, literally have a master's degree in this.

Government regulation does not raise the *price* of health care. Government regulation increases the costs of doing business to the standards of the regulation by forcing every service provider to meet those standards. Those increased costs deter marginal providers from operating in some cases, drive up prices in others, but are not necessarily going to increase prices in all cases. In fact, in many cases, government regulation actually decreases operational and total costs, by forcing systemic changes that remove the potential for failure. For example, back in the dark ages before RNs had degrees and the Joint Commission was a thing, hospital costs were lower and there was far less regulation; but a lot of those unregulated hospitals had horrific facilities, little-to-no accountability and wildly undertrained or untrained staff. Yes, correcting these things costs money, but so does not correcting them. Yes, it is broadly accurate to say government regulation correlates with price increases, but there is not direct causation. Does anyone really want to go back to the days of journeyman physicians, "one-per-state" labs/imaging or sawdust floors?

The price of health care as we currently know it is directly derived from the educational structure of our providers (expensive, time-consuming, arduous and did I mention expensive?), the decentralized and inconsistent nature of our suppliers and payors, the lack of accountability of payors for outcomes and the American belief in correlating physical health to monetary value and employment status, and a culture of unrealistic and expensive aspirations and assumptions. Trying to make a profit out of caring for the elderly, sick and non-productive members of our society is a literal impossibility; allowing the kind of business decisions that allows for healthcare operations to be profitable caring for those people makes quality outcomes -and- price containment impossible.

More regulation would make things better. Particularly if that regulation assigns clear financial responsibilities to government, service providers and payors/patients.


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## SandpitMedic (Jun 4, 2019)

RocketMedic said:


> *Raises hand*
> 
> Hi, literally have a master's degree in this.
> 
> ...


Regulation and directive, yes. “Free for all” or subsidized, no. 
I agree with your sentiment. Well said.


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## Carlos Danger (Jun 5, 2019)

RocketMedic said:


> Government regulation does not raise the *price* of health care. Government regulation increases the costs of doing business to the standards of the regulation by forcing every service provider to meet those standards.



"Government regulation doesn't raise the *price* of healthcare. It just raises the price of *providing* healthcare" OK, sure, if you like semantics…..but what do you think happens when the cost of providing a service increases?

The American Hospital Association has said that the cost of compliance with the 380 or so federal regulations (not counting CMS requirements or insurance regulations) that affect acute care hospitals cost nearly $50,000 per year PER BED, on average.  That's just the direct costs that can be easily measured like the cost of expensive software, IT departments to manage it, compliance offices, and educators who spend as much of their time making sure staff members are up to date with the latest reporting requirements as they do best clinical practices. It does not account for the time that nursing and clinical staff spend on this stuff. It is very significant.

CMS compliance is a whole other ballgame. Notwithsanding the fact that healthcare spending makes up over 30% of the federal budget and growing (with little positive impact on health outcomes, at least in the case of medicaid), compliance with CMS requirements absolutely eclipses compliance with other federal, state, and insurance regulations, in terms of what it takes to make sure you get at last crumb that CMS pays. Most people would be absolutely shocked at how much of modern medical care is dictated directly or indirectly by the bureaucrats at CMS. Even those with good private insurance are indirectly affected to a very significant degree.

Since the 1970's, the number of providers in the US has increased by about 150%. The number of healthcare administrators, however, has increased by something like 3700%. Why is that? Does the healthcare industry naturally value the contributions of bean counters more than clinicians? I doubt it. It's another result of the massive cost of compliance with federal, CMS, state, and insurance requirements.

At the same time, physician career satisfaction is at a record low and 90% say they would not recommend medicine as a career, and most cite the increasingly complex administrative requirements constantly being added to their list of responsibilities. I can tell you anecdotally, that many of us providers are also increasingly disenchanted by a sense that there are just so many people in line to profit from the care that we provide to patients. 

Rural hospitals are closing left and right, and the ones staying open are cutting important services because they simply can't afford to provide them considering the pittance paid by CMS and how difficult they are to keep happy. The only way to make money on CMS patients (which are a very large percentage of many rural hospital's clients) is volume. As long as that is that case, the efforts to switch to a value-based reimbursement scheme will fail.

The cost of healthcare was supposed to fall after the ACA was passed in 2010. It was supposed to be this miraculous piece of legislation that all the really smart people supported because it would reign in costs, make healthcare more available, and make us all healthier. It was supported by the insurance industry because it protected them from competition. It was supported by states and hospital systems because the federal funding they rely on would have been slashed without it. What really happened? The cost of healthcare and healthcare insurance has risen even faster than it did before the law went into effect, and dozens of rural hospitals have closed. 

Meanwhile, more and more practices and surgery centers are opening that refuse any type of insurance. These make private payment arrangements with individuals or their employers. Because they avoid the incredibly complicated mess of CMS and insurance billing and compliance, they tend to have very transparent pricing, cost WAY less than traditional providers, and have outcomes that are as good or better. That's right: the only part of the healthcare industry that is actually thriving and lowering costs is the small corner of the industry that has managed to shield itself from as much government involvement as possible. 

If I ran a business or an entire industry and it did poorly, no one would question that it was my responsibility. Once things started doing poorly, if I doubled down on the same strategies that caused it to do poorly in the first place, people would say that I was stupid and that it was completely my fault when it continued to fail. 

Well, make no mistake, the government absolutely runs the healthcare industry, and things have gotten worse and worse every year for decades now. But for some reason we give politicians and bureaucrats a pass when it comes to the actual effectiveness of their programs. It's as if intentions are more important than actual results. We haven't even talked about the VA, which is an utter national embarrassment and is a perfect prequel to what British-style completely government-run healthcare this country would actually look like. 

The healthcare system is absolutely imploding and lots of people are really suffering, and so many people just want to do more of what has clearly not been working. I wish I could say I'm surprised.


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## RocketMedic (Jun 5, 2019)

@Remi , you’re lumping cost-containment measures along with regulations. CMS and private insurers maintain complex reporting requirements in order to deny as many claims as possible and to limit their costs of operation (both in payments and how much it costs for them to process a claim). I am more directly referencing regulations focused on quality, safety and access.

Could regulations as existent be overhauled? Absolutely, and there’s a lot of duplicative, overly-focused and poorly-directed requirements, and once we start digging into CMS administrative requirements, a lot that are superfluous. But removing regulatory mechanisms isn’t the right answer either. 

Regulations directed at improving safety and quality are good things.


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## RocketMedic (Jun 5, 2019)

The single greatest price driver in US healthcare is the fact that there is no single designated payor for services and the funding of healthcare is nearly entirely dependent on the whims and will of glorified middlemen who broker healthcare services with an eye towards cost efficiency and short-term operational benefit.


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## SandpitMedic (Jun 6, 2019)

Great arguments gentlemen. I am thoroughly enjoying your dissertations.


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## DrParasite (Jun 6, 2019)

While this was mostly from the hospital's perspective, this video has some solid points (And I'm really loving this series, although I will also admit that it does leave out some details that would not support the host's point of view):


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## MSDeltaFlt (Jun 23, 2019)

jgmedic said:


> Hey guys, So i work as a FAE-Medic for a very rural fire district in San Diego County. We have a minimum ground transport of 50-60min by ground to the closest receiving, 1.5 hr to STEMI, over 2 to trauma/Stroke. We obviously fly anything critical, but my question is this. How do you guys feel when you get flights for so-called borderline patients. The managers at the HEMS companies tell us to always use them, but i know that's most likely profit driven. We have flown patients with resolving neuro symptoms or traumas that meet criteria but really don't have major injuries or even symptomatic presumed cardiac chest pain. Pt's that in the city would not go to code to the ED, but out here get a helicopter. I guess what I want to know is how do you flight crews see these patients in terms of necessity or are we just over triaging.




If you wouldn't transport lights and sirens to the ED within the city limits then why would you fly them?!?   That is in essence the same thing.  STEMI/CVA that are that time sensitive, really bad trauma's.  Yeah, fly them.  But if your patient is stable enough to stop at every red light, then they are stable enough to either ground pound to either the local ER or to the specialty center if your management will allow.

Speaking from experience, lawndarting for MOI only sucks something I really don't want to type on this forum.


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