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HEMS - taking patients for a ride

Discussion in 'HEMS and Air Medical Transport' started by NomadicMedic, Apr 16, 2017.

  1. NomadicMedic

    NomadicMedic formerly DEmedic

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    Sounds good in theory, but the entire system is different in the US.

    In the majority of places, the Helicopter service is an independent, private company with no connection to the local agencies. (There are some government agencies that staff HEMS, but they're few and far between)

    We don't have a clinically trained person at our dispatch centers that can make care guided transport decisions. They follow a simple decision tree. And as for best resources, in many cases, it's either a ground paramedic or a helicopter.

    Most helicopter services here don't staff with a doc. A flight nurse and Paramedic is the usual crew.

    Most locales don't have a physician or critical care team to send as a ground based unit.

    Another huge disparity between EMS in the US vs the European model.


     
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  2. VentMonkey

    VentMonkey Crackpot Premium Member

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    Right, but as this article, and many have eluded to:

    Is the HEMS industry even capable of remaining a viable commodity in spite of its less than consumer friendly costs?

    Clearly, Medicare reimbursement restructuring created this massive growth in competition between companies within the industry who are (literally) putting bases in hangars on the same airport property directly in sight of one another's airframes.

    Where's our breaking point? When do we stop the profit driven double downing, much like...any, and all for profits within the EMS industry?
     
  3. EpiEMS

    EpiEMS Forum Deputy Chief

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    @VentMonkey, so I think you're referencing the idea of service duplication. There's a ton of study in this area...especially for hospitals. The whole certificate of need concept was built to "mitigate" this risk, but there is a limited amount of evidence for their success (and ample evidence of harm) for CONs. Now, maybe EMS is different, but I don't think so.


    Sent from my iPhone using Tapatalk
     
  4. E tank

    E tank Forum Captain

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    This is a big conversation.

    IMO, HEMS should be treated like any expensive, subspecialty care. Not every hospital has a cath lab or interventional radiology lab. Insurance covers these, not in small part because, as expensive as they are, they supplant far more expensive alternatives (surgery) in plenty of cases. Further, HEMS programs in Maryland or Wisconsin are not the same as HEMS programs in Idaho or Wyoming. Comparisons to other countries' systems, as noted above, are apples to oranges.

    For starters, gov't tax breaks (not subsidies) to not for profit hospital based programs would help, I think. But with so many NFP programs offering "memberships" that are valid within "networks" affiliated services, patients living in those areas would do well to pony up the 60 bucks a year or so.

    There are too many helicopters and they're over utilized.
     
    NomadicMedic and VentMonkey like this.
  5. E tank

    E tank Forum Captain

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    I need to amend that statement. I really don't know that there are too many helicopters. I retract that statement. I'll stick to the idea that they are over utilized, though.
     
  6. E tank

    E tank Forum Captain

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    The problem with trying to qualify the utility of "certificate of need" laws is that the heterogenicity of health care delivery across the United states is vast. An entire state medical system with a catchment of less than a million and a half, give or take, does not need 7 heart surgeons, 3 neonatal ICU's and a cath lab at every inpatient hospital. But that same system may utilize as many helicopters as a metropolitan area of 9 million.

    Some of what drives this stuff is quality of life for folks working in these sub specialty areas. One cath lab suite could handle the work of three in some towns, but call would be hell and the elective schedule would go 10 hours a day every day. Getting subspecialists to come to a town like that isn't always that easy.

    Anyway, more fodder...
     
  7. VentMonkey

    VentMonkey Crackpot Premium Member

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    Why? I actually agree with this. There are too many, and they can often be over utilized. That said, I have seen a remarkable trend in better judgment overall with many of our county's paramedics.

    While not every flight nurse or paramedic will like this statement, it's true, and truths hurts. HEMS is still every bit the part EMS, and egos are just as plentiful...

    ...unfortunately.
     
  8. E tank

    E tank Forum Captain

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    It may be Vent, I just don't know. What's the threshold for too many? That's a hard number to come up with. The unit availability should never be 100% but what should it be for the best, most reasonable utilization of the resource for the most possible legitimate transports? Again, a lot comes down to where you are. Its tough.
     
    NomadicMedic likes this.
  9. VentMonkey

    VentMonkey Crackpot Premium Member

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    It does; add to this our every growing population as a first world country.

    My county alone is a good example. We're already half a million or so within the city limits, yet also have some extremely rural roads and coverage areas that can, and will take ground responders longer to get to a patient than it will us. This is a good thread topic.
     
    NomadicMedic likes this.
  10. Tigger

    Tigger Dodges Pucks Community Leader

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    At the very least I wish every HEMS transport was reviewed for efficacy. While we review all of our calls for clinical issues, operational ones like these are not often brought up, which I hope will change. Also, someone needs to have the authority to say "that was not an appropriate HEMS utilization." While I understand that no two patients and calls are alike, at a certain point we need to identify trends and put a stop to excessive use.

    We are also certainly struggling with how to deal with flying moderately injured patients out of the backcountry. Most of these patients do not need a helicopter but it is dangerous to extricate non-ambulatory patients out of some of our ATV areas. So many of these patients get flown, and probably stuck with unnecessary bill. While HEMS is of course more risky than ground transport, I'd say being strapped to a stokes on the back of a mule coming out on 8 miles of what are charitably called roads is also rather dangerous.
     
    EpiEMS likes this.
  11. Tigger

    Tigger Dodges Pucks Community Leader

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    At the very least I wish every HEMS transport was reviewed for efficacy. While we review all of our calls for clinical issues, operational ones like these are not often brought up, which I hope will change. Also, someone needs to have the authority to say "that was not an appropriate HEMS utilization." While I understand that no two patients and calls are alike, at a certain point we need to identify trends and put a stop to excessive use.

    We are also certainly struggling with how to deal with flying moderately injured patients out of the backcountry. Most of these patients do not need a helicopter but it is dangerous to extricate non-ambulatory patients out of some of our ATV areas. So many of these patients get flown, and probably stuck with unnecessary bill. While HEMS is of course more risky than ground transport, I'd say being strapped to a stokes on the back of a mule coming out on 8 miles of what are charitably called roads is also rather dangerous.
    What at @SpecialK describes for activation would be excellent. Though the helicopters are provided in a different manner in this country, there is no reason why crews could not consult their own (hopefully educated) clinical supervisor to get approval for HEMS use.
     
  12. SpecialK

    SpecialK Forum Captain

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    In the UK and New Zealand the ambulance service and HEMS are separate entities. In some, but not all, cases some clinical crew come from the ambulance service but some employ their own staff.

    Pretty much everywhere it's either a ground or helicopter response. The trick is deciding which one and if a helicopter is going to be sent, which helicopter if more than one is available.

    If you do not have somebody clinically trained in the control room (not sure how exactly that's possible but righto ...) then you could always you know, get some? At some point in history it was a "new" idea for the people doing it as well? Not sure how that can't be solved?

    Shouldn't make a difference really.

    Many do not, but again, this shouldn't be a problem, it's not a requirement.

    Doesn't sound like there's anything preventing this from being tried?
     
  13. Chase

    Chase Flight Nurse

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    Remi has been in this business much longer than I so
    There are some companies who will take anything and everything but that is not always the case. We get tons of training on flight utilization and medical necessity then have all our charts review by documention specialist. If you are constantly taking flights that get denied by insurance then you will hear about it. It doesn't do most companies any good to take flights that don't meet insurance criteria and will never collect on the private billing.

    Also it does not take a helicopter to ruin someone's finances from medical cost. When I was in college I ended up going to the ER as a Level One then kept for a few hours and sent home. Bill was $16k+ after insurance. The insurance company tried to deny a bunch of stuff since they didn't think I met trauma criteria (which I didn't) so I personally got billed for the $4500 "Level One Activation".

    So I do not blame HEMS companies completely, they are doing what everyone else in medicine does. They need to collect big when they can because the majority don't collect.
     
  14. EpiEMS

    EpiEMS Forum Deputy Chief

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    This is a really good point - and I think this should be a best-practice at the agency level. Perhaps something to bring up to the medical director, even, given that HEMS transport is a "treatment" in and of itself?
     
  15. DrParasite

    DrParasite The fire extinguisher is not just for show

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    Hi, former air medical telecommunicator here..... We originally dispatched for 4 helicopters (up from 2 back in the day), and when I left, I think we had something like 10, just covering NJ. We never turned down a request (except when it was unsafe to fly, IE, weather), and it was always whomever was closest (with a little bit of politics thrown in), but helicopter transports are big money. That was why lawsuits were initially filed to open up the medevac system to private entities (and boy did it open up)

    http://www.nj.com/south/index.ssf/2016/07/southstars_grounding_means_no_more_free_air_medica_1.html
    http://www.nj.com/burlington/index.ssf/2016/10/legislators_call_for_south_jersey.html

    back to the topic at hand....

    So all you guys, who rarely have a nice thing to say about any dispatchers, are going to let them decide whether you, the person in the field, needs a helicopter?

    or even better, your going to trust a "experienced air ambulance paramedic" who now works full time in control, and hasn't seen a real patient in 10 years, and allow them to overrule your clinical judgement?

    In the litigious US, assuming the ground paramedic calls for the helicopter (and rightfully so), but the dispatcher doesn't feel the patient warrants it (because the paramedic didn't paint a good enough picture), and the patient dies as a result...... who should pay the punitive damages?

    Honestly, it makes more sense to have the medevac approved by an field supervisor, medical director, or someone in the EMS agency's administration, if you can't trust your paramedics to call for the HEMS appropriately. Or if HEMS are being called inappropriately, than the agency should be responsible for QA, and for providing appropriate guidelines for when a helicopter should and should not be used.

    If you joe public can't trust you to call for additional resources appropriately, why should they trust you to treat the patient?
     
  16. EpiEMS

    EpiEMS Forum Deputy Chief

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    Doesn't this speak to why state-level CON laws aren't necessarily the best way to limit duplication of services (if, indeed, they do)?

    Fair point - but I don't think this is the whole story. Price discrimination doesn't necessarily mean that they are shifting costs. And costs, obviously, are not immutable, so perhaps there is a more fundamental issue?
     
  17. SpecialK

    SpecialK Forum Captain

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    Sorry? When did I ever say ambulance personnel said anything bad about the control room staff?

    And where did you get the idea the air desk staff don't see patients? Every single one of them still works on the helicopter.

    It's not about overruling anybody; it's about ensuring the most appropriate resources are sent to patients who need them. Helicopters are overrated, and overused, and historically there has been some quite poor decision making by ambulance personnel about what needs a helicopter and what doesn't and historically the control room staff have had limited assistance in deciding which helicopter to send.

    Helicopters are overrated, overused, very expensive (i.e. scant resource) and often cover a very large area so need to be used wisely. Take for example a patient who is one hour by road from the hospital; when you add up time to take off, fly, land, load, take off again, fly back and unload it's just as quick to take them by road. There is also very limited room to treat a patient in a helicopter, particularly this is worse at night as the lights are dimmed to maintain night vision for the pilots.

    Again, you are looking at this the wrong way. It's not about denying anybody. and certainly wouldn't be the role of the control room allocating staff to do so because they are not clinically trained. This is why in many places the job of air ambulance tasking is undertaken by experienced air ambulance clinical personnel in a central hub to determine whether or not to send a helicopter and if so, which one to send.

    If you have, as you say, ten helicopters, which of the ten do you send? What if the closest one is not available? What about crewing configuration? Are they all the same in terms of, for example night or weather flying capabilities, which hospital does the patient need to go to and does this change what is done? is what the patient needs available by a road based response? do we send the helicopter before, or at the same time as, a ground ambulance?

    Just like how if you call an ambulance the closest ambulance is not automatically sent to you no questions asked, the same needs to be true of helicopters, just because a crew requests a helicopter, you don't blindly send them a bloody helicopter ....some of the jobs I've seen helicopters turned out for have ended up being utter rubbish and it didn't actually make one iota of difference to the patient except for a "little bit quicker" ride to the hospital. This is not a good way to use a resource regardless of what it is.

    The new method (and that used in many places internationally - see previous) is much better it seems as it allows for much more informed decisions to be made about what the patient needs are and how best to meet them rather than just sending them helicopters willy nilly as was previously done in the past with some very questionable results.

    In reality it's nothing more than good triage, like what Control do all day every day to people who call in; deciding who should get an ambulance (which is most people - I think at last count the Clinical Hub screened out about 5-10% of calls) and of those who need one, who gets one first and from where ... exactly the same principle just applied to helicopters.
     
    Last edited: Apr 18, 2017
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  18. DrParasite

    DrParasite The fire extinguisher is not just for show

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    That was more of the general "you", for those people who are always looking to complain about those in dispatch, not you personally
    really? so people rotate from the helicopter to control, on a regular basis? I'm not familiar with any US based system that does that, a people are usually assigned to either control or the field. cross training might occur, but I haven't seen one that offers a regular rotations.

    BTW, I think it's a great idea, and wish more places in the US operated like that.
    I will agree that they are over used, and over rated, but I think a more efficient way to correct the poor decision making by ambulance personnel would be to correct the issue at the start (IE, what are they calling for, why are they calling, ok, you guys are calling for the wrong reasons, here is why you should call for the helicopter), instead of having having experienced air ambulance personnel decide whether or not to send a helicopter. But I think we might need to agree to disagree on this one
    whether it's the ambulance control room, or the helicopter control room, it's still a person who is not on location making a decision to send the helicopter, based on their interpretation of the situation. But I might be looking at it a different way, so I will agree to disagree
    to answer your question, if I have 10 helicopters, I send the closest one that is available. If they are not available (maintenance, on another assignment, no staffing, etc), then they don't count, and I move to the next closest available one. if three helicopters decline due to weather, then the requesting agency is advised the request is declined due to weather / safety reasons.
    All should have the same crew configurations (1-2 pilots, 1 flight medic, and 1 flight medic/Nurse). so no matter which helicopter arrives, they should have the same basic training. ditto the weather and night capabilities, I would imagine all the training for the pilots is the same. if the patient is a trauma, they are flown to the closest appropriate trauma center (typically as the crow flies). if it's another specialty center (stroke, MI, etc), same thing, closest one, often determined by dispatch. If they don't, that is acceptable, however it requires justification in writing after the fact to their coordinators as to why they made that decision (in case there is any question aftwards)

    Helicopters can be requested by any public safety official on the scene (decision predates me). so if the cop pulls up and says it's a bad wreck, they can request a helicopter before EMS arrives. I'm not saying I agree with it, but that was how the system was set up. typically only EMS or ALS will cancel the helicopter.
    wait, you don't send the closest ambulance? why not?

    and for the record, we have ALL been on calls where people called an ambulance and it turned out to be utter rubbish.

    But I go back to my original point.... instead of denying the helicopter, wouldn't it be better to prevent these inappropriate requests from being made in the first place?
    Here are the guidelines from the ACEP:
    https://www.acep.org/uploadedFiles/..._Medical_Services/GuidelinesForAirMedDisp.pdf
    and from the US government:
    https://www.ems.gov/ficems/june2012/Draft Manuscript for HEMS Evidence-based Guideline.pdf
    and from the NJ Department of health:
    http://www.nj.gov/health/ems/special-services/fly-or-drive-criteria/
    and from a commercial service from NY:
    https://www.mercyflight.org/content/pages/utlization

    Does the international community has any objectively written guidelines, that are better than what other agencies have been using? or are they left completely up to the helicopter dispatcher's subjective discretion?
    I used to have dreams about being able to tell people they didn't need an ambulance when they called 911 for BS...... I can't think of a single system in the US that allows this (and if there is one, I'll apply tomorrow!)
     
  19. Tigger

    Tigger Dodges Pucks Community Leader

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    I would not want to call the flight company to see if it's appropriate, I'd rather be calling my clinical supervisor or my medical control. If they think it's inappropriate and I can't make a good case, then I would be overruled and that would be it.

    I doubt there would be any punitive damages in the above scenario as there is no way to possibly prove that the helicopter could have made any difference nor is there any expectation that a helicopter must be made available to the patients. In many states there isn't even a legal expectation to send an ambulance.
     
  20. Remi

    Remi Forum Deputy Chief Premium Member

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    So you are saying it's OK for HEMS programs taking people to court over bills for a service that the patient didn't need and probably didn't consent to, just because the HEMS programs "need to collect big when they can"?

    Also, it isn't about taking flights that are denied by insurance. Many insurers do pay a portion of the HEMS bill, but that doesn't help the family much who then gets billed for the difference, which in some cases is tens of thousands of dollars. If the flight was truly medically necessary that's one thing, but they rarely are. It also doesn't necessarily make it all OK if the insurer covered the whole bill. Because we are still talking about insurers being billed for an unnecessary service, which drives up costs for everyone.

    An analogy would be if everyone who presented to the hospital with any complaint of chest pain or discomfort was immediately whisked to the cath lab for angiography. And we kept doing it because "catheterization is the definitive treatment for AMI" and "time is muscle" and we simply ignored the fact that few patients benefitted and most weren't even having an MI. In fact in spite of knowing that, we built more and more cath labs, right next door to each other in some cases. And we had no qualms sending large bills out to people for procedures that we knew they didn't even need. A hospital could never get away with that, of course - it'd be called fraud, and people would end up in prison. HEMS can do almost exactly the same thing though, and it is called a public service.

    A HEMS transport is a medical procedure, not unlike a heart cath or a surgery. It carries costs and risks and potential benefits. Like any procedure, it should only be done when the expected benefits outweigh the risks and the costs, and preferably when the patient understands that analysis and consents. I think if we analyzed HEMS transports objectively the same way we analyze other procedures, we would be pretty blown away with how loosely we apply that cost/risk:benefit analysis.


    When I interviewed for my last HEMS job, I asked them during the interview "How do you handle patients who have a hard time paying their bill". They told me that they always bill insurance, and whatever cost is left over they will bill the patient for. But if the patient calls and tells them they can't pay the bill, they simply write it off. They don't pursue it in court, and they don't report it to collections. The programs I worked at before each had the same policy. Not to sound too holier-than-thou, but I honestly would not have taken the job if they told me that they pursue payment from people who can't pay.

    Why was that so important to me? Because I know that statistically speaking, not only do a very low percentage of people flown by HEMS even benefit clinically from it, but in many cases, you aren't even saving any time with HEMS. Clearly, some level of over-triage is desirable when you are talking about critical patients. But we are talking a massive level of over-triage here, like NNT's likely in the dozens, if not hundreds.

    So after years of flying patients who clearly did not need to be flown and reading about AEL and Air Methods dragging people to court and putting them into bankruptcy for transports that the patient never provided informed consent for and in many cases was very obviously not even necessary, I just decided I didn't want any part of that.

    I can't accept the "well the rest of healthcare does it, so......" argument mostly because the rest of healthcare doesn't do it to nearly the extent that HEMS does. There are many HEMS programs that still preach "the golden hour" and "mechanism of injury" or "we have RSI and you don't" as justifications for using them, and even though they all give lip service to utilization, the reality is that they could not care less how little their patients benefit, as long as they get paid. I also don't see many hospital patients getting sued in court over unpaid ICU bills. The unscrupulousness of some of these HEMS agencies is just not duplicated anywhere elsewhere in acute care, at least not that I've seen.

    The reality is that many - possibly a majority? - of HEMS bases would simply close down if they were forced to find a way to only transport patients who really have the potential to benefit, or if they stopped billing patients who never consented to their services. Transporting patients who don't need to be transported and then billing them for it is literally a big part of their business model. Because we all know that there simply aren't nearly enough critical or time-sensitive patients to provide the call volume that these bases need to survive. Yet they are still there.

    I know there are good HEMS programs out there in regions with very long transport times to tertiary care that have high clinical and safety standards and really do strive for appropriate utilization. That's what we all like to think of when we think of HEMS. But for every program like that, there's at least one bottom feeder HEMS base that uses barely-adequate airframes and staffs with minimally qualified people and routinely gets people to the hospital in the same time the ambulance could have, could never justify what they do on clinical outcomes, and routinely sends out huge bills to people who they flew to the trauma center who probably could have gone to the local ED by POV and been just fine. So as fond as I am of HEMS, I have to agree strongly with this article.
     

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