HEMS - taking patients for a ride

[VFlutter]

I agree with what you are saying and I do not think companies should be taking these patients to court when it is questionable. But should insurance and medicaid be paying more instead of just turfing it to the patient? You have many more years in the industry then I and maybe I am just naive but i truly can not think of a patient whom I have flown that wasn't necessary. Most of that is because the local ground services lack CCT and RSI.

 

[StCEMT]

Most of that is because the local ground services lack CCT and RSI.

Is this on the IL side?

 

[EpiEMS]

But should insurance and medicaid be paying more instead of just turfing it to the patient?

I'd find it hard to imagine that they'd be willing to...

And it'd be tough to mandate them to if the service isn't warranted. Heck, I'd rather see EMS agencies that request HEMS unnecessarily pay for it...

 

[VFlutter]

Is this on the IL side?

Yes. Saint Louis and most of Missouri is much different than Illinois.

 

[StCEMT]

Yes. Saint Louis and most of Missouri is much different than Illinois.

Oh ok, gotcha. For some reason I thought I recalled you saying you were based out of the STL Missouri or St. Charles areas.

 

[VFlutter]

Oh ok, gotcha. For some reason I thought I recalled you saying you were based out of the STL Missouri or St. Charles areas.

I was at first but now just across the river

 

[Carlos Danger]

But should insurance and medicaid be paying more instead of just turfing it to the patient?

Even if insurance paid 100% in every case and no patient ever saw a bill for a HEMS transports, you would still have the problem of insurers having to shell out for an expensive procedure that is usually not done out of necessity. The fact that the consumer usually doesn't see the cost of healthcare and expects to pay little if anything out of pocket is part of the reason for the healthcare mess that we have. So I don't think hiding the cost by shifting it to insurers is the right approach.

maybe I am just naive but i truly can not think of a patient whom I have flown that wasn't necessary. Most of that is because the local ground services lack CCT and RSI

I don't mean to be negative, Chase. I know you are excited about your new career, and I am happy for you. I loved HEMS and still miss it. Not trying to be a downer here, just pointing out an important issue that often gets ignored. I wouldn't use the word naive; I'd say you are just learning and are appropriately focusing on the safety and clinical aspects of you new role.

How do you know that all the flights you've done were necessary? Do you mean necessary as in, the patient almost certainly wouldn't have survived if your helicopter or another one hadn't been available?

Take a look at the research on HEMS effectiveness. Again, not trying to be a downer, but I'd say very generally speaking, that if a program isn't routinely saving at least 30 minutes over ground transport times and giving blood for hemorrhagic shock or doing some other intervention that simply isn't feasible for ground EMS to perform, then they probably aren't doing anything that ground EMS can't do for less money.

 

[SandpitMedic]

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?

This post hits the nail squarely on the head.

 

[SandpitMedic]

After three pages of posts, I've only seen one person come close to the root of the issue.

As Remi stated, all these companies care about is their bottom line. Period. End of story.

Some are better at safety and QA/QI and better airframes than the competition, but at the end of the day it's about $.

That's it, so as long it is a for profit business, you will have entities scrounging to get as much as they possibly can.

 

[SandpitMedic]

Regarding calls for service....

I have no option/authority of not transporting once the request is made (save for declining for safety).
If I show up to a patient and determine they don't warrant a flight, I can't turf them, or I GET FIRED if I did. That's declining revenue, and big brother does not like that.

Additionally, I don't have a crystal ball, and you can be the best provider ever but you still can't say anything for certain in the field. Hypothetically, even if I could decline the service...If I deem them turfable and they have a bad outcome guess who is getting sued and possibly facing charges for neglect, the company with deep pockets and little old me also. It doesn't matter if not taking the helicopter ride actually caused the poor outcome. It only matters what the lawyers will argue and can convince a jury of. "Poor Mary Jane, mother of 4, would be alive today if that Paramedic had just transported her by air."
No company is going to take that liability. That's the same reason no ground ambulance can refuse transport. Once you make patient contact you're stuck unless you have a strong documented reason or the patient initiates the refusal.

 

[E tank]

After three pages of posts, I've only seen one person come close to the root of the issue.

As Remi stated, all these companies care about is their bottom line. Period. End of story.

Some are better at safety and QA/QI and better airframes than the competition, but at the end of the day it's about $.

That's it, so as long it is a for profit business, you will have entities scrounging to get as much as they possibly can.

Perhaps...but being a for profit business and providing a needed service ethically are not mutually exclusive. Don't throw the baby out with the bathwater.

Sure there are exceptions and not-for-profit is no guarantee of safety or quality.

 

[VFlutter]

I don't mean to be negative, Chase. I know you are excited about your new career, and I am happy for you. I loved HEMS and still miss it. Not trying to be a downer here, just pointing out an important issue that often gets ignored. I wouldn't use the word naive; I'd say you are just learning and are appropriately focusing on the safety and clinical aspects of you new role.

How do you know that all the flights you've done were necessary? Do you mean necessary as in, the patient almost certainly wouldn't have survived if your helicopter or another one hadn't been available?

Take a look at the research on HEMS effectiveness. Again, not trying to be a downer, but I'd say very generally speaking, that if a program isn't routinely saving at least 30 minutes over ground transport times and giving blood for hemorrhagic shock or doing some other intervention that simply isn't feasible for ground EMS to perform, then they probably aren't doing anything that ground EMS can't do for less money.

I agree with everything you are saying. However it is tough on knowing where to draw the line on the financial side of things. Do I think HEMS bills should be bankrupting people whom can not pay the bill or pay for bills which are truly not necessary? Absolutely not. But I do think HEMS provides a valuable ,albeit expensive, service. I think it would be awesome if HEMS was no-profit like London HEMS or Maryland.

I agree that a lot what we offer can be done on the ground however that is not the case in most places. I think the level of care we provide is beneficial to a lot, not all, of patients.

I guess to be fair I should say that I feel that none of them were blatantly unnecessary like I have seen with other companies. I.e. Stroke patients outside of treatment windows, CHF on nitro and 2L NC, etc. On scene calls I feel like most of the patients would have died or been worse off without. For CCT IFT I feel that most are sufficiently critical enough (Intubated, drips, etc) that our level of care was beneficial. I have very few flights without interventions, vent adjustments, etc. Could some of those ICU patients go by ground with a true CCT truck? Absolutely. But not all areas have adequate ground CCT. We also transport a lot of cardiac critical care (VAD, ECMO, IABP).

So again I do agree that a lot of what we do can be done on the ground for cheaper, and I do wish we had the option of ground transport, but not all ground system are up to that.

 

[VentMonkey]

@Chase you're going to find yourself self "Chasing your tail". Yes, pun intended.

We had this exact same discussion on the board my first week of Creighton's CCP class. The end result was there's no quick, or clear cut answer.

Will the bubble ever burst? Inevitably, perhaps. For now, there are a dozen reasons to argue both sides of the air vs. ground debate, their viability, justifications, and sustainability.