The uncoupling of Fire and EMS

[Veneficus]

As people rally against tax raises, demand less government affiliation, and are even started to look at government salaries as overly generous, are we witnessing the forces come together that may end the merging of EMS and Fire?

I was reading this article:

http://www.emsworld.com/article/article.jsp?id=16918&siteSection=1

recalling this one:

http://www.ems1.com/jobs/articles/475988-ohio-committee-wants-paramedic-roles-reduced/

and one of my friends brought this to my attention:

http://www.fox8.com/news/wjw-layoffs-txt,0,1562158.story

Not to mention:

http://nationallawforum.com/2011/04...e-bargaining-rights-of-ohio-public-employees/


It seems logical to me that if cities are suggesting finding private EMS providers instead of municiple ones to reduce costs that the fire based EMS is not the economic panecea its proponents have always claimed it was.

It also seems that what Americans want is not what they are willing to pay for. That makes me wonder if they really want it?

Now most of us think what we do is valuable, even important, but it seems the general public no longer does.

So here are the questions:

What are the next likely steps in the progression?

What is a tangible and economically demonstratable way to convince people to pay enough tax to support these programs since the chest pounding of being heroes seems to be losing its audiance?

Would new leadership from outside the established ranks be able to help?

 

[mycrofft]

Fire Departments will fight it

EMS is what keeps enough people on thier rolls to fight fires and still treat employees as something other than mules, if they want.

The American public will in large part believe anyone who will guarantee them that if elected, "water will run downhill but never reach the bottom", and they will get rid of those who can't deliver that...then they will run up deficits since they won't raise funding sources (taxes, either raising them or collecting from heavy hitting contributors like oil companies).
Fire depts can fiond a way to still be part of EMS, even if it is just a refiguring of the organizational charts.

 

[Veneficus]

EMS is what keeps enough people on thier rolls to fight fires and still treat employees as something other than mules, if they want.

The American public will in large part believe anyone who will guarantee them that if elected, "water will run downhill but never reach the bottom", and they will get rid of those who can't deliver that...then they will run up deficits since they won't raise funding sources (taxes, either raising them or collecting from heavy hitting contributors like oil companies).
Fire depts can fiond a way to still be part of EMS, even if it is just a refiguring of the organizational charts.

I have no doubt FDs will fight it, my question is can they succeed?

Certainly not using the arguments they have been up to this point I think.

 

[Veneficus]

Maybe I should be more clear on what I am asking...

If you were the head of a mniciple agency that handles EMS, what is the plan in today's economic and political realities of not seeing your department outsourced or downsized to a skeleton crew?

 

[abckidsmom]

It also seems that what Americans want is not what they are willing to pay for. That makes me wonder if they really want it?

Now most of us think what we do is valuable, even important, but it seems the general public no longer does.

I see this a lot when dealing with child safety seat issues. I think we have delivered safety to people for so long, and are capable of delivering more and more safety, but people are reaching the limit of discomfort they are willing to put up with to achieve baby steps forward in safety.

So what if a defibrillator arrives at 5 minutes instead of 8? Only the AHA and EMS system admin can appreciate the difference.

The general public really don't care...only people who have the education to see the difference.

I see this most often in counseling parents to rear face their toddlers in a car seat, or to leave their elementary age kid in a booster. They just don't see the benefit being worth the inconvenience.

I think it's the same with tax dollars.

So here are the questions:

What are the next likely steps in the progression?

What is a tangible and economically demonstratable way to convince people to pay enough tax to support these programs since the chest pounding of being heroes seems to be losing its audiance?

Would new leadership from outside the established ranks be able to help?

I don't think it's going to work like that. The chest pounding of being heroes combined with education of the people to be able to appreciate the difference in service levels. The people have to actually care.

Sadly, our apathetic society is not willing to pay a high price for this.

Maybe we should show them the video of what fire and ems look like in Moscow and see if they'd like to swing more that way?

 

[mycrofft]

What would I do...

If I were the sort who could do something, in an urban to close-suburban setting:
1. Make currency as a paramedic mandatory to train and work as a firefighter.
2. If possible, contract transport (including everything from picking them up off the floor to the hospital, except for technical extrication) to a private company.
3. Stop responding a firefighting crew and truck to every EMS call.
4. Contract out medical control, probably some company in Florida or Bermuda.
5. Downgrade response vehicles to something cheap small and economical to run since transport will no longer be done by FD.
6. Two man EMS crews.
7. Cap EMS responders' pay to parallel a fifth year firefighter's to encourage them to cross into firefighting and move newer hires in (lower pay, less accrued benefits).
8. Break the unions.
9. Two-tier response system; lots of Basic units, and a series of single ALS stationed in an area apportioned based upon population.
10. Have contract, either with emergency responder or with another company if cheaper, to take calls deemed non-emergent by responders.
11. Make each employee do fire response only for first year, then refresh and work EMS if they want, but subject to cross-manning pumpers etc. on demand.
12. Mandatory annual physical fitness test including lift, and a weigh-in.
13. Leave town before I was fragged by firefighters.

 

[usalsfyre]

Mycroft, your still using the fire service

How about legislation to chuck the ISO(as useless an organization as NAEMT) out of the state, make the realization that modern buildings are meant to burn and poorly suited to interior attack and reduce fire service staffing levels to a more realistic point and stop using the fire service (expensive) to plug up gaps in EMS coverage.

If I wasn't worried about reimbursement I'd work with the state to be allowed to run a front-loaded model putting a well trained single Paramedic or Intermediate in a response vehicles (cheap) and triage out those who don't require stretcher transport by ambulance (expensive). The response vehicles can then transport the non-emergent cases to the ED with minor treatment (anti-emetics, certain analgesia, ect). That way you can drastically increase the number of resources on the road while lowering overall cost. Of course, our medicolegal environment and reimbursement structure will never allow this...

 

[rescue99]

More than a decade ago, EMS folks were waging bets on just how long this whole fire based, advanced life support gig would last before evidence proved what a financial loss it is. Local bets gave it about 7 years. We figured about 7 years and cities everywhere would be seeking respite from the high cost of doubling the size of their fire departments. That's just about how long it's taken too. Communities have been saying, it's too costly, with no greater benefit for the past 3-4 years, and studies seem to support the opinion.

 

[CAOX3]

People place more importace on their possessions, houses and cars, their willing to pay for that, ie fire and police. Lets face it the majority of our call volume is repeat customers.

People are not going to pay in the form of taxes in this economy something they might never use.

EMS has a reckoning coming and it aint going to be pretty.

 

[usalsfyre]

EMS has a reckoning coming and it aint going to be pretty.

Very true, and what some have been trying to make us see for a while. The scary part is it might be too late.

 

[medicsb]

FD (or PD) first response has been shown to improve outcomes from cardiac arrest. So, in my opinion both FDs or PDs SHOULD be included in an EMS system as it would be less costly than putting single EMTs in cars to do first response. But, there is no need what-so-ever for ALS engines/ladders/etc. (no published data to support this costly practice). Hell, you probably do not need more than one FF cross trained as an EMT, so you could probably just put FFs through a medical first responder course, which would save on initial training and con-ed; also, less training deserves less pay, which means more savings. Have FF/EMT be a promotion within FDs. Only dispatch engines to for potential cardiac arrests (e.g. unconscious or not breathing).

Also, recruit PD to transport any penetrating trauma in the back of the squad car if an ambulance isn't already on scene (best for urban, high density communities with a trauma center close by, such as Philadelphia, where this is done).

I don't mind EMS being mixed with an FD so long as the name of the department acknowledges EMS (e.g. [town or city name] emergency services or [town or city] department of fire and EMS) and as long as the EMS side of the department is equally, if not strictly, over seen by physicians so as to ensure as much evidence-based practice as possible, including deployment practices and not just for medical & trauma care (fire chiefs and fire unions should not be dictating EMS response or levels of care).

Ultimately, I don't see many FDs losing EMS. Even if some lose transport, I'm sure that they'll continue with ALS engines or try to institute such a program. And as soon as the economy turns around, they'll do everything they can to get it back. Non-fire EMTs & paramedics NEED to organize (not necessarily unionize), so that they can advocate for themselves and turn EMS to its own true profession.

Oh, I guess I should include that there is probably very little patient benefit for the present-day paramedic skill set. So, a tiered response system is, in my opinion, most ideal. Those with the current paramedic skill set should be targeted to those who are most likely to benefit. This could save money, depending on how it is implemented. However, I do believe that the present day "EMT" skill set is too low. So an AEMT/EMT-I level would probably be a good base level skill set (e.g. supraglottic airways, 12 lead acquisition, ASA, nebulized albuterol, CPAP, blood glucose assessment, SpO2...) for ambulances only to serve as a bridge to paramedic care.

 

[Veneficus]

Rather than rehash who should be doing EMS or why, does anyone have any idea how to sell the public on funding EMS and not simply outsourcing it?

 

[mycrofft]

Find a scapegoat for high prices then tax them anyway.

Bogeymen worked to get more and more money from taxpayers for Dept of Defense, big oil and big medicine subsidies, law enforcement, etc. (And the German National Socialist Party) . Name a culprit, and sic the public on them to assuage feelings of powerlessness; next, regretfully/temporarily/gradually ramp up taxes anyway, then blame your predecessors and successors for it.

"HMO's" proved that Americans will never be prevention oriented, just rescue oriented.

Social welfare programs like child protective services, the foster child system, and legal protection for victims of family abuse under restraining orders. etc., prove the American are like penguins on the ice...it's all fine, ignore the screams from below and the shark fins circling the iceberg.

So get used to the status quo until it is stripped down out of its BS to the lower level of over-all care offered now but covered up by nearly everyone involved...followed by a vicious backlash and return to business as usual.

 

[thegreypilgrim]

It also seems that what Americans want is not what they are willing to pay for. That makes me wonder if they really want it?

Now most of us think what we do is valuable, even important, but it seems the general public no longer does.

So here are the questions:

What are the next likely steps in the progression?

What is a tangible and economically demonstratable way to convince people to pay enough tax to support these programs since the chest pounding of being heroes seems to be losing its audiance?

Would new leadership from outside the established ranks be able to help?

Here are my thoughts on the matter. Americans are sort of schizophrenic about taxes and social investment programs. We have a deep-seated suspicion and aversion toward taxes, but we demand quality public services. Just look at the current hysteria over Medicare and Rep. Paul Ryan's budget plan. Now (wonderfully ironic) the Republicans are being beat to hell in the town hall meetings because people don't want them messing around with Medicare/Medicaid. And, although Americans don't like taxes, polls show that most Americans want the top-earners to pay more taxes.

So, there's a desire to reduce costs without losing out on the quality of the service. Perhaps the best way to direct public opinion about this is to draw attention to this provision of the Medicare Ambulance Services policy:

The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.

It should be rather easy to stir up public exasperation with this when it is pointed out that the vast majority of ambulance transports are not necessary. It could then be argued that paramedics could be trained to treat people in their home and reimbursed for their clinical time when ambulance transport and ED work-up are not necessary.

Fire departments would oppose this, but it would put them in (for once in their history) a politically awkward position. Suddenly they would appear to be holding back progress, and with the public's growing awareness of the costs of their pension programs, this would be unwise. If they continue to oppose it, there's a good chance the public would finally tell them, "No". So, here's what would need to happen.

(1) Introduce legislation to restructure CMS policy on ambulance reimbursement to no longer require actual transport, but to encourage treatment in home and payment of paramedics for their clinical time.

(2) Simultaneously create legislation that links (1) to a newly proposed education standards scheme to be commissioned by the appropriate national body (I'm thinking CoAEMSP). Essentially, a legal framework which provides sizable federal grants to educational institutions to create curricula based on the proposed core principles. These training programs must consist of enough college credit hours to confer an Associate's degree (60-80 credits) or higher.

(3) Currently licensed providers can be grandfathered in, but this is unlikely to appease the FDs. Only time would tell exactly how much political capital they're willing to expend on this, but one of three outcomes will follow.

(3a) FDs successfully block the proposed changes. We'd be back to square one with this, but in 10-20 years when the system collapses it will be at the hands of the FDs and the public will have a historical record for this.

(3b) FDs accept changes. Cultural inconsistencies between FD (public safety) and EMS will likely erode FD participation in this (how many FFs can you see doing senior or infant wellness checks, helping substance abuse patients with their med compliance, etc.?). FD will eventually just de facto no longer get involved with EMS as opposed to being removed from it de jure.

(3c) FDs fight changes and lose. Now we have to pursue one of two options. Either we privatize EMS or incorporate it into a publicly operated service. Americans tend to deify the private sector, so I would imagine this is what people would want. Efforts could be made to encourage state and local governments to pass legislation requiring EMS organizations operate on a non-profit basis or as a highly regulated utility in order to eliminate the scourge of profit-motivated services and the loss of quality associated with them. More ideally I'd like to see the case made for a tax-subsidized public service. Much like a nationalized single-payer health insurance system this would actually be much more cost-effective (King County, WA is able to fund KC MedicOne entirely with small levies attached to resident's property taxes). This would fund either municipal or statewide third service organizations which I think would be preferable to private NPOs, but politically would require much investment.

 

[Shishkabob]

FD (or PD) first response has been shown to improve outcomes from cardiac arrest.

No, it hasn't.


Quicker access by trained personnel has.

 

[usalsfyre]

thegreypilgrim, sounds great, and I would agree with it if I could trust more than 20% of paramedics I work with to make an appropriate triage decision. If we're grandfathering people in without additional education I see this plan being a failure, either providers will shun responsibility and continue to transport everything (likely considering that most providers look for every possible reason to pass the buck now) or you will see a lot of patients inappropriately triaged out with the expected results. Most likely I'd say you'd see lots of the former with just enough cases of the later to make spectacular headlines...

 

[Veneficus]

Here are my thoughts on the matter (cut for brevity)

It sounds good until the property tax part.

As we see currently, property tax is a fickle friend. Because of major devaluations in property, municipalities and the services depending on it are getting decimated now.

I think it would be better to eliminate property tax entirely and go with an excise type of tax. That way more than just property owners will be paying for services. Everyone who spends money would.

However, the thing that really complicates that is people on fixed income like seniors. Since the amount they would spend in excise would create a sharp rise in their cost of living. Unlike property tax reductions for seniors, it is harder to create programs to shield people from excise.

In order to help this I decided to go with excise instead of VAT. That way you could at least exclude rises in utilities like electric, gas, and sewage. But I don't think food items would be easy to shield from it either, So there would be an associated increase in cost of that.

It would also help reduce costs to seniors who own their own homes, as well as eliminate one reason for raising rent on those that don't. (I am not fool enough to think rent would go down just because property tax is eliminated)

 

[thegreypilgrim]

thegreypilgrim, sounds great, and I would agree with it if I could trust more than 20% of paramedics I work with to make an appropriate triage decision. If we're grandfathering people in without additional education I see this plan being a failure, either providers will shun responsibility and continue to transport everything (likely considering that most providers look for every possible reason to pass the buck now) or you will see a lot of patients inappropriately triaged out with the expected results. Most likely I'd say you'd see lots of the former with just enough cases of the later to make spectacular headlines...

This, admittedly, is a glaring problem. Unfortunately I don't see a real way around it. I suppose we could develop an abridged training program that's focused on primary care oriented issues for those being grandfathered in to attend, but I'm not all that confident in the effectiveness of something like this. There's really no other option that I can see, though.

 

[thegreypilgrim]

It sounds good until the property tax part.

As we see currently, property tax is a fickle friend. Because of major devaluations in property, municipalities and the services depending on it are getting decimated now.

Well, I'm not tied to any particular existing tax category to affix funding for public EMS. The property tax thing was just an example of what King County does.

Perhaps if we had a national sales tax or a carbon tax that might be possible. Or, just create a whole new "Ambulance Tax" that people pay for separately I don't particularly care.

 

[usalsfyre]

This, admittedly, is a glaring problem. Unfortunately I don't see a real way around it. I suppose we could develop an abridged training program that's focused on primary care oriented issues for those being grandfathered in to attend, but I'm not all that confident in the effectiveness of something like this. There's really no other option that I can see, though.

Have CoAMESP and NAEMSP create a program focused on primary care issues, appropriate triage, treat and release and referral outside of the ED. Ensure it includes didactic and clinical components. Then set a date that Medicare will no longer pay anything outside of BLS non-emergent rate unless it's documented a services medics have completed this curriculum. I don't know how to deal with the issue of BLS services, outside of eliminate them.