How to evolve EMS

[NysEms2117]

Or simply make EMS exclusively municipal -> abolish privates (keep gurney vans, but don't call them 'ambulances' ffs) <- will require an overhaul of healthcare insurance (NOT talking about the Obamacare horror show). If a 911 is not a 911 -> downgrade to private, otherwise respond with municipal.

Municipal as In town/city or county? What about hospital based ems? Hospital have ems that cover for that level 1/2 tc's region?(spitballing)


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[Qulevrius]

Municipal as In town/city or county? What about hospital based ems? Hospital have ems that cover for that level 1/2 tc's region?(spitballing)


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Either/or, budget-dependent. Public/civic services should be resident-subsidized, not paid out of pocket as it is the case with private EMS. It'll slightly raise the taxes in metro, but the overall individual financial impact will be significantly less than it is today. Hospital-based EMS - if contracted with the city/county, otherwise not EMS (because they deal with a single provider, makes them monopolists). Alternatively, a state/county/city approved agencies that split their ERAs and cover for all respective hospitals.

 

[NysEms2117]

Either/or, budget-dependent. Public/civic services should be resident-subsidized, not paid out of pocket as it is the case with private EMS. It'll slightly raise the taxes in metro, but the overall individual financial impact will be significantly less than it is today. Hospital-based EMS - if contracted with the city/county, otherwise not EMS (because they deal with a single provider, makes them monopolists). Alternatively, a state/county/city approved agencies that split their ERAs and cover for all respective hospitals.

Well I know where I am Albany med is a monopoly because there's literally no other place to go. There's saint peters hospital but they are a level 3..
Possible solution: would you be opposed to putting emt-B level training in the police academy, having Leo's respond, and they can determine if it's life or death enough for the new style ambulambs we talked about? Because they can still bvm them if absolutely necessary ect ect



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[Qulevrius]

Well I know where I am Albany med is a monopoly because there's literally no other place to go. There's saint peters hospital but they are a level 3..
Possible solution: would you be opposed to putting emt-B level training in the police academy, having Leo's respond, and they can determine if it's life or death enough for the new style ambulambs we talked about? Because they can still bvm them if absolutely necessary ect ect



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I think it's already in works in many places. At least in CA, LEOs are pretty much required to be Basics. No one expects LE to do more than just render initial first aid, alerting EMS if required.

I also will not pretend to know how things work in most of the states, since am pretty much only familiar with Kommiefornia's prehospital care. But if I were to give a concrete example, I'd say the closest thing to the model described, is HALL Amb in Kern. Yes, it is private, but - the owners is also the Bakersfield's mayor and charts the policies. They are an exclusive provider for the entire county, with 2 other small private companies as mutual aids. Their dispatch is unified and every civic service agency is routed through them. The rigs are equipped with EMS/FD/PD receivers and get live time updates on emergencies. They have very aggressive protocols, thanks to - yet again - their owners-slash-the village's big cheese. Their stations are strategically situated to cover all hospitals in their response area, and due to the county's sheer size, they have a rotary wing div.

Basically, this is how I see it being done.

 

[VentMonkey]

But if I were to give a concrete example, I'd say the closest thing to the model described, is HALL Amb in Kern. Yes, it is private, but - the owners is also the Bakersfield's mayor and charts the policies. They are an exclusive provider for the entire county, with 2 other small private companies as mutual aids. Their dispatch is unified and every civic service agency is routed through them. The rigs are equipped with EMS/FD/PD receivers and get live time updates on emergencies. They have very aggressive protocols.

Without flooding this thread with HALL info, quickly let me just point out he isn't the mayor much longer (if at all?), so who knows how that will effect change/ dynamics on scene.

Granted, the man has left a rather large imprint on our delivery model, but EMS' problems as a whole have already been beaten to death, then once again articulated---quite well---by yourself and @Summit.

Lately, this place has had me in a bit of a funk as people continue to pop up who do nothing for us as whole so to again reiterate my point just look at some of the recent activity on here, everything from a "20 plus year vet" to others claiming to have the cure all by offering a barely passable vocational cert the ticket to a fast dollar. This is a huge reflection on the reasons as to why we cannot seem to come out from being "stuck in the mud" of health care's armpit. As long as we keep glorifying what we do, and promote ways to do it and makes "lots of money" how can we take ourselves seriously let alone as legislators, bill passers, and politicians (you know the folks with actual clout) to take us seriously?

Sorry guys, perhaps I oughta sit on the sidelines and watch for a bit. Thanks @NysEms2117 for this thread though, I think it's things like this and people such as yourselves that have kept me afloat.

 

[EpiEMS]

Public/civic services should be resident-subsidized, not paid out of pocket as it is the case with private EMS.

The question here, though, is this: Is EMS an essential public service? If so, where do we fall on the public safety/healthcare spectrum? I would argue that defining EMS as an essential public service puts us closer to the public safety side of things, but the fact that we have no external benefits* to non-users makes us more of a healthcare "thing", if you'll pardon the colloquialism.

I love EMS, but is it an essential public service? Eh, maybe. Depends on the social compact.

*Other than providing a sort of safety net, whereas fire and PD do have clear positive externalizes (i.e. your neighbor's burning house could kill you/damage your house, so it's good for everybody to pay for fire protection somehow).

 

[Qulevrius]

The question here, though, is this: Is EMS an essential public service? If so, where do we fall on the public safety/healthcare spectrum? I would argue that defining EMS as an essential public service puts us closer to the public safety side of things, but the fact that we have no external benefits* to non-users makes us more of a healthcare "thing", if you'll pardon the colloquialism.

I love EMS, but is it an essential public service? Eh, maybe. Depends on the social compact.

*Other than providing a sort of safety net, whereas fire and PD do have clear positive externalizes (i.e. your neighbor's burning house could kill you/damage your house, so it's good for everybody to pay for fire protection somehow).

The way I see it, it absolutely is. Any state/county/city/town resident is a tax payer. We all pay property taxes, water & trash, electricity and healthcare. As a matter of fact, anyone and everyone registered for work or school, has to pay the healthcare fee. But the situation today is biased towards the abusers rather than people in actual need, because of the way the system works. Do you think a passed out drunken bum in the park needs an ambulance ? But then there's PD, and when you're a hammer, everything looks like a nail - so, it's a public disturbance and needs to be dealt with. Oh, is he drunk ? That means he's AMS, ha. Let's look in the protocols... yeah, here it is. Hey guise, guess what - we don't have to drag his arse to a drunk tank, let the EMTs deal with him.

*5 min later -'Whee-ou, whee-ou, a rig pulls up*

PD: Ok fellas, he's all yours
EMTs: Bloody wonderful...

End up taking the bum to the ER, because where else would you take him ? He's still ETOH, but now comes about and is pissed & hungry. Gets cleaned up a bit, eats some summiches, sleeps a little then voila, he's back on the streets, doing what he's good at.

Creativity aside, what did just happen ? My, yours and that guy next door's healthcare fee happened. So, if we were trying to figure out a way to deal with the system, what would it be ?

 

[EpiEMS]

The way I see it, it absolutely is. Any state/county/city/town resident is a tax payer. We all pay property taxes, water & trash, electricity and healthcare.

Healthcare is a tough one, though - we're not talking about immunizations here, we're talking about healthcare for individuals without any clearly defined positive benefit for others.

End up taking the bum to the ER, because where else would you take him ? He's still ETOH, but now comes about and is pissed & hungry. Gets cleaned up a bit, eats some summiches, sleeps a little then voila, he's back on the streets, doing what he's good at.

Creativity aside, what did just happen ? My, yours and that guy next door's healthcare fee happened. So, if we were trying to figure out a way to deal with the system, what would it be ?

So there's a couple of things:
1) Alcohol intoxication is not necessarily a medical emergency. So, we may have "overtriaged" here.
2) Who's paying for EMS? Is it Medicaid? Is EMS not really getting reimbursed?
I think the distribution of costs is important to consider here.
3) Does taking this guy anywhere improve anybody's life? Probably not.
4) I don't know if there's any way to bias the system in favor of people in need rather than abusers other than fines/surcharges. If the boy cries wolf and gets a $250 bill (which he may or may not pay...), he might think differently in the future. However, we have to weigh that against the risk of the nice old lady who is having a massive MI, but doesn't want to bother anybody and is afraid of overtriaging herself because she doesn't want a bill.

 

[Qulevrius]

Healthcare is a tough one, though - we're not talking about immunizations here, we're talking about healthcare for individuals without any clearly defined positive benefit for others.

It doesn't have to be an immediate positive benefit for others (such as trash removal/disposal), it just has to be there. The fee should go towards municipal EMS and be spent on provision of better care (continuous education, mandatory additional certs, up-to-date equipment etc). Then, when EMS is really needed, the taxpayers know that they'll get their money's worth.

So there's a couple of things:
1) Alcohol intoxication is not necessarily a medical emergency. So, we may have "overtriaged" here.
2) Who's paying for EMS? Is it Medicaid? Is EMS not really getting reimbursed?
I think the distribution of costs is important to consider here.
3) Does taking this guy anywhere improve anybody's life? Probably not.
4) I don't know if there's any way to bias the system in favor of people in need rather than abusers other than fines/surcharges. If the boy cries wolf and gets a $250 bill (which he may or may not pay...), he might think differently in the future. However, we have to weigh that against the risk of the nice old lady who is having a massive MI, but doesn't want to bother anybody and is afraid of overtriaging herself because she doesn't want a bill.

ETOH isn't but AMS is. And being altered as a result of being intoxicated, is one of these grey areas in an already abused system. This wasn't a hypothetical scenario, it's a daily reality.

Right now, private EMS is being paid (a little bit) by city - IF they have a 911 contract. 95% of the cake goes to IAFF, and since private EMS are just pushing the gurneys for them, that's what they get. That is also the reason for every large private EMS establishment, to have an IFT div (because that's the only profitable thing in the existing system). Long story short - 911 isn't profitable, unless it's subsidized.

Nope, no lives will be improved by taking that guy away. But if you're trying to address common sense, then it's a losing game. And you're correct, people should be penalized for crying wolf, and these fines should be enforced same way the parking tickets do (up to, and including passing it to collection agencies). Unfortunately, there's nothing that can be done about sick people who won't call 911 because they're afraid of monetary loss. On a side note though, the same nice old lady oftentimes won't call 911 simply because she's old and is afraid to go to a hospital. Happens every day.

Can it be improved ? Maybe with public awareness. That could easily be another article to spend taxpayer's money on (hint: communal paramedicine). But it should absolutely not be based on handouts.

 

[NysEms2117]

Well according to that model to me the appropriate way to deal with it is to add another tax for rehabilitations, such as rehab for alcoholics. Then for the psych patients we would need to re build mental institutions instead of hospitals or prisons. And that's more money. Which people won't pay.


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[Qulevrius]

And that's more money. Which people won't pay.

And this is where we start sliding into politics. Or not

 

[NysEms2117]

And this is where we start sliding into politics. Or not

If you'd like to discuss that I would in pm. But that would blow this up


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[Qulevrius]

If you'd like to discuss that I would in pm. But that would blow this up


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Let's just put it this way: there's a political party that is keen and very good with spending other people's money, and there's one that is good with collecting it.

(don't think I violated any board rules, did I ?)

 

[NysEms2117]

Let's just put it this way: there's a political party that is keen and very good with spending other people's money, and there's one that is good with collecting it.

(don't think I violated any board rules, did I ?)

Nope. Just was trying to avoid e-fist-fights lol


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[EpiEMS]

It doesn't have to be an immediate positive benefit for others (such as trash removal/disposal), it just has to be there.

I don't know if I agree, but I see your point, certainly. My broader point is that we have to decide what social compact we have - and what services we as a society must provide. That is to say, these are ethical questions. Improving EMS, that's more of what we as a profession can work on - whether that is necessarily advocating for third services/municipal EMS/splitting from Fire, that's more in our ballpark. Not that we don't have anything to say about values-based issues, but that the conversation on that needs to be much broader.

ETOH isn't but AMS is. And being altered as a result of being intoxicated, is one of these grey areas in an already abused system. This wasn't a hypothetical scenario, it's a daily reality.

As a provider, I would generally prefer to have some way to protect myself and clinically differentiate cases where the AMS is due to acute alcohol intoxication versus other causes - however, I'd argue that a reasonable practitioner may be comfortable releasing said patient if they're hemodynamically stable, able to protect their airway, don't have any obvious trauma or deficits, and we can (probably) push other conditions that may cause AMS further down our differential. If we could do that, we can save some moolah for sure.

 

[DrParasite]

Just to jump into the public safety vs healthcare.....

Lets be selfish for a moment: which benefits us more?

I think public safety does. Pensions, better pay, government benefits, ability to operate with a negative operating income due to influx of tax funds (just like the PD and FD), agency head is equal to the other two agency heads, you can look out for your own people without having to worry about what others in healthcare think, makes for a good CAREER.

But Healthcare does have it's perks too: easier to transfer to other areas of healthcare, better interactions with MDs because you both work for the same boss, potential for more cutting edge abilities because you are associated with a big heathcare entity.

But also remember, both sides also have their drawbacks too.

 

[Qulevrius]

But Healthcare does have it's perks too: easier to transfer to other areas of healthcare, better interactions with MDs because you both work for the same boss, potential for more cutting edge abilities because you are associated with a big heathcare entity.

Ultimately, that promotes nepotism more than competency.

 

[EpiEMS]

Just to jump into the public safety vs healthcare.....

Lets be selfish for a moment: which benefits us more?

I think public safety does. Pensions, better pay, government benefits, ability to operate with a negative operating income due to influx of tax funds (just like the PD and FD), agency head is equal to the other two agency heads, you can look out for your own people without having to worry about what others in healthcare think, makes for a good CAREER.

But Healthcare does have it's perks too: easier to transfer to other areas of healthcare, better interactions with MDs because you both work for the same boss, potential for more cutting edge abilities because you are associated with a big heathcare entity.

If it were up to me, I'd rather be part of a public health department...or maybe a public hospital system (like Boston or NYC*EMS prior to the FDNY merger), might help get the best of both worlds.

Ultimately, that promotes nepotism more than competency.

Government has as much (or more) nepotism (loosely defined) as anywhere else, I'd say...and the good old boy's club is as active in PD and FD as it is in healthcare (but healthcare is, on average, better educated and more diverse).

 

[Summit]

I think public safety does. Pensions, better pay, government benefits

Healthcare has better pay and benefits than public safety if you look outside of EMS. What you mean to say is that at the current EMS level of entry requirements, public safety provides an inflated compensation package.

Arguably FD only has the pay they do because of politics, lobbying, and unions.

If you want to see what the market thinks of FD pay, well look at the departments getting 4000 qualified applicants for 2 slots. That is an indication compensation is too high vs pool of qualified applicants.

 

[Qulevrius]

I don't know if I agree, but I see your point, certainly. My broader point is that we have to decide what social compact we have - and what services we as a society must provide. That is to say, these are ethical questions. Improving EMS, that's more of what we as a profession can work on - whether that is necessarily advocating for third services/municipal EMS/splitting from Fire, that's more in our ballpark. Not that we don't have anything to say about values-based issues, but that the conversation on that needs to be much broader.

There's a system in place, called the Medical Corps. These guys are non-paid volunteers, (usually) don't do anything medical as their primary job, and are being deployed in case of wide-scale emergencies only. They are the ultimate reservists. That is geared 100% towards the community, but there are no positive outcomes for them personally, except for extra brownie points with the Creator.

Now what I'm talking about is the potential of having emergency medical services available to any tax payer, but tax payer only. It means no freebies, no handouts and no BS. You live in a city and pay your healthcare fees = you're eligible. That would be geared towards getting rid of welfare queens and people who otherwise mooch off of the system. Part of the social security packet dedicated to healthcare/emergency services ? Absolutely. Incentives for well-educated, competent civic service providers ? Hell yes. Right now, LE + FD are rather lucrative jobs because of their benefits and pensions, but what about EMS ?

As a provider, I would generally prefer to have some way to protect myself and clinically differentiate cases where the AMS is due to acute alcohol intoxication versus other causes - however, I'd argue that a reasonable practitioner may be comfortable releasing said patient if they're hemodynamically stable, able to protect their airway, don't have any obvious trauma or deficits, and we can (probably) push other conditions that may cause AMS further down our differential. If we could do that, we can save some moolah for sure.

And this, once again, goes towards privates vs municipal services. The privates will be dispatched to any captured call, because the 911 throws them a bone. Cops, on the other hand, could care less, and since people are lazy by nature, they'd rather turf it. That is a HUGE problem, because it takes an emergency unit off the street, for a BS call. And if, as a private, you AMA the said bum, you'll end up in hot water regardless of how medically valid your decision was. Reason - 'you can't bill AMA'.