RocketMedic
Californian, Lost in Texas
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Motivated by insomnia, Paramedics on Facebook, and a sincere eagerness to professionalize.
Why Obamacare Is the Best Thing to Happen to Emergency Medical Services Since Johnny and Roy
Obamacare (The Affordable Care Act of 2010) is one of the most controversial, hotly-contested and broken laws to ever stagger out of Washington, D.C. By most measures, it is a brutish, clumsy effort at a national mandate to insure every American by subsidizing private health care plans and applying a hefty dose of Stick Therapy to incentivize participation- but not so much as to be effective. In practice, Obamacare will likely not survive in its current form for a significant length of time without major changes, but that is expected by practically everyone. To put it in terms familiar to anyone from the Midwest (Obamacare's hottest resistance), Obamacare is that wet, humid feeling you wake up to on tornado-emergency days. The storm is ahead and will leave things changed to a degree we probably don't comprehend yet (even if we can make some guesses).
Health care in the modern world has done some amazing things. Low-cost vaccinations have literally eradicated plagues and ensured that unprecedented numbers of humans live long, productive lives. Medications ranging in cost and discovery from “total accident in a petri dish” to “end result of multi-trillion dollar research” have greatly eased suffering, cured and reversed disease processes and hold the line against aging and premature death and even allow geriatric sex. It is not an exaggeration to say that modern medicine has literally reshaped society for the better in the 20th Century- everyone from a young wounded war veteran who is alive because of outstanding and aggressive trauma care to a child born four months too soon to the grandfather with COPD who takes a cocktail of medications daily is literally alive because of modern health-care practices, doctors and pharmaceuticals. What this means to us is that there are more people living what are generally longer, healthier and more productive lives, absent modifiers for environment, lifestyle and such. As one might expect, health care has done this by becoming a profession in just a few generations- the days of the classically-trained (minimal at best, by current standards) door-to-door doctor and the town GP who is known for improvisation, grit and experience have ended, replaced by an impressive and expensive medical organization that gives impressive results at great cost. Medicine today is better-informed, better-documented, better-trained and better-performing than at any time in the past; it is also far more expensive. This mirrors any other service or product. As a society, we are not going to choose to regress to the dark ages of health care- do you really think that people are going to give up ambulances, high-quality medical testing, research and state-of-the-art care? Those that say “yes” should probably stop taking all of their medications now and lead the way.
The dark side to this rosy picture is that modern medicine is allowing us as a society to experience the full benefit of the process of death and its cost; anyone who is even slightly knowledgeable about health care can tell you that death is currently inevitable. As recently as fifty years ago, there simply weren't enough geriatric, sick Americans to really maintain a professional nursing home- you either got old and stayed healthy enough to live alone or you didn't, and when you died, it was most likely at home or at work and it was of an acute emergency or caused by the immediate aftermath of one. A heart attack in 1960 was fairly limited in treatment options or even recognition, rehabilitation more of a guess than a science. Contrast that to today, where systems exist across most of the United States for the reasonably prompt and rapid treatment of most acute illnesses and trauma and even volunteer yokel EMTs know buzzwords like “STEMI” or “stroke”. Quite a few more sick people live longer lives now, and then there's the Marginals. Who are they? Marginals are people who would have died off on their own, or who have chronically bad health, either through bad luck, fault of their own or some combination of the two. They are the very old, the lifestyle-crippled, diabetics, the mentally ill, the drug and alcohol-addicted, the genetically doomed and the severe asthmatics, the early cardiacs and the obese. These people, simply by nature of their conditions, are more reliant on health care and are more expensive to keep alive. Most of the cost of health care is directly related to the continued care of these people. As a doctor at William Beaumont Army Medical Center once told me, “the current health care system would be perfect if we didn't spend eighty percent of our funding on people who have less than five years to live.” Now, I am not claiming that these people are not worthy of health care or consideration. If anything, they are more in need than most of us. However, there is a harsh reality that we must acknowledge as professionals- resources are limited, demand is growing and service must adapt to continue to exist.
We already know what the health care of the future is going to look like- a single-payer (read: government-funded) system with moderate wait times for most things, an increased emphasis on preventative care and a hard line for the management of chronic conditions with rationing of health care based on objective medically-based triage. This is the same system successfully implemented in Great Britain with the NIH, France and Germany, Japan, Australia, Canada and quite a few other First World nations. As with any system, this will have its positives and its flaws. Currently, the American health care system provides the world's highest general standard of care (unless you're in not in a large city, poor, or are simply too stubborn to use it) at the world's highest cost. Other nations with different approaches vary, but tend to offer more conservative care at far lower costs to the vast majority of their citizens. Once again, no system is perfect, and the very wealthy and very poor generally triage themselves to the front and back of the line in any system. The difference is that the American system can literally turn all but truly extraordinary wealth into poverty with just one acute illness. With Obamacare, we have essentially given the titans of the health-care funding industry a chance to dictate terms to society- “participate on our terms or die” in exchange for lavish sums of money and a monopoly on health care. There are many vested interests in maintaining the status quo- health insurance companies who have no desire for a cheap, effective and popular government-funded competitor that would naturally attract most of the prime customers (healthy, affluent and reliable bill-payers who generally don't want more than a few easy medications and coverage against catastrophic events and are rather easy to please with cheap, mediocre service), the nursing home industry that relies on Medicare payments to warehouse America's elderly and marginals too ill to live alone attended by “nurses” and the best medical emigrants of the Third World, and medical providers of everything from ambulance service to Z-packs who have carved out a niche for themselves and wish to continue to exist in that role. Change will be forced not by Washington politics or tax threats but by the simple crush of aging, high-maintenance Baby Boomers choking too few Generation-Xers and Millenial paychecks with demands for services, transferred insurance premiums and simple long waiting lines. The answer to this is always rationing- externally-imposed guidelines that dictate further treatment or its withholding. This was originally derided as the “death panel” by anti-Obama conservatives and was viewed as a literal panel of faceless G-men in black robes deciding that Grandma didn't need to live anymore (and then shooting her, if she voted Republican), but was actually an expert panel that would review different treatment methodologies for cost and effectiveness for reimbursement and coverage under Medicare on a systemic level without bias for individual cases (hardly a negative, considering that every private insurer has a similar system that fearlessly refuses coverage for more expensive alternates based on cost alone). These are not the real triage mechanisms of Obamacare though- those mechanisms are defined in the Medicare refusal-to-pay hospitals for problems that are readmitted after only days. These will rapidly stop one of the most reliable and stable sources of income for hospitals and force them to either start admitting people to ensure that they stay out of the emergency department on repeat visits (at a financial loss, in many cases, and necessitating a massive increase in capacity at great cost) or that they stop receiving emergency patients (and thus providing emergency care). This poses a host of financial problems to Americans- what exactly do we want to do with our ill, our chronically ill, and how do we pay for it (and how do we treat them appropriately without choking our hospitals with dying old people)? This answer is simple: lack of funding and financial penalties are going to force hospitals to stop taking patients to emergency rooms for frequently-recurrent problems resulting from chronic disease processes; these patients will be shifted into the long-term rehabilitation and nursing home system to keep limited acute-care resources available for salvageable cases and those industries are going to have to improve themselves to maintain either an acceptably high level of service (with actual nursing!) or a truly low-cost 'death camp' solution for the Marginals who aren't fortunate enough to be able to make it into a real nursing home. (Yes, the days of Third-World 'nurses' are limited, thanks to the relentless push of the nursing lobby to educate their profession away from their vocational roots. It's going to take a while, but it will happen.)
Emergency medical services are in a unique position in American health care. We are taken for granted in most of the nation, but have a fragmented and divisive industry that is everything from a van ambulance happy to only take old folks to doctor's appointments and dialysis to a full-fledged paramedic-only fire department and everything in between. In terms of the service we provide, we have settled on “medical treatment and transport”, which is rather vague, if accurate. Currently, we really don't have much more to offer then a ride to the hospital and some potentially-lifesaving interventions (depending on where you work) and possibly a few pain medications. What can EMS do in the coming days of rationed health care? Well, if our Australian colleagues are any indication, quite a lot. Our job ensures that we are called to subjective emergencies on a daily basis, where we triage, treat and often transport based on protocols handed down by our medical directors and enforced by our agencies to various extents. Deviation from protocols in terms of medicine is highly dependent on individual factors, but there is one constant that rarely changes- an American paramedic is generally not allowed to refuse transport to a patient, just as an emergency room is not allowed to refuse care (even if they do not actually provide anything other than basic care). Aside from being quite taxing on resources, this ensures that we as an industry limit our utility- is there a real functional difference between Yellow Cab and AMR in terms of cost effectiveness vs service provided for most ambulance patients from the perspective of an insurance payer or Medicare, especially in light of studies showing that the vast majority of patients require little or no medical care beyond the taking of vital signs? Today, these concerns are drowned out by marketing and the relatively easy profits available in emergency medicine, but in a rationed environment, these questions will be asked (as they were in Australia and Canada). The answer that our Commonwealth colleagues have chosen is to increase their functional utility by broadening their educations, which earned them the trust needed to start working on their own and making health plans, as opposed to following protocols alone. This resulted in considerable cost savings to hospitals and insurance providers, which then resulted in the further expansion of paramedic practice and mandated increased education- which also has the pleasant side effect of increasing paramedic wages and actually giving us a true place as medical professionals, not simply tradesmen. Make no mistake- this shift was not caused by a desire to improve patient care (most American paramedics can do more on a vocational-tech certificate than a British paramedic can do with a master's degree in terms of actual medical care, and our patient outcomes are roughly similar, if a bit less painful for the American patient) but by simple funding and operations within a rationed-care environment. We can see the start of this in American EMS with the birth of the “Advanced Practice Paramedic” and “community paramedicine”, which is currently trying to survive challenges from the home-health industry and our own less-than-forward-looking colleagues.
Obamacare, for EMS, is a mixed reward: everyone will hypothetically have insurance, but most people who we see frequently still will not, and those who have insurance will probably pay a lot less for service then they have before, if at all. In a future where hospitals are not going to get paid for seeing Grandma Falls-a-lot for every single fall in her nursing home and those same nursing homes are going to actually have to venture into acute care, we cannot rely on simple low-pay (Medicare-rate) high-volume calls to fund our operations. There will still be markets for BLS transport for stretcher-bound and wheelchair-bound patients to and from various appointments- if anything, those will increase for the next fifty years. For the highly-developed paramedic services, Obamacare and its successor are going to functionally mandate that we educate ourselves to begin providing triage service and developing care plans. That will allow us to start billing for services rendered (against the promise that failing to pay will not only saddle hospitals and insurers with costly medical care resulting from a transport to a hospital for a home-treatable condition) and move away from the bill-for-transport model that has influenced the growth of our industry and places a premium on call volume, not results (for example, what is the first thing that most people think of as a “high-performance system”. Bet your first thought is 'busy').
As we know, EMS in the United States is very, very, very fragmented. There are four main types of providers: private services, public services, fire departments and volunteers. These all come in a variety of actual employers ranging from hospitals to mom-and-pop small businesses to firefighter-paramedics. All have the same goals most of the time (patient care) and all have different reasons for existing and different motivations, and all will be affected by rationed health care dollars. Let's look a little deeper so we can really understand what we face.
Private companies have always been in the medical-transport business. Their primary goal is the same as any other company- to make money. Some choose to focus exclusively on the medical-transport market, relying on high volumes of low-pay Medicare transports with minimally-trained personnel and discount secondhand equipment that's 'technically legal' to provide basic interfacility service with a little more peace of mind than a layman with a Dodge Caravan (albeit with similar functional results). As you can imagine and many EMTs can attest, these companies absolutely detest the performance of real medicine under their auspices and the liability inherent and are more than happy to simply make sizable profits for taxi service. There is not a lot of support to improve EMS education or broaden the scopes of practice from these services- why mess with perfection? It is not fair to paint private services with the same brush, however- many more services do genuinely care for their communities and strive to provide state-of-the-art care and actively embrace advances in paramedic practice (as long as there's a profit to be made). In general terms, though, private services will exist as long as there is a need to provide service and there's a profit to be made. Private services have an advantage over other forms of service in that they are not recurrent costs to the public- even private services that receive a stipend in exchange for the provision of emergency coverage are not saddling the public with the expenses of their employees in terms of pensions and health care. Private services are also (hypothetically) competitive with one another to maintain costs and standards as established by their contracts- failure to meet these terms can and does result in the selection of a competitor for service. This tends to keep things competitive on an administrative level in terms of cost as opposed to other models of service.
Fire services (paid and volunteer) provide ambulance service to the majority of America's land mass and a significant minority of its citizens in a role that ranges from 'first responders' to 'only game in town'. Firefighters got into medicine with Johnny Gage and Roy DeSoto, and really became pervasive as a result of their own success in changing fire codes, building construction and educating the public as to the importance of fire safety. In decades past, fire was a nightly occurrence, and a firefighter could legitimately expect to spend a career routinely battling house fires sparked by everything from 1900's finest electrical wiring to Great-Grandmother's vintage and routinely-used gas heater vs a down quilt. That's (luckily) changed with modern fire codes and technology that has severely diminished the rate (if not the severity) of house fires. In this new reality, fire departments found themselves overstaffed and underutilized- engines that once ran three or five fires a day now spent a week in-station between blazes, and smoke alarm checks often led to alarm resets, not breathless rescues. Fire officers across the country scrambled for a new field to monopolize to protect their budgets, and EMS was a logical extension of fire protection: crews are already organized and present, equipment and training are easy, and they're already paid for. Fire departments quickly began using EMS certification as an entry requirement, leading applicants with no real love of medicine for its own sake to “check the block” and get onto a fire department. There's nothing wrong with that motivation, but it does tend to breed an attitude that medical work is simply an add-on certificate or necessary prerequisite for becoming a “firefighter”, with all that that implies for fire departments. That is not to say that fire-based EMS is bad- I personally know many excellent, caring and proficient paramedics who are also firefighters, or who even prefer fire suppression to medical care- but it is an observation that there is, once again, a limited incentive to change practices that 'work' until their utility can be demonstrated. Also unique to fire departments is their commendable marketing and generally standardized training and practices across the paid components- most fire departments are constantly out in public view touting the utility of their services and doing wholesome, community-related things with shiny fire engines, fit personnel and teamwork (pretty much the exact opposite of the stereotypical EMS operation). Even at my current employer, I have had irate citizens complain to me at a Circle-K where I've been fortunate enough to get posted for a few minutes that “y'all burn up my tax dollars just waiting for hours at a time idling those big trucks all day” or complaining that it took ten or fifteen minutes to get to them after they called, but praising the rapid response of the fire department. (Last night, we even caught a nursing home relocking the front door after the firefighters went in, completely ignoring the ambulance right behind them). This isn't a bad thing- to the contrary, it's exactly what other EMS services need to be doing as well. The advantages to fire EMS are strong- employee conditions, longevity, pay and lifestyle are generally better than private EMS, equipment may be better, and most importantly, there are superior pensions, health plans and far better job security as fire-medics than as simple medics. On the downside, those same firefighters are tied to their communities (and thus vulnerable to economic downturns) and are often less able to change to meet demand than private companies are- meaning that a busy 24-hour shift that a private company would simply hire another ambulance crew to cover within the terms of their contract is instead handled by paying overtime and/or compromising patient care and patient/crew safety by remaining awake for 20 to 24 hours. Fire services can also somewhat less flexible and open to change and improvements- there is a far greater respect for tradition and old practices in a firehouse than a posted ambulance. On the whole, fire-based EMS tends to go one of two ways- either a full-fledged “everyone's a fire-medic” like El Paso, Texas or Houston or San Antonio or segregated “separate but equal” departments like FDNY-EMS. Some fire-based services (like El Paso) do it relatively right, where EMS duty is not a punishment and care is acceptably up to par, other departments (KCFD in Kansas City, Washington D.C., FDNY, and everyone's most-pitied Detroit, for example) are operational cesspools with poor morale, low pay, problems with budget and retention and existential challenges. From my perspective, it would be nice to have the benefits of a fire department, but I really don't care for the fire-suppression side of fire service. Many paramedics feel the same. Luckily, in an environment where dollars are limited, I think that more fire services are going to try and become the primary emergency medical providers, and with luck, broader paramedic educations will become as standard as SCBAs, and hopefully departments will realize that EMS is not necessarily best-managed in the same way that a fire is from either a medical perspective or a financial one.
Public services are, in my opinion, the way forward. Today, third-service models like my current employer are akin to your local utility companies, where an EMS service assumes a limited monopoly for a certain area to service, that service is generally operated by a local government separately from the fire department (but in close cooperation). Oftentimes, the employees will be contracted to a private company, but that is a subcontract, other public services work directly for the third service. My current employer is a public-utility third-service that contracts its employees to a private company (this is probably what the future look like for EMS). Third-services are outwardly similar to the fire department, but do not have the task of fire suppression in mind- their only mission is to provide medical support, and can thus focus their resources on the provision of medical care and transport to those who need it. That is not to say that third-services are the be-all of medical improvement and care – they are only as good as their funding, staffing and practices- but it does provide a fairly solid funding base for competition for private companies who want to staff those positions and a stable medical-focused career for professionals who want to make a living helping people. In an environment with limited funds, it is going to get easier to separate the ambulance that you need every day from the fire truck that you don't, and that is going to cause the creation (either obvious or effective) creation of a lot of third-services. This is exactly what happened in Great Britain, Canada and Australia, where private ambulance service has been marginalized and fire departments generally stick to suppression, but large third-services provide medical care.
The blighted, painful cyst on the *** of American emergency medicine is the volunteer. Volunteers are fantastic, giving, thoughtful people. They run towards danger (literally, as we saw in West, TX). They cover a geographic majority of the country with grit, compassion and a fair amount of experience, and they are glad to do it. Professionalism varies (the same as anywhere else), educations vary (the same as anywhere else) and the level of service varies (from BLS-if you're lucky to full-fledged ALS care). Volunteers are great people who provide a vital service for as close to free as it gets- so why the negative view? First, volunteers are all hobbyists with certification, licensure and authorization- a dangerous mix. They are as close to unregulated as they can possibly be- as long as they don't do anything really criminal, it's not like they have a livelihood to lose. Malpractice? Meh, “it's an art, not a science”. What are you going to do, take their pay? That's covered by their full-time job. They're generally unreliable- one of the primary benefits of a paid crew is that you know they're there, whereas many volunteer setups are ad-hoc at best. Volunteers have managed to successfully agitate against the growth of paid professional positions in both fire and EMS (see the First Aid Councils in New Jersey, best summed up as volunteers protecting their hobby to the nth degree) to the extent that paramedics today learn a little less than many paramedics did twenty years ago, all on the grounds of “its's too hard for us to have full-time jobs and be EMS with all of this silly book learnin' anyways.” Volunteers are quick to tout their successes, but how can a profession advance itself beyond a set of skills and a ride to the hospital when a full 70% of its members are actively opposed to education that is more extensive than an afternoon inservice or requires a backround education more advanced than middle school. That's not to mention the staggering amount of ignorance, stupidity and downright negligence that volunteer EMTs are allowed to get away with that professionals are not and the generally horrifically-low standards of volunteer proficiency or the personal threat that volunteers pose to paid personnel (especially in a limited-funding environment.) For this, look no farther than Paramedics on Facebook. Go on, look at some of the discussions and the general impression the volunteers make. Would you really want someone who cannot spell, conjugate or articulate a concept beyond a pedantic “treat the patient” or “BLS b4 ALS” in charge of determining whether you or your loved one qualifies for a rationed spot in a hospital based solely on “years of experience” and “gut feelings” and an EMT card from 2005? Paid services can weed out the retards if there is proper incentive. Volunteer services often choose not to. (side note for all of the insulted vollies who read this- would you tolerate a volunteer at your full-time job, taking your work?) Fortunately, like Indian Summer, Obamacare is the death knell for volunteer services and the days of the Vocational Paramedic. Limited funding and a need to do more than Medical Taxi is going to change our industry from a stepchild to a full-fledged profession. The days of the hobbyist are as limited as the Recreational Nurse in the hospital. The volunteers simply won't be able to educate themselves reliably enough to keep up.
So, with that, what sort of EMS system will the 5-year old I helped last week find herself looking at when she finishes her bachelor's degree in paramedicine? I think that the 911 trucks will either be fire-department red or third-service something, that she will be able to leave quite a few more patients at home with an educated care plan and a few medications and some information, and that those patients she does take to hospital will find themselves in longer lines for all but the most acute care. She will have better job security, better pay, and more potential for career development than I do. The medicine will be similar, but she'll have quite a few more assessment tools and the training to use them. I don't envy her the paperwork she'll have to do. I do know that if I want to be her supervisor, I need to start working towards that goal now, because when the money stops, things get real fast. I'd rather not be some yokel at Mom and Pop's EMS, a firefighter with no time or patience for “medical stuff” or EMT Ricky Rescue when my job depends on real performance.
In short: In twenty years, we will all work for a large, third-service funded by supplemental fees (ie TotalCare's water bill) and be a lot like Canadian or Australian paramedics.
