How to fix EMS

[thegreypilgrim]

Going to school for two more years won't make me a better paramedic; it's for career development, Rather, it would be if there was a career ladder to speak of. Those opportunities are few and far between in single role EMS.

I think the paramedic curriculum could accommodate significant expansion if it were spread out over an additional 2 academic years. Beyond that a broader foundational education could turn the role of Paramedic into a much more versatile one.

2 - In the role of prehospital EMS, how much more can realistically be done? Our role is to assess, treat if necessary, and transport to a hospital. It would be nice if we could transport the pt to a more appropriate destination, or perform more treat and release functions, but we're not performing field surgery, field CT's and X-Rays, nor are we capable of performing blood work or diagnosing and writing a treatment plan based on any of the above results.

As POC diagnostic technology continues to progress this will become less of a concern. And diagnostic imaging studies are over-rated. In other parts of the world (namely Europe) they are used much less frequently than they are here and European healthcare systems consistently outperform the US in terms of medical outcomes and cost-efficiency. A lot can be done with a solid clinical history and physical exam.

If you want to talk about expanded scope and functions outside of 911, then we're getting away from EMS, and transitioning into roles that PA's, BSN's, and NP's are better suited for.

I think it's the other way around, actually. Roles that are better suited for paramedics are being filled by BSNs and mid-level providers simply because there is a lack of properly educated paramedics. Why should nurses be doing prehospital QA/QI? or disaster/CBRNE planning? Why are there nurses on school campuses or serving as industrial HSE Officers?

3 - OLMD consult can address that. Many, if not most systems here will be too litigation phobic to enable provider initiated refusals and anthing past minor treat and release. We have urgent care facilities that can do treat and release.

There's actually little to no evidence that OLMD improves paramedic decision making or clinical outcomes of patients. I did my senior research project on OLMD and, of the dearth of literature addressing the subject (most of which dates from the 80s and 90s) OLMD is associated with delays, miscommunication, and redundant reiteration of orders already covered by protocol (very few "novel" OLMD orders actually occur). Furthermore, it's enormously expensive for hospitals to maintain the facilities necessary for OLMD operations. The far better option would be to send a provider to the scene that's actually capable of making an appropriate decision in the first place.

Without Medical Direction, I would say that we need a lot more than four years of medical education to pracitce independently. I don't know of any medical professions in the U.S. that can practice with true autonomy that have only four years of medical education.

There will always be Medical Direction, but what I propose is Medical Directors serve primarily as consultants to oversea the ongoing education of the agency's providers and to manage the QA/QI processes. In other countries, paramedics are independently licensed, so why can't American medics do the same? Furthermore, other countries don't use "protocols" to govern paramedics actions in the field. They simply have a defined scope of practice, and then the agency adopts evidence-based guidelines to serve as just that - guides for practicing within your scope.

 

[thegreypilgrim]

There are similar situations in other professions, an example would be Security in relation to Law Enforcement.

An example of what? I'm not understanding what you're trying to say here.

In my opinion I do not agree with your decision to push more regulation on the private sector.
(change all for-profit to non-profit) If I want to pay a private company to transport me to a medical facility thats my decision. Who are you to take that away from me?

For the same reason you aren't allowed to call a private security firm if someone rapes you or you're not allowed to call a private fire suppression company if your house is on fire. Such services are part of the public infrastructure, and undermining them compromises public safety/health. Think about the consequences of market liberalization on services like those. Those who can afford them will procure their services well enough, leaving the most vulnerable and least well-off of society dependent on a now fiscally gutted public program. It's a gross affront to social justice to have such disparities in programs that address basic social necessities.

Now, if you're already in a hospital, and you've completed your course there and are being discharged home but still aren't well enough to ambulate without assistance I have no problem with you wanting a private company that will cater to your needs to transport you home.

Its called consumer based capitalism, which drives supply and demand.

That's all well and good, but unfortunately market principles don't apply to things like healthcare. Demand for healthcare isn't a function of consumerism. I don't choose to undergo PCI in the same sense that I choose to buy a new TV. There just isn't an equivalency there. In fact, the commercialization of healthcare is the primary reason why the American healthcare system is completely unsustainable.

Besides wont obama care fix all of this in 2014 when it goes into effect? (sarcasm)

(1) It's not "Obamacare". It's the Patient Protection and Affordable Care Act (PPACA). Let's discuss this like rational adults and avoid the Fox News pejoratives, please.

(2) Many provisions of PPACA have already been implemented. For instance, if you're under 26 you can now thank PPACA that you can remain on your parents' health plan.

(3) No, it won't solve America's health policy problems because despite intense misinformation campaigns by interest groups and the media, PPACA is not a single-payer insurance program (i.e. the dreaded "socialized medicine" people talk about and what every other industrialized nation in the world has). It still uses the same privatized system of insurance networks which are the very things causing our problems. They are defective products (much the same way private ambulance companies are), which needs to be replaced with a publicly funded program.

 

[looker]

thegreypilgrim,

I hope I do not get slammed by mods for discussing PPACA so here it goes.

Yes you can stay under your parents plan until you're 26 and all of other nice stuff, so lets get in to the ugly stuff.

Starting in 2014 precondition goes away. You know that one thing that made people really buy insurance in case you got sick so you would have health coverage. If you could afford it, you would buy it. With precondition going away, people will wait till they are sick and only then will they buy insurance. Basically it will be buying insurance in the back of ambulance. I know what some will say, that is why there is penalty for not buying it. Yes but penalty is a) A joke b) IRS can't force you to pay it, they can only withhold tax return if they owe you money. The only thing PPACA will do is bankrupt health insurance company in about 5-10 years being only sick will buy insurance.

 

[JPINFV]

Starting in 2014 precondition goes away. You know that one thing that made people really buy insurance in case you got sick so you would have health coverage. If you could afford it, you would buy it. With precondition going away, people will wait till they are sick and only then will they buy insurance. Basically it will be buying insurance in the back of ambulance. I know what some will say, that is why there is penalty for not buying it. Yes but penalty is a) A joke b) IRS can't force you to pay it, they can only withhold tax return if they owe you money. The only thing PPACA will do is bankrupt health insurance company in about 5-10 years being only sick will buy insurance.

Would being an insurance salesmen and an EMT be worthy of a raise, or a commission?

 

[thegreypilgrim]

Starting in 2014 precondition goes away. You know that one thing that made people really buy insurance in case you got sick so you would have health coverage. If you could afford it, you would buy it. With precondition going away, people will wait till they are sick and only then will they buy insurance. Basically it will be buying insurance in the back of ambulance. I know what some will say, that is why there is penalty for not buying it. Yes but penalty is a) A joke b) IRS can't force you to pay it, they can only withhold tax return if they owe you money.

Well color me shocked, but I actually agree with you Looker. Albeit, for entirely different reasons. Guaranteed issue is not going to drive up adverse selection to unsustainable levels. Sure, a large segment of the population are estimated to not comply with the new law, but so what? That's the least of our problems. The real problem is a mandate completely throws off the constraints placed on enrollment into insurance programs that used to be imposed by risk aversion. People used to weigh the costs of premiums against their expected risk, which limited how much they were willing to pay. Now that constraint is gone, and insurance companies can charge whatever they want.

The only thing PPACA will do is bankrupt health insurance company in about 5-10 years being only sick will buy insurance.

Lolz, in this day and age of "too big to fail" I am slow to believe this. What's going happen is the government will subsidize low-income groups which will shift costs to taxpayers as opposed to the market players, effectively negating any cost savings from enrolling more people into the insurance system (which wasn't even the primary problem to begin with).

What we need is a single-payer system that eliminates the private market except for supplemental and/or elective procedures (and is completely self-sustaining and non-eligible for federal reimbursement).

 

[looker]

Well color me shocked, but I actually agree with you Looker. Albeit, for entirely different reasons. Guaranteed issue is not going to drive up adverse selection to unsustainable levels. Sure, a large segment of the population are estimated to not comply with the new law, but so what? That's the least of our problems. The real problem is a mandate completely throws off the constraints placed on enrollment into insurance programs that used to be imposed by risk aversion. People used to weigh the costs of premiums against their expected risk, which limited how much they were willing to pay. Now that constraint is gone, and insurance companies can charge whatever they want.
Lolz, in this day and age of "too big to fail" I am slow to believe this. What's going happen is the government will subsidize low-income groups which will shift costs to taxpayers as opposed to the market players, effectively negating any cost savings from enrolling more people into the insurance system (which wasn't even the primary problem to begin with).

What we need is a single-payer system that eliminates the private market except for supplemental and/or elective procedures (and is completely self-sustaining and non-eligible for federal reimbursement).

I am going to reply to both of your statement. Lets take the first one regarding control of how much insurance charge.

Insurance company will be required to charge an age group same price. So 55 year old smoker, cancer survivor, cva, chf will pay same thing as 55 year old that is non smoker, never had cancer, in great shape etc. Not only that but that 55 year old that is very healthy will not buy insurance because well he do not need it. He will buy it only if and when he gets sick. On the other hand the sick person will buy insurance and insurance company will be required to pay out thousands, maybe even millions if the person gets hospitalized in ICU for a while.

What will basically happen at the end is we will have single payer system because health insurance company's will go out of business. This business model is not sustainable.

 

[looker]

Would being an insurance salesmen and an EMT be worthy of a raise, or a commission?

Sure for every health insurance you sell you get x% cut.

 

[RocketMedic]

I am going to reply to both of your statement. Lets take the first one regarding control of how much insurance charge.

Insurance company will be required to charge an age group same price. So 55 year old smoker, cancer survivor, cva, chf will pay same thing as 55 year old that is non smoker, never had cancer, in great shape etc. Not only that but that 55 year old that is very healthy will not buy insurance because well he do not need it. He will buy it only if and when he gets sick. On the other hand the sick person will buy insurance and insurance company will be required to pay out thousands, maybe even millions if the person gets hospitalized in ICU for a while.

What will basically happen at the end is we will have single payer system because health insurance company's will go out of business. This business model is not sustainable.

We've already been seeing this for years. My employer exists because of Medicare's funding. If you go and take any incentive to purchase insurance beforehand away (which will happen in 2014), people will stop buying insurance policies (after all, you can get one later, once you start feeling bad), and an even larger portion of funding will come from Medicare and government subsidies.

Looker, your company primarily is funded by Medicare reimbursements, yes?
PS- are you hiring?

 

[looker]

Looker, your company primarily is funded by Medicare reimbursements, yes?
PS- are you hiring?

Yes, no.

 

[RocketMedic]

That's OK. I have no desire to work in SoCal or strictly IFT