American Healthcare, the next house of cards

[Veneficus]

I seriously need a blog.

In another thread the discussion of the role of the NP threatened to hijack it. So here we are.

As I thought about the last reply, I realized that the common ground of the two sides (my antagonist I highly respect and had many valid points.) was that the American Health system is messed up. (Hardly news I know)

This afternoon however, I realized it is the next economic bubble.

Right about now you are probably thinking, how does this affect or relate to EMS?

No matter what type of EMS system you work in in the US a large part of your pay comes from tax dollars; whether it is municiple, state or through federal healthcare spending.

Now back when I learned economics reading The Count of Monte Cristo and a few classes in anthropology. I learned of the producer/consumer ratio. In the USA, 24-26% of the economy is healthcare. Those numbers are expected to climb with an aging population.

But the people receiving healthcare are consumers. On a fixed income, which is expected to decline as more draw from the pool. Healthcare workers are not producers. They protect wealth, which further manipulates the producer/consumer index by removing their contributions.

When consumers outnumber producers or production capacity, there is collapse.

Now American healthcare isn't the best in the world. (remember the propaganda about owning a dotcom or your own house?) Last I saw it was #47. But it spends billions more than #1. See a problem there?

To fix it, we keep adding layers, mid level providers, techs of all shapes and sizes, and all of this doesn't reduce costs, it adds to them.

Now all of this would work out if we could export our healthcare, or at least draw some medical tourism to use it. But the cost makes that utterly impossible on a large scale.

Of course the simple answer is we must reduce costs and increase taxes. But will that really work? Who are you going to raise taxes on? Producers, which whether an individual or especially a company, can cause those producers to go elsewhere and they do.

Forcing an employer to absorb the cost of healthcare makes his product uncompetative and they leave or outsource.

This creates further shift in the producer/consumer ratio.

See where this is going?

Now when cost reduction comes in, keep in mind that a lot of the mid level people, RTs, NPs, PAs, were added as a bandaid to the system. So when cost reduction comes about, there will be an unlayering. These people will have amassed considerable debt to reach their position. Worse still, the rest of the world gets along perfectly fine without them. Which means their position is only good in the current US system. Unlike a physician or nurse, they are not portable.

Everyday on the internet I keep seeing adverts for hot healthcare jobs. Transcriptionists, med techs, you name it.

Many EMTs here are finding the market quite saturated right now. Agencies from municiple to hospitals are freezing hiring or cutting back. Back in the day of wooden ships and iron men, my EMT cert all but allowed me to write my own ticket. Now even Medics are having trouble.

All of this growth is unsustainable and will be followed by contraction.

What is yor backup career when you can't make money in medicine?

 

[Chimpie]

You don't need a blog. Discussion forums, especially ours, lead to more engaging discussions than most blogs. A conversation flows better on a forum than a blog.

I agree that the market is quite saturated now, but I think that will start to change in the next couple of years. As markets start to increase and industries start to return to pre-2007 levels, those who don't have jobs in EMS will find work elsewhere.

 

[jrm818]

"contraction" sounds like a nice possibility I'm stuck between expecting "Violent implosion" and expecting "gradual disintegration" myself...In the mean time I'll rake in as many millions in EMS as possible, to tide me over during the coming Apocalypse.

As far as "added layers" of healthcare in the EMS world specifically: I do realize that EMS is one of those "added layers," but unlike midlevel providers, my impression is that EMS was NOT designed to replace physicians in a role that would otherwise be physician filled, but to fill a niche that was never quite filled (or maybe never existed?). The community paramedic model may alter that a bit, as such providers seem to perform a lot of services that once-upon-a-time were filled by doctors making house calls.

Unlike midlevels, paramedics exist in many healthcare systems. I've actually always wondered how places like France manage to staff their ambulances with emergency physicians. Do they just have a dramatically lower call volume than the in the US, a physician factory hidden somewhere, or do they have some way of allocating and rationing their physician response? Do the physicians continue care for their patient once in the hospital?

 

[abckidsmom]

This has me thinking, and I think that while you have a good overall point, the bubble isn't going to be as awful as you say.

But I could be sticking my head in the sand since I look at my healthcare education as a life insurance policy. I was just telling someone yesterday that if I needed to, I could be back to work full time in under 3-4 weeks in almost any market. Nurses and paramedics are just a necessary commodity. But they're not a mid-level provider...they just fill a caregiver role, which is always going to be needed.

I don't see the consumer of American healthcare accepting the wards and 1:12 ratios of times past, but I need to stew on the economics of the situation before I can speak to that. I'll be back.

 

[46Young]

EMS may be a needed commodity, but consider this: If the job market becomes tight, there will be much less available job opportunities. This may curb the turnover in EMS somewhat, further limiting these job openings. More people will be less apt to leave their current position, since it's unlikely that they'll be able to get jobs elsewhere. No more jumping from employer to employer to get an extra buck an hour. I don't know if this will happen, though. I'm just thinking aloud.

I understand the OP's point that PA's, NP's (noctors) and RT's are more or less band aids for the system.

 

[JPINFV]

You don't need a blog. Discussion forums, especially ours, lead to more engaging discussions than most blogs. A conversation flows better on a forum than a blog.

I think it really depends on how the post is written. Longer, more essay style posts are geared more towards blogs than forums whereas shorter, more conversation style posts (especially when you look at paragraph length of essay vs conversation) are geared more towards forums. The big problem with new blogs vs established forums is getting readers.

 

[JPINFV]

Now American healthcare isn't the best in the world. (remember the propaganda about owning a dotcom or your own house?) Last I saw it was #47. But it spends billions more than #1. See a problem there?

If I recall correctly, that 47 rank is for life expectancy. Is life expectancy the only contribution made by health care, or just the easiest to tract? Doesn't public health projects contribute more to life expectancy than medicine? As an example of life expectancy vs quality of life, would you rather use a walker or wheel chair and live 5 years or have a hip replacement and live 3? What about things like diet and exercise that medicine can't control (we can advise, but we can't dictate)?

Of course the simple answer is we must reduce costs and increase taxes. But will that really work? Who are you going to raise taxes on? Producers, which whether an individual or especially a company, can cause those producers to go elsewhere and they do.

Forcing an employer to absorb the cost of healthcare makes his product uncompetative and they leave or outsource.

I think another issue is that there's a disconnect between the consumer and the producer when company insurance is used. If I'm insured through my company, then I either have to pay a lot more (especially since if I drop my company's insurance, I don't get a pay raise equal to the employer's contribution), or take what ever plan is issued. Similarly, since the employer is sharing the cost, I have less of a reason to pick and choose what treatments or tests I want. Even in medicine the "I want it all" attitude needs to be tempered.

What is yor backup career when you can't make money in medicine?

[since I should answer the question]

Backup career? I honestly never thought that out. However, I've always been of the mind that you can make a decent living doing anything. I'm sure that the store managers (note: Not assistant managers, not crew leaders, but store manager and up) make decent money. The question is are you willing to go in, even if you have to start working at the bottom for minimum wage, and work your way up? A job, any job, at any company is an opportunity. You never know what doors will open up either internally or through networking that you will be able to walk through. Are you (generic "you") willing to treat any job as an opportunity, or just something that needs to be survived for the next 5 hours?

 

[WTEngel]

Fear and uncertainty

America is going through rough times. Unfortunately this is a result of government de regulation (by both major parties) allowing most Americans to live beyond their means...a situation that they themselves should not have allowed to happen. But credit is the American way, right?

What is happening right now may hurt, but it is a bad medicine that we must all swallow. More people are paying cash now and getting away from putting things on credit. Lessons learned by people who are weathering these hard times will hopefully be passed on to our children and our Children's children, and hopefully history will not repeat itself.

Private insurance is inherently flawed. The flaw that makes it an unworkable situation is that private insurance companies are designed to operate at a profit. When you want to operate at a profit, to provide the minimum services at the cheapest rate. This leads to a whole set of problems that include patient's being declined certain coverage, physicians waiting months on end to be paid 20% of what they actually bill for a service, and so on. This causes physicians to find "creative" ways to get things covered, for the benefit of themselves and the patients, and they also end up overcharging to recoup what the procedure or treatment was actually worth.

Do you think an IV and fluids actually cost 100$ or whatever outrageous price is billed? No way, but the physician anticipates getting maybe 20% of that, and out of that 20% he/she must pay for the procedure itself, and all of the IV starts and fluid sets that will end up going unpaid for. Who loses? The uninsured or underinsured patient who does not have the negotiating power that the large insurance companies and Medicaid / Medicare have.

When insurance companies calculate the average life expectancy compared tp the cost of medical care and decide it is a better business practice to allow the patient to die, rather then spend the extra money to live in comfort for a few extra years, it is clear that the system is not working.

Healthcare workers have a good amount of job security, and i don't see that changing. People will always need to be taken care of when they are sick and injured. What i do see changing is how things are paid for, the amount that is paid for certain things, and possibly entry level salaries and new positions created, not necessarily positions currently filled.

Allied health needs to be careful though. Look at what happened to the autoworkers. They got used to being able to demand such high salaries and benefits that it ended up costing the companies a lot of money in promised benefits over time. Then when times got tough and people stopped buying cars, we see what kind of trouble ensued.

So as long as allied health and other medical professions continue to provide outstanding care, the staffing side of things will be ok. What needs to be fixed is the insurance and payment side of things. That will take everyone waking up and realizing what is going on, which is not going to happen overnight.

You can get people to cross an ocean to fight for freedom, but they can't be bothered to walk across the street and vote. I am paraphrasing, and i forget who said it, but it really speaks to a lot of issues we are currently having.

 

[abckidsmom]

EMS may be a needed commodity, but consider this: If the job market becomes tight, there will be much less available job opportunities. This may curb the turnover in EMS somewhat, further limiting these job openings. More people will be less apt to leave their current position, since it's unlikely that they'll be able to get jobs elsewhere. No more jumping from employer to employer to get an extra buck an hour. I don't know if this will happen, though. I'm just thinking aloud.

I understand the OP's point that PA's, NP's (noctors) and RT's are more or less band aids for the system.

I meant to add that I think you're unnecessarily lumping RTs into that group. I find their specific skill set, especially in critical care, to be a needed specialty. We had 1-2 RTs in our unit, and they worked hard, and while I supposed the nurses could have done that work, we'd have needed several more nurses to allow them the time to babysit vent weaning processes, think up creative vent settings, and consider alternative therapies.

 

[Veneficus]

I supposed the nurses could have done that work, we'd have needed several more nurses to allow them the time to babysit vent weaning processes, think up creative vent settings, and consider alternative therapies.

Actually I forsee this being covered by making anesthesia or whatever intensivist is covering the ICU work harder.

 

[abckidsmom]

Actually I forsee this being covered by making anesthesia or whatever intensivist is covering the ICU work harder.

Hmmm. I've never worked in an ICU like that. I worked in a STICU and a MICU, we had a couple of teams of MICU physicians who handled their own patients, same for surgery (at least 2 teams of physicians) and Trauma (only one team).

You mean having whatever physician that's handling the patient make all the vent decisions? I don't know about the practicality of that. The residents we dealt with worked really hard and barely kept up. Lots of days we'd make it through a whole day and *finally* get a chance to talk about the vent-weaning, POD9 little old lady who just wasn't so dramatic. I feel like the real progress in those boring patients is made by nursing and RT.

In the new reality of people expecting (and actually) living forever, there will be far more boring patients, IMO.

 

[Veneficus]

Hmmm. I've never worked in an ICU like that. I worked in a STICU and a MICU, we had a couple of teams of MICU physicians who handled their own patients, same for surgery (at least 2 teams of physicians) and Trauma (only one team).

You mean having whatever physician that's handling the patient make all the vent decisions? I don't know about the practicality of that. The residents we dealt with worked really hard and barely kept up. Lots of days we'd make it through a whole day and *finally* get a chance to talk about the vent-weaning, POD9 little old lady who just wasn't so dramatic. I feel like the real progress in those boring patients is made by nursing and RT.

In the new reality of people expecting (and actually) living forever, there will be far more boring patients, IMO.

Not that I am advocating rationing, but serious cost/benefit ratio must be looked at in the treatments of many patients.

As JP pointed out earlier, about wheelchairs and quality of life, in my observation the results aren't so optimistic.

Most patients are not that exciting, but it doesn't excuse a physician from taking care of them. I understand the lack of physician argument, but there is also the truth that physicians like nurses have done a lot to keep their numbers smaller that what is required by today's patient population.

It is hard to fault people for looking out for their own interests, but really my point is the system is unsustainable and nobody is doing anything about it. So when it crashes it is going to hurt a lot.

It is not a question of removing mid level providers, it is a question of reforming the system in some way that works. As I pointed out, these providers are not found in any appreciable quantity outside of the US. They are part of what has been a temporary fix, and that doesn't mean when a real fix finally comes about they will have the opportunity they have today. I don't think they will be eliminated as a whole, but the amount of open positions may decrease substantially. If that were to come to pass, it is not like they could just move to another country or possibly find work that pays the same.

Also there has to be concern for the lower end providers like techs. If the docs and nurses spent less time administrating, they would be spending more time with patients. That would elimiate some of the lower end need. There is also the possibility that a true fix would shift the adminstration duty from clinicians to administrative labor, which would put these people in the position to retrain or find other work.

What we know for sure is the system cannot continue how it is going. I was just musing on the consequences of the basic economics of it. There is no way to reduce costs without reducing layers of service. (aka people) Do you think they are going to start cutting physicians?

 

[Veneficus]

Since this is a forum, let's make this a little more interactive.

If you (whoever you are) were tasked with reducing your departments budget by a modest 20% in the next 3 months, while trying to minimally impact revenue, what cuts would you make? How would you reconfigure how your dept operates to do this?

 

[WTEngel]

Cost cutting measures

Overtime first and foremost. Since this situation is hypothetical I can't say specifically how the cut would be made, but thats the first line item and could potentially make up a large portion of the costs you want to reduce. Study how much overtime your department uses, when and why it is used, and then take appropriate measures to cut it.

Second, eliminate repetitive and unnecessary tests and procedures. Appropriate QI and QA should be able to point out what tests and procedures are not necessary, incorrectly ordered, and in some cases repeated due to collection error, processing error, or other easy to fix issues.

Third, encourage your staff to be better stewards of the resources in the unit. If you are doing a minor suture procedure, and a major plastics tray is opened, the cost of sterile processing and consumable items has been completely lost. Getting more supplies than necessary for a certain procedure and over stocking should be avoided. Also, there is a high incidence of waste and even employee theft of items from a lot of units.

Process improvement using Lean Six Sigma type process studies are worth their weight in gold. Figure out all the things that do not directly relate to positive patient outcomes and attempt to reduce them to the lowest acceptable levels. Instituting engineering controls from the top down goes a long way to limit wastefulness and redundancy.

 

[46Young]

I meant to add that I think you're unnecessarily lumping RTs into that group. I find their specific skill set, especially in critical care, to be a needed specialty. We had 1-2 RTs in our unit, and they worked hard, and while I supposed the nurses could have done that work, we'd have needed several more nurses to allow them the time to babysit vent weaning processes, think up creative vent settings, and consider alternative therapies.

If the job duties and expertise of an RT could not be handled by a nurse with additional education and training, as a subspecialty, then I agree with you. Otherwise, saying that you would need a couple of nurses to take the place of a couple of RT's in your unit seems like a one to one exchange to me.

 

[46Young]

Since this is a forum, let's make this a little more interactive.

If you (whoever you are) were tasked with reducing your departments budget by a modest 20% in the next 3 months, while trying to minimally impact revenue, what cuts would you make? How would you reconfigure how your dept operates to do this?

My dept is a fire based dept that does EMS ground txp. Identify aides to the Fire Chief, Asst Chief's, etc, and return them to the field. Implement furloughs. Set a certain amount of allowable OT slots per day. If any more bang in sick, you go to rolling brownouts. You put an engine, an ambulance, a truck out of service, or two, three, whatever, and spread those people to other stations to fill in the holes. Overnight brownouts regardless of staffing issues is similar to SSM in a sense, since call volume is typically lower at night. 5% pay reduction. It's the same as losing a step, since each step increase is 5% of our base. Set the tempature controls to 68 F, and make it policy to not change it, to include placing ice packs on the thermostat, or heating it, either. Do a hiring freeze, and use OT instead. Up to a certain point, it's actually cheaper to pay out in OT, since you're not paying the hidden costs, such as fringe benefits, insurance, etc. Put off replacing apparatus. Destaff positions as older members retire. Order EMS supplies for the station rather than restock at the hospital. It's much cheaper to do so. Suspend tuition reimbursement. If all else fails, then RIF. Let the public decide if they want to pay extra in property taxes for adequately funded emergency services (worked for us!), or if they are comfortable with the reductions and all the coverage issues that come along with that.

You want draconian measures (20%), that's what I would do.

 

[46Young]

It is hard to fault people for looking out for their own interests, but really my point is the system is unsustainable and nobody is doing anything about it. So when it crashes it is going to hurt a lot.

It is not a question of removing mid level providers, it is a question of reforming the system in some way that works.

Reform? It's all part of the Cloward-Piven strategy. Overburden the gov't with entitlements and a flood of other impossible demands, cause economic collapse, and then the public will be receptive to a socialist style of gov't. Basically forcing political change through orchestrated crisis.

Keynesian economics, anyone?

 

[Veneficus]

Reform? It's all part of the Cloward-Piven strategy. Overburden the gov't with entitlements and a flood of other impossible demands, cause economic collapse, and then the public will be receptive to a socialist style of gov't. Basically forcing political change through orchestrated crisis.

I don't really see the definitive march towards socialism that seems to be part of popular politics today.

What I do see is a system that doesn't inherently work that nobody seems to have the will to fix. I think orchestrating such a collapse is a very risky gamble. In America's two party system, the party in power when it happens will pay a rather extreme price.

A total collapse of roughly 1/4 of the nations economy, coupled with a pay to play medical system I think is more likely to motivate people to ropes and torches and pitchforks than passively accepting whatever crumbs are thrown their way.

 

[firetender]

Blogs and Bogs:

You don't need a blog. Discussion forums, especially ours, lead to more engaging discussions than most blogs. A conversation flows better on a forum than a blog.

I agree that the market is quite saturated now, but I think that will start to change in the next couple of years. As markets start to increase and industries start to return to pre-2007 levels, those who don't have jobs in EMS will find work elsewhere.

Doing a blog is about drawing attention to yourself, it seems to me, if you have a philosophy or approach or product that you think will stir up some stuff. Chimpie's right; I see a lot more discussion here than there, though here is somewhat a converted audience (laced with differing opinions as well as detractors!) and there the views could be viewed as revolutionary with application to the public at large.

I think it depends on how large of a sounding-board you want/need. Also, I think a Blog is best geared toward mobilizing a targeted population, while Forum's like these are really about conversation.

According to this site, http://www.emsemployment.net/index.html EMS prospects for employment will be increasing, and that's largely because my generation, the Baby Boomers will be circling the drain.

IMHO the next few years, to soon be overdosed with the decrepit like myself, will probably be the straw that breaks the camel's back, as so clearly articulated by Vene.

 

[SanDiegoEmt7]

What is happening right now may hurt, but it is a bad medicine that we must all swallow. More people are paying cash now and getting away from putting things on credit. Lessons learned by people who are weathering these hard times will hopefully be passed on to our children and our Children's children, and hopefully history will not repeat itself.

We can only hope.

Since this is a forum, let's make this a little more interactive.

If you (whoever you are) were tasked with reducing your departments budget by a modest 20% in the next 3 months, while trying to minimally impact revenue, what cuts would you make? How would you reconfigure how your dept operates to do this?

This isn't hypothetical in the least. Rather than discuss pure business tactics, I'll just say some of the political changes that could help our healthcare systems:

-Make people responsible for their increased costs to the system. You smoke, you are morbidly obese, etc. you pay more into the system.

-Place limits on tax covered services. Publicly funded services should be limited to medically necessary procedures, preventative care, etc. but not drugs and risky procedures that don't have a proven benefit (other than making the patient feel like all options were exhausted).

-Reform the provider liability. Many tests and procedures are done simply for CYA reasons. Enact laws to protect providers and this will reduce the waste.

On the business side of things:

-I agree WTengel, eliminating overtime greatly reduces payroll costs. Supplies are overstocked and often wasted.