EMS Education, Outdated Ideals and "Common Sense"

[EpiEMS]

So if Jim, the MBA with no medical training bought your ambulance company and decided that... since he's the owner he can tell you, the licensed provider, how to practice paramedicine, you'd be fine with that?

In the scheme of things, managing one business is like managing any other. Different nuances depending on the field, but a business is a business. Jim owning XYZ EMS is no different than Jim owning XYZ Car Maintenance without any mechanical experience.
Granted, I do think that EMS should be a public service. But emergency departments? I see costs that can be saved by insourcing.

 

[RocketMedic]

Well, I agree with that -- on an institutional level. These are the same places that don't want you bypassing them toward trauma or STEMI centers, because they want those dollars.

Not sure about the individual providers, though. In any case, I imagine there's a way to integrate community EMS practices with the local hospitals, tying them in with the system as it progresses.

Heck, the personnel in question could be hospital employees. Actually, that might be more plausible than trying to make this happen via existing ambulance services.

Having worked for two hospital-based ambulance services that did this, I can safely say that it is horrible having to bring a patient to my Category-IV rural access hospital with a STEMI or new-onset CVA or level-2 trauma that we categorically could not definitively treat, when we had world-class hospitals with staffed specialty clinics literally 20 minutes farther away in the opposite direction. It was all for the money, and it was horrible.

AMR, on the other hand, let us bypass and fly out to our heart's content, and Gerald Champion didn't mind (probably because they were primarily funded by the USAF). Here in Oklahoma City, it's not an issue for EMSA- we have a pretty well-developed (if silly) transport plan.

 

[Veneficus]

In the scheme of things, managing one business is like managing any other. Different nuances depending on the field, but a business is a business. Jim owning XYZ EMS is no different than Jim owning XYZ Car Maintenance without any mechanical experience.
Granted, I do think that EMS should be a public service. But emergency departments? I see costs that can be saved by insourcing.

Unfortunately medicine is not like any other business.

The fees you can charge are regulated. (In every civilized country in the world) Which means you need evidence (usually in the form of practice guidlines backed up by research) that what you are doing is worth paying for.

You cannot simply terminate the relationship very easily for delinquent payment.

In the event of the emergency room, there is a law that states you have to treat everyone regardless of their ability to pay. (A severely underfunded mandate in the US)

Does your business have to mow the lawn for people who cannot pay simply because their lawn needs cut?

Then there is standard of care, which means you cannot withold certain treatments because they do not make money. Conversely, you cannot perform procedures or "upsell" procedures that do make better money.

That stuff is even before customer service and satisfaction.

As well, your reimbursement for service is not static. You might not perform 3 bypasses a day in each OR because there are not that many people that need them. But you will still be paying those surgeons and OR teams whether they are working or not.

When you do not have a service a patient needs, you must refer them out to your competitor, you cannot offer them your list or "close enough."

Also, when you insource, the doctor no longer falls under the rules of a contractor. Which means the hospital needs to cover the cost of her mistakes or provide the malpractice insurance because the doctor is now an employee of the hospital.

Do you think it will save money to pay all of the doctors expenses, benefits, and salary with regulated reimbursement system?

What are you going to offer to attract quality help? To Whom?

Doctors are not laborers, they make independant decisons, they are involved in all aspects of operations, they are not all equally capable, and most of them are smarter than the average guy down at the shop.

You cannot run a hospital without doctors. Doctors know that. They are most likely going to demand a percentage. Because there is a finite number of each specialist, it gives such doctors considerable bargaining power.

If I produce 5x more income than my coworkers do you think I will settle for the same salary?

If I do procedures my coworkers do not do you think I will accept the same salary?

If I have more patients because of their satisfaction do you think I will accept the same salary?

I assure you, I can take my show on the road and my patients (your customers) with me. I can even set up a private practice that caters only to those patient needs, which makes me far more efficent than your ED.

Now I like working for a fixed salary, not a percentage, for a variety of reasons. But the moment you treat me unfairly, I am gone. Because I do have options and they only grow with time.

At this very moment, around the globe, some specialists are in such shortage with such a demand, they tell hospitals what they want. If the hospital cannot pay, then it cannot have them.

How long do you think your ED will be open when you can only hire dregs?

How will you compete with ED hiring board certified EMs when you cannot afford them?

 

[EpiEMS]

Unfortunately medicine is not like any other business.

Broadly, it's more regulated than most, but, like any other business, it's got cost drivers and sources of revenue, labor and management, physical plant, human capital, etc. etc. There's nothing, fundamentally, different between a hospital producing health care and a farm producing agriculture. There's demand, there's supply, everything is there.

The fees you can charge are regulated. (In every civilized country in the world)

More or less. But in the US, they're regulated only because Medicare/Medicaid set rates, and private insurers usually negotiate. There's always a market for totally private care, as small as it may be. Fixed rates aren't something that makes health care not a business -- electric power rates are fixed, but I wouldn't say ConEd isn't a business (it's just a bad one).

Which means you need evidence (usually in the form of practice guidlines backed up by research) that what you are doing is worth paying for.

That makes it even easier to do -- evidence is provided by private research institutions, government research institutions, what have you. If I can have a QI physician aggregate data and identify problems, that's a boon for me as the administrator, owner, equity holder, or bond holder.

You cannot simply terminate the relationship very easily for delinquent payment.

That's true. But neither can lots of regulated industries. And there are subsidies and charities that do care for those who can't pay, just like we do for other industries -- food is a right and a business. So is education.

In the event of the emergency room, there is a law that states you have to treat everyone regardless of their ability to pay. (A severely underfunded mandate in the US)

Does your business have to mow the lawn for people who cannot pay simply because their lawn needs cut?

EMTALA is an unfunded mandate, absolutely. But it's a cost that the business has to take into account to do business. There can be some degree of cost shifting, as needed. Plus, not-for-profits do this of their own accord. I don't think that analogy is appropriate, given the ability of the business to cost shift: If I don't pay for having my lawn mowed, the landscaper doesn't tell my neighbor to pay more.

Then there is standard of care, which means you cannot withold certain treatments because they do not make money. Conversely, you cannot perform procedures or "upsell" procedures that do make better money.

Physician agency/provider agency is a serious issue that makes decision making tough. I need to read up on this, but I'm not aware that this is really any different from lots of other regulated industries. There are mechanisms by which deviations are punished, just as in any other industry, say, law or any skilled trade (think: defective car repair leading to morbidity or mortality as a form of malpractice)

Pt 1 of 2

 

[EpiEMS]

As well, your reimbursement for service is not static. You might not perform 3 bypasses a day in each OR because there are not that many people that need them. But you will still be paying those surgeons and OR teams whether they are working or not.

These are costs that get reimbursed and paid for. There is reimbursement, in the US, for standby costs -- not as much as there should be, now -- but it exists. Insurers provide it, government provides it. Heck, charity provides it. It's just another cost to account for.

When you do not have a service a patient needs, you must refer them out to your competitor, you cannot offer them your list or "close enough."

That assumes physicians compete with physicians -- an internist is not a perfect substitute for a cardiologist. It would be irrational not to refer, especially if there's some degree of a relationship between the two, say.

Also, when you insource, the doctor no longer falls under the rules of a contractor. Which means the hospital needs to cover the cost of her mistakes or provide the malpractice insurance because the doctor is now an employee of the hospital.

I can't speak to this, I have no legal background. But with scale, there are often cost savings.

Do you think it will save money to pay all of the doctors expenses, benefits, and salary with regulated reimbursement system?

That I don't know. It is done, though, isn't it?

What are you going to offer to attract quality help? To Whom?

Valid point -- I see this as the big issue. However, look at pharmacy -- pharmacists (the PharmD types) are now employees rather than owner/operators. This is a model that could easily be implemented. It reduces the upside, sure, but there is less risk as an employee (and less time commitment, which is one of the reasons that pharmacy is now one of the most egalitarian of professions).

Doctors are not laborers, they make independant decisons, they are involved in all aspects of operations, they are not all equally capable, and most of them are smarter than the average guy down at the shop.

Mechanics, lawyers, pharmacists, bankers, etc. all make independent decisions. They're not all equally capable, nobody ever said they were. Pay can be based on merit in a vertically integrated system. Not every widget has the same level of productivity, so, of course their pay will differ.

You cannot run a hospital without doctors. Doctors know that. They are most likely going to demand a percentage. Because there is a finite number of each specialist, it gives such doctors considerable bargaining power.

If I produce 5x more income than my coworkers do you think I will settle for the same salary?

If I do procedures my coworkers do not do you think I will accept the same salary?

If I have more patients because of their satisfaction do you think I will accept the same salary?

Wage is inextricably related to productivity, that's a fact. These are all components of that ability to produce healthcare.

I assure you, I can take my show on the road and my patients (your customers) with me. I can even set up a private practice that caters only to those patient needs, which makes me far more efficent than your ED.

That's true, but that's a niche market, and you're welcome to do that. I, for one, can see that as a valid alternative for those who would like to pay -- just as people do in many areas (like dermatologists in Manhattan not taking insurance, say).

Now I like working for a fixed salary, not a percentage, for a variety of reasons. But the moment you treat me unfairly, I am gone. Because I do have options and they only grow with time.

But this is no different than any other sort of professional-level employee at the top of his or her field. There's a market for superstars, and always will be.

At this very moment, around the globe, some specialists are in such shortage with such a demand, they tell hospitals what they want. If the hospital cannot pay, then it cannot have them.

Understood, but as I've said, there's a market for superstars. And wages rise for those fields that are understaffed, inducing entry in the long run.

How long do you think your ED will be open when you can only hire dregs?

How will you compete with ED hiring board certified EMs when you cannot afford them?

I'm not sure what you mean, exactly.

 

[Veneficus]

ok, that was a very well thought out applications of economics as it should relate to medical care.

I will agree that some hospital systems are insourcing doctors in various specialties. One in particular is because that specialty has a very difficult time making money.

I would like to point out though your original statement was about insourcing ED physicians. Which in order to support your point quickly mushroomed into entire medical centers.

While larger, particularly academic medical centers can do this, many smaller facilities cannot.

But it is similar to large corperations eating up smaller ones.

You are also risk the assumption that your doctors are referring in your hospital, or at least system. In my experience this is the case sometimes.

Most doctors I know refer difficult patients to the "superstars" as you say. Difficult patients are recurring patients. If you don't have superstars, in just about every discipline, when a patient goes, they will move their entire medical care under that roof. Particularly in cases like nephrology.

Generally, superstars also like to work together, which means you will have to hire at least a couple, and most likely a handful.

You will also have to deny such talent to your competition.

If you don't think so, I invite you to look at the areas where two or more major healthcare centers are competing. (Like Cleveland Clinic and University Hospital systems)

You also have to deny location to your competition. Otherewise, remote locations will feed the major center and draw revenue from you.

While this is true in any business, in healthcare, it gets expensive really fast. It also may require you to take a loss in some areas just to maintain a presence.

There is probably many more thingsyou wrote that deserve a response, but it is late and I am tired. So I have to apologize and may come back to it.

But I leave you with this thought.

If the business of healthcare actually worked, then the US healthcare system would not be on the verge of bust, costs would not outstrip resources, and healthcare benchmarks would not be in the 40s compared to all other nations while costing exponentially as much as everyone else.

Recent "advances" in attempting to manage this aren't really advances, they are very clever ways for each stakeholder to try and protect his share of the pie which ultimately is not sustainable.

Countries that pay doctors considerably less also educate those doctors for considerably less. Which means they do not "need" such exceptional salaries.

In order to succeed in US healthcare, it goes from small business to big business very quickly and there is only room for so many sharks in the pond.

 

[EpiEMS]

I can't disagree with that. As you say, the system is nearly busted -- both in terms of inputs and outputs!