How to fix EMS

[JPINFV]

1 - An RN and an RRT treat patients without a 4 year degree. The progression to BSN doesn't really include any further medical education. I suspect that the same holds true for respiratory therapy. In EMS, it's the same thing. 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.

In part because, at least in California, nurses have assumed roles that should be ran by paramedics. Fox had a TV series called "The Academy," and did their third season with Orange County Fire Authority. Why was an RN and not a paramedic the one who was critiquing the medical aid scenario near the end of the academy? (link to episode) Especially when were talking about EMTs handling a diabetic case?

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.

Is the only role for EMS forever simply assess, treat, transport? Why would it not be possible to treat/release or initiate alternative pathways? While most agencies aren't doing blood work, as technologies like iStat mature, would that be always true? Additionally, is there a difference between the needs of an agency with a 30 minute average transport and a 5 minute average transport? Should EMS split into a rural medic and urban medic designation if the needs of the different environments don't mesh enough?

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.

Aren't EMS already functioning in some of those roles simply because of the needs of the agency, regardless of if the training, education, and agency support are available?

To go to a fire department analogy, aren't civil engineers and building inspectors more apt at building inspection than fire fighters? By transitioning into a prevention mode, aren't fire departments getting away from fire suppression? More importantly, isn't that a good thing?

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.

Too many systems employ technicians and not professionals. Too many providers in those systems have no problem acting like technicians. Too many providers who act like technicians demand to be treated like professionals. Why should other health care professionals treat someone who acts like a technician treat the technician like a professional?

In EMS, I suppose that an Attending Physician in Emergency Medicine would be the top level of the profession. We're at the bottom. What liberties and level of autonomy are you looking for, exactly? 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's a difference between acting without a safety net and requiring providers to throw themselves into the safety net. There a huge difference when it comes to requiring providers to throw themselves into a safety net in a perceived chance to shed off liability. Being a professional requires taking on an appropriate level of liability.

CCT and specialty transport is done by nurses in many places. Good luck taking that over with our extent of disorganization.

So EMS providers are, once again, their own worse enemy?

 

[JPINFV]

I've seen several post implying specific field diagnosis is impossible because we lack diagnostic imaging. Do we suck that bad at H&PE? Can we not assess and if the findings are ambiguous transport for further diagnostics?

I think the bigger issue is the concept that a diagnosis is final. It's not.

 

[medicswag]

EMS should partner with their organization and seek to benefit from their strength and influence. What's the alternative, the IAFF?

I agree with this. why do paramedics and nurses have to serve in separate and distinct roles? To what extend does the paramedic and the nursing knowledge/skill base overlap? How much reform would be neccessary to overcome the downfalls of each profession? Could it be that healthcare could benefit from a "hybrid" provider?

Lurking on this forum (among others), I have seen many Paramedics wanting to be nurses, many nurses wanting to be paramedics. I believe there are programs that allow clinicians to "bridge" from one discipline to the other.

I feel EMS may have much to gain if not being absolved into nursing, atleast forging a much stronger association, mutually beneficial relationship.

 

[medicswag]

repost

 

[46Young]

How to fix EMS? It's apparent to me that many who first get into EMS, and even many medics, mainly have an interest in prehospital 911 EMS. There aren't too many that have their main interest in interfacility txp, let alone community outreach, home visits and wellness checks, and other expansions of scope in that direction.

I say, have two seperate education tracks. The first could be "EMS Speciaist," and the other could be "Paramedic." The former could be educated and trained for 911 prehospital EMS only. The latter could encompass all manners of IFT, as well as the expanded scopes many here are advocating. Really, I don't feel I need a four year degree to do what I'm doing in the field. It's really not that challenging, 911 EMS. IFT EMS would be challenging if we were collectively doing more than babysitting nurses, RT's, and Fellows for most of the "real" calls.

Alternatively, make 911 EMS an Assosciate's, make it a Bachelors for IFT and flight, and a Master's for anything above and beyond that. As far as independent thinking, I feel that we need a lot more than four years of medical education to have any real autonomy, write our own guidelines, divorce ourselves of the need for a medical director, and the risk or liability that comes with that responsibility. A Masters and above are overkill to function as a 911 medic, no?

With either scenario, I feel that 911 EMS should be 100% municipal. Many are saying that 911 EMS results in a negative cash flow, so going municipal makes sense. If it's a positive cash flow situation, then the local gov't makes out.

The current trend seems to have FD's assuming EMS txp resonsibilities. Since the fire service the mandate of being a catch-all for whatever the locality cannot handle, EMS has fallen into the fire service's hands in certain cases as a result. In other regions, it has been a hostile takeover for the wrong reasons. Regardless, you don't really need anything above a 911 medics with two years of medical education to do the job effectively. If you can't get enough medics to apply for dual role positions, then consider hiring EMS only recruits. If you want treat and release capabilities, if you need the capability for provider initiated refusals, or for txp to more appropriate destinations than an ED, the solution is simple - as a requirement to sit for the test for EMS Supervisor, you'll need to have the additional education as above, one of those two examples. No need for everyone to be overeducated for the position. If a new procedure or capability or procedure comes out, these supervisors train the rest of the department.

The reason I say fire based municipal EMS is that this is the only EMS model that provides a real, attainable career ladder for EMS personnel, with several areas of specialty to focus on to keep motivation high, prevent burnout, provide positions other than in the field or dispatch, provide superior pay, benefits and retirement, and also as a superior resume builder for a post EMS career. In my department alone, besides there being the career ladder with 10 rungs, you can move into fire prevention, the Fire Marshall's office, the Peer Fitness Program, be in EMS Admin, teaching recruits and also CEU's alongside our PA's, and BSN's. There are numerous "off the road" positions, unlike single role EMS, which is basically running calls in the bus, or dispatch for nearly everyone.

Those that feel restricted by 911 EMS would be better served going into the areas that advocates of advanced scope in EMS would like to see. You can work in clinics, do community outreach, do real, independent IFT, etc. Most in EMS have no interest in doing any of these things, however. Or, if you like 911 EMS and also all those other things, get a FT job in 911, and work PT in those other areas.

 

[JPINFV]

Alternatively, make 911 EMS an Assosciate's, make it a Bachelors for IFT and flight, and a Master's for anything above and beyond that. As far as independent thinking, I feel that we need a lot more than four years of medical education to have any real autonomy, write our own guidelines, divorce ourselves of the need for a medical director, and the risk or liability that comes with that responsibility. A Masters and above are overkill to function as a 911 medic, no?

I don't think independent thinking or judgement is necessarily the same as independent practice. Using a current example from California, California is introducing a critical care paramedic level and an advanced practice paramedic level. One of those levels explicitly includes digital intubation. It honestly never occurred to me that methods of intubation would be limited by scope of practice. In my mind, if paramedics were professionals (in contrast to technicians), then the intervention of "intubation" would be the scope of practice. It would be up to the paramedic, based on his or her education, training, available tools, and patient assessment, to choose which method (laryngoscope, digital, use of a gum bougie, etc) would be best for that individual paramedic for that individual patient. That is independent judgement at its core.

With either scenario, I feel that 911 EMS should be 100% municipal. Many are saying that 911 EMS results in a negative cash flow, so going municipal makes sense. If it's a positive cash flow situation, then the local gov't makes out.

I think, depending on the area, that a regional approach would be more efficient. Be it a county agency or a quasi-government non-profit entity. In Orange County, CA (which is characterized by many small to moderate sized cities), a bunch of the cities are looking at giving up their fire departments and contracting with the county fire agency (Orange County Fire Authority).

I also think that we're going to switch from an emergency medical care system to a prehospital care system that integrates more fully with the local hospitals and health care providers for alternatives to both funding* and the 'everyone goes to the ED' issue.

*This was discussed at EMS World when dealing with issues like funding to introduce CPAP to EMS. Devices like that are saving the hospitals a ton of money by reducing ICU days, and given the cost saving, some of the systems represented were reporting success with having the hospitals help offset introducing new treatment modalities.

 

[46Young]

I don't think independent thinking or judgement is necessarily the same as independent practice. Using a current example from California, California is introducing a critical care paramedic level and an advanced practice paramedic level. One of those levels explicitly includes digital intubation. It honestly never occurred to me that methods of intubation would be limited by scope of practice. In my mind, if paramedics were professionals (in contrast to technicians), then the intervention of "intubation" would be the scope of practice. It would be up to the paramedic, based on his or her education, training, available tools, and patient assessment, to choose which method (laryngoscope, digital, use of a gum bougie, etc) would be best for that individual paramedic for that individual patient. That is independent judgement at its core.



I think, depending on the area, that a regional approach would be more efficient. Be it a county agency or a quasi-government non-profit entity. In Orange County, CA (which is characterized by many small to moderate sized cities), a bunch of the cities are looking at giving up their fire departments and contracting with the county fire agency (Orange County Fire Authority).

I also think that we're going to switch from an emergency medical care system to a prehospital care system that integrates more fully with the local hospitals and health care providers for alternatives to both funding* and the 'everyone goes to the ED' issue.

*This was discussed at EMS World when dealing with issues like funding to introduce CPAP to EMS. Devices like that are saving the hospitals a ton of money by reducing ICU days, and given the cost saving, some of the systems represented were reporting success with having the hospitals help offset introducing new treatment modalities.

Now I understand the difference between independent thinking and independent practice. Independent thinking/judgment still require medical oversight, but much more lattitude is given when making clinical decisions. This requires more than two years of medical education, depending on what degree of lattitude you're looking for. I, like others, would like to see billing in skills hours rather than by the mile and category of txp.

A prehospital care system that integrates with local hospitals would be a wonderful thing as you describe it. Are there any systems currently working to that end? I'd like to present this idea to my department and the region at large, and it would help to have an example of how this can work, or at least some working ideas.

Edit: Could someone explain to me how to use quote tags to break up someones post and reply to each specific point?

 

[JPINFV]

Now I understand the difference between independent thinking and independent practice. Independent thinking/judgment still require medical oversight, but much more lattitude is given when making clinical decisions. This requires more than two years of medical education, depending on what degree of lattitude you're looking for. I, like others, would like to see billing in skills hours rather than by the mile and category of txp.

I too agree that billing should be based off of interventions provided (and transport would be included as an intervention when appropriate).


With that, I think I've found the best way to illustrate what I'm personally talking about. It's not about cutting out medical directors, or necessarily protocols. It's about insuring that paramedics have the education, training, tools, and institutional support to make good decisions. That includes the ability (both mental ability and institutional ability) to deviate when appropriate without requiring hand holding. Medical directors would still be involved to help monitor education, training, and providing support. Online medical control would be for when providers honestly need help with something. Not as a helicopter parent or method to shift responsibility for a hard decision.

It means things like having the ability to preclear evidence based deviations (like, say, a paramedic as an individual introducing D10 into his personal practice before protocols are changed) with the medical director.

The cookbook type mentality and one size fits all approach is responsible for so much damage to EMS as a profession that it's not funny. I imagine the fire service would have significant issues too with a career ladder if the line officers had to call the fire chief for every difficult on scene decision or deviation from SOP like paramedics have to with the medical director.

A prehospital care system that integrates with local hospitals would be a wonderful thing as you describe it. Are there any systems currently working to that end? I'd like to present this idea to my department and the region at large, and it would help to have an example of how this can work, or at least some working ideas.

I think it's necessary for any system seriously considering alternative transport options. I don't see how showing up without warning or preplanning to the local urgent care center would work out well... for anyone. It was mentioned also that one of the community paramedic programs saved some ungodly (several thousand) bed hours. I just emailed the person who gave that presentation (I think it was that one where the CPAP funding issue was discussed. I really should have taken notes) and I'll pass on what he replied with.

Edit: Could someone explain to me how to use quote tags to break up someones post and reply to each specific point?

[_quote] message [_/quote]

No underscores. Also, if you remove the first and last tags, you can highlight and click the

and it will add them automatically.

 

[firecoins]

(1) Transfer federal oversight of EMS from NHTSA to the Department of Health and Human Services (HHS).

fine

(2) Convert all privately owned, for-profit ambulance companies to not-for-profit status. Compensate any investors for past investment.

Meaningless. Companies still have to cover costs. Its an overstep of government authority anyway.

(

3) Convert all fire department operated EMS programs to an independent state (preferably), regional, or municipal agency. Downgrade FDs to CFR level

Who will pay for this? It costs billions. Fire Depts run EMS to save municipalities money. So we are going to force cities to pay for this. Major tax increase.

(4) Commission the NAEMSP and/or ACEP to draft new principles and standards of EMS education, and introduce legislation granting HHS the authority to issue federal grants to accredited educational institutions to develop curricula based on said principles (i.e. community colleges and universities only).

Sounds great. I support higher standards. Volunteer agencies are now unable to train members. Now who will cover the loss of these agencies? The for profit companies are gone in your proposal. We need more billions of dollars to create more independant municipal EMS agencies.

(6) Eliminate the EMT provider level. Upgrade the AEMT to require an AS degree and Paramedic to BS degree.

No more EMS volunteers. Why would we train FDs responding to EMS calls as first responders only to the current CFR level? If increasing education, why not the current EMT?

Couldn't people trained the EMT-B level handle the non emergency calls?

(7) Staff all ambulances with two AEMTs which will be able to handle the majority of calls. Place Paramedics in rapid response vehicles with a driver (non-medically trained) for intercept - only auto-dispatched in limited set of calls.

So we will have 4 people in 2 response vehicles? Why not put the AEMT and a Medic in the ambulance, forget the untrained driver and the extra vehicle. Save money and get the better trained people to the calls.

(8) Restrict IFT services to non-emergent discharges, repatriations, or other routine pre-arranged transports for bed-ridden people (i.e. dialysis, PCP or specialist appointments, etc.). No SNF or urgent care to ED "non-emergent" transports from privately owned IFT organizations without referral from the primary emergency response agency.

Why not have EMT-Bs for this? And why must they be non profit to do this?





]

 

[usalsfyre]

Firecoins, your living inside the paradigm. Yes the number of ambulances and paramedics would be reduced. The thought being AEMTs could handle 80% of calls appropriately. The other thought is does NJ really need 400 EMS providers for 200 municipalities? Does every tiny borough and township in PA need an ambulance? Does the city of Houston need 300+ "EMS" (i.e. dialysis derby) providers?

Finally, show me a fire-based system that actually saves money....

 

[firecoins]

The whole point of fire based ems is to not have 2 separate services and give an excuse to having a large stand by fire service. It isn't a good thing for EMS but forcing municipalities to separate them is a fantasy that costs billions of dollars.

Many municipalities in NY and NJ rely on unreliable volunteer services. Entire counties in many cases. Sure there are the private for profit companies that do the non emergencies. Since we are eliminating both in the process of properly educated providers, the counties will now be uncovered by anyone. Your solution is they don't need a service?


---
I am here: http://maps.google.com/maps?ll=41.098631,-73.923563

 

[firecoins]

Fewer ambulance run by indepndant municipal agencies with properly trained personnel. Sounds good of everyone is covered. There is no money for it though.


---
I am here: http://maps.google.com/maps?ll=41.098631,-73.923563

 

[usalsfyre]

The whole point of fire based ems is to not have 2 separate services and give an excuse to having a large stand by fire service.

Why do we need as large a standby fire service, excepting certain large cities? Typical suburban FDs (where fire-based EMS is strongest) don't staff enough people and don't have the fire load and building construction to make interior firefighting practical anyway. Fires that are any larger than incipient stage in these areas often end up being defensive anyway, and defensive tactics don't need a large standby fire service. Not to mention, who's covering EMS while the ambulance is involved in firefighting operations/the ambulance is unavailable for firefighting while doing it's primary job.

It isn't a good thing for EMS but forcing municipalities to separate them is a fantasy that costs billions of dollars.

Your assuming FD staffing staying the same. Separate EMS, you've mainly simply moved money around, in the above plan often to lower paying positions (no need to have an engineer or LT on an ambulance like many FDs do). Cutting FD jobs though has been made out by the IAFF to be un-American, even though post 9/11 they often grew to bloated proportions.

 

[firecoins]

Why do we need as large a standby fire service, excepting certain large cities? Typical suburban FDs (where fire-based EMS is strongest) don't staff enough people and don't have the fire load and building construction to make interior firefighting practical anyway. Fires that are any larger than incipient stage in these areas often end up being defensive anyway, and defensive tactics don't need a large standby fire service. Not to mention, who's covering EMS while the ambulance is involved in firefighting operations/the ambulance is unavailable for firefighting while doing it's primary job.

You dont need large firefighting stand by crews but they aren't going to change for EMS.

Your assuming FD staffing staying the same.

Come to NYC and tell the FD your closing down fire houses. They fight tooth and nail for every job and every house. FDNY is already running EMS as a separte unit but it props up the FD. It would cost millions of dollars NYC doesn't have to return EMS back to NYC health and hospitals.

Separate EMS, you've mainly simply moved money around, in the above plan often to lower paying positions (no need to have an engineer or LT on an ambulance like many FDs do).

FDNY EMS is already a separate division. No LTs to cut.

Cutting FD jobs though has been made out by the IAFF to be un-American, even though post 9/11 they often grew to bloated proportions.

Right! And they will out lobby any change to FD based EMS because it cuts FF union dues.

 

[usalsfyre]

You dont need large firefighting stand by crews but they aren't going to change for EMS.

It's not really the FDs choice in the end. We're already seeing some backlash over funding levels here, despite being in the middle of the worst fire season in the state in 50+ years.

Come to NYC and tell the FD your closing down fire houses. They fight tooth and nail for every job and every house.

NYC is probably one if the few places that does need a large standby firefighting force due to the proximity of construction, however, everyone is going to fight tooth and nail. Why? Because a refusal to look at their operations and "200 years of tradition unimpeded by process". The beginning of the end of my last fire-service job was when I mentioned to the chief and a coworker the idea of interior firefighting to protect already destroyed property was stupid to me.

FDNY is already running EMS as a separte unit but it props up the FD. It would cost millions of dollars NYC doesn't have to return EMS back to NYC health and hospitals.

Can't speak intelligently to this. But the fact that going from an autonomously acting position with responsibility similar to a unit officer (paramedic) to a bucket FF is a "promotion" to me shows how jacked the system is up there.

FDNY EMS is already a separate division. No LTs to cut.

Not really FDNY specific but how many FDs run dual medic trucks and all ALS engines? How much money are we saving putting two AEMTs in an ambulance and say one paramedic per three or four ambulances?

Right! And they will out lobby any change to FD based EMS because it cuts FF union dues.

Public unions aren't very popular at the moment, and if they continue screaming about "heroes", "9/11" and "people will die" I predict they will get less so.

 

[firecoins]

FDNY EMS is one of the few dual medic systems I know and it isn't well reguarded outside of NYC. Of course you also have the advantage of so many hospitals being so close. BLS can be just as good here sue to the short transports with the ERs providing quick and effective ALS themselves.

Getting rid of for profits? I don't think its necessary. Not in NYC at least.

Nursing homes calling me instead of 911 is a problem but its the nursing homes that are the problem. Its not my fault the RNs at nursing home are either incompetant, complacent or overworked but I get set serious emergencies out of them. It weird showing up to an emergency and FDNY EMS is present for a less emergent situation than I am getting. The nurses clearly don't know what constitutes an emergency. Than I have to fight them on destination.

 

[Bullets]

We talked about this today at work, and ive got it

Everyone who calls 911 and get transport gets 2 things...

1) Trauma Naked
If you get admited you changing into a hospital gown anyway, so lets help the hospitals by stripping our patients prior to arrival at the Hospital


2) Rectal thermometer
Diagnostic vital sign, critically important for accurate diagnosis

 

[46Young]

I too agree that billing should be based off of interventions provided (and transport would be included as an intervention when appropriate).


With that, I think I've found the best way to illustrate what I'm personally talking about. It's not about cutting out medical directors, or necessarily protocols. It's about insuring that paramedics have the education, training, tools, and institutional support to make good decisions. That includes the ability (both mental ability and institutional ability) to deviate when appropriate without requiring hand holding. Medical directors would still be involved to help monitor education, training, and providing support. Online medical control would be for when providers honestly need help with something. Not as a helicopter parent or method to shift responsibility for a hard decision.

It means things like having the ability to preclear evidence based deviations (like, say, a paramedic as an individual introducing D10 into his personal practice before protocols are changed) with the medical director.

The cookbook type mentality and one size fits all approach is responsible for so much damage to EMS as a profession that it's not funny. I imagine the fire service would have significant issues too with a career ladder if the line officers had to call the fire chief for every difficult on scene decision or deviation from SOP like paramedics have to with the medical director.





I think it's necessary for any system seriously considering alternative transport options. I don't see how showing up without warning or preplanning to the local urgent care center would work out well... for anyone. It was mentioned also that one of the community paramedic programs saved some ungodly (several thousand) bed hours. I just emailed the person who gave that presentation (I think it was that one where the CPAP funding issue was discussed. I really should have taken notes) and I'll pass on what he replied with.





[_quote] message [_/quote]

No underscores. Also, if you remove the first and last tags, you can highlight and click the

and it will add them automatically.

Thank you.

 

[thegreypilgrim]

Meaningless. Companies still have to cover costs. Its an overstep of government authority anyway.

NPOs are more efficient in that there's less administrative overhead, and the burden of executive salaries is virtually nonexistent. All revenue generated above base operating costs is reinvested into the community/organization and not put in somebody's investment portfolio.

And the US government has nationalized or partially nationalized industries in the past. What I proposed would not even go as far as that.

(Who will pay for this? It costs billions. Fire Depts run EMS to save municipalities money. So we are going to force cities to pay for this. Major tax increase.

I challenge the notion that FD-based EMS is more cost-efficient for local governments.

And you're not really going to see much in the way of additional expense in setting up the new agency - just a lot of transferring funds from one organization to another.

Sounds great. I support higher standards. Volunteer agencies are now unable to train members. Now who will cover the loss of these agencies? The for profit companies are gone in your proposal. We need more billions of dollars to create more independant municipal EMS agencies.

There will be some added expense here, but it wouldn't necessarily have to be at the municipal level. It can be done at the state or regional level to capture sufficient funds in cash-strapped areas so the burden isn't entirely leveled on individual communities.

So, sure it's going to result in more taxes, but these are taxes that are more than offset by savings in out-of-pocket expense to the typical consumer/citizen and to the system as a whole. An EMS service as advanced as the one I propose could significantly reduce hospital admissions, length of admissions, and the number of unnecessary transports. Furthermore, wouldn't you rather pay a small levee tacked onto your property tax or utility bill that covers you for the whole fiscal year as opposed to hundreds (or even thousands) of dollars in ambulance fees used on a case-by-case basis? Or are you just objecting to it simply because it's a tax?

No more EMS volunteers. Why would we train FDs responding to EMS calls as first responders only to the current CFR level? If increasing education, why not the current EMT?

Couldn't people trained the EMT-B level handle the non emergency calls?

There's no advantage of the EMT-B over CFR plus AED. In my opinion EMT-B's cannot provide much to the typical 911 request for medical aid. The training just isn't up to the challenge of an appropriately detailed HP&E nor can they provide much therapeutics beyond high-flow 02 and hemorrhage control.

A better approach is to send two "enhanced" (under the new training I proposed) AEMTs to every call who can screen out non-urgent runs. Non-emergent patients don't get transported. Problem solved.

So we will have 4 people in 2 response vehicles? Why not put the AEMT and a Medic in the ambulance, forget the untrained driver and the extra vehicle. Save money and get the better trained people to the calls.

Most calls will just have 2 AEMTs in an ambulance (the new BLS) with ALS available for intercept upon request (auto-dispatched in only select cases).

Frees up ALS to treat most critical patients, therefore most efficient use of resources.

Why not have EMT-Bs for this? And why must they be non profit to do this?

Explained above.

 

[Harvey]

There are similar situations in other professions, an example would be Security in relation to Law Enforcement. 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? Its called consumer based capitalism, which drives supply and demand. Besides wont obama care fix all of this in 2014 when it goes into effect? (sarcasm)