I work for a large county wide EMS system covering 790,000+ people in a 399 square mile area with around 250 EMT's and Paramedics. We were warned by the State to expect some changes in our call volume, wait times at the ED, and increased paperwork due directly to implication of the ACA.
More changes are coming and more challenges to the EMS world because of ACA. I'm holding off on making a claim of good or bad on most of them.
More details after the squiggle. (please note these are not the opinion of the agency I work for, this is what I was told at inservice training and have seen. This is not 100% because i'm only seeing a small part and getting much from second hand. And there is the whole changes coming as more of ACA kick's in.)
Possibly caused by ACA.
For starts, we were warned that our call volume was going to go up. This is based of the experience of the last time the state expanded the medicaid accessibility. When medicaid enrollment goes up, so does the use of the Emergency Department (ED) and Emergency Medical Service (EMS) system as well as medical care in general. It is just how it is.
I work an area that is low income. This means a majority of my patients are either uninsured or on medicaid and medicare. (many on both) Of course I live in the area also, since EMS is notoriously low paid.
This warning came true. Our system did 101,000 calls last year, about 270 calls a day to the 911 service. Between Dec 26 and Dec 31, on the days I worked, we saw an average of 250 calls a day. Winter is our slower time. From 1 Jan to 6 Jan, we have averaged 304 calls a day. If this stays at this level, we will see over 110,000 calls. If it follows the pattern, we could break 115,000.
Prior to 1 Jan, we would be told to "clear the hospitals with out paperwork" about once every few days. This means as soon as you get a patient off your stretcher to get back on the street and do your paperwork later. Normally we have 20 min after arrival to complete the paperwork. But if we have all the squads in the ED doing paperwork, 911 calls can't be responded to. Since the first of the year, we have been told that two to three times a shift. (on the B shift anyways, and i've been told this is true for A shift.)
The reason is that not only are we bringing more people to the ED, but more people have been going to the ED. "walk-in's" have increased at the ED's i've been to. Even the ones that normally had empty rooms half the time are making us wait so they can "find a bed". Hall beds are becoming a regular feature in many of the ED's in the last week. (Charge Nurses HATE hall beds, and I agree also.)
Now is that due to ACA? Maybe. It could just be a bubble and we could see a reduction in 911 calls as people get treatment for their health issues. It has only been a week. Yet the state warned us to expect the increase and to expect that to become our normal. This is based on past experience.
Certainly Caused by ACA.
The number of calls from doctor's offices for emergency transport. Last year i did two calls where the person has an appointment at the doc's, shows up and the doc sends them to the ED for emergency treatment.
I've done five this week. In each of those cases the person made the appointment with their newly gained insurance. Each had been feeling bad for months but had held off on getting care because they did not have insurance. They got to the doc's office and we got called. I "blame" ACA for that. (a good blame, but it is a direct result of ACA, otherwise they would have just gone on suffering till they suddenly collapsed and died.)
Paperwork, Paperwork…I thought were were going to be all electronic?
While the ACA requires the Bush Administrations' goal to be 100% electronic in medical records and billing, it still counts as "paperwork" to those of us filling it out. (Bush set the goal of electronic medical records, the ACA gave authority to the DHHS to set up rules on them, and they said the goal will be met.)
On 1 Jan, I had two more tabs appear on my electronic Patient Care Report that were mandatory to fill out. One deals with insurance, the other is additional demographics about the health history. More mandatory tabs are coming. At the ED the receptionist is getting four forms signed where they use to get two. Nurses are having to chart more information per patient on intake.
The law did not say "you will gather the following…" it said regulations will be established by the DHHS. Which then made the rules to collect X and Y as mandatory collections and to submit it to them. (Why is my patients race a mandatory collection point? Really what does it matter?)
But each question we have to fill out takes more of our time. Right now we have 20 min from arrival to the ED to unload the patient from the back of the squad, go to the triage nurse, give a report, get the patient registered with the Hospital, place them in a room/hall bed, clean up and sanitize the stretcher, restock the squad and complete the report. This is doable if, IF, the triage nurse is not trying to juggle 12 different things and you had a simple case. Yet we are told, more is on the way.
I'm willing to collect information from a person if it will help with their treatment and care and to a lesser extent billing. But what race they are, how often they go to the doctors, how often they did not have insurance, are they aware of smoke stoppers, work history, etc? I know a lot of "unknown" will be checked so we can close the report and get back on the road.
Challenges we know are coming but don't have details on.
The biggest will be the Accountable Care Organizations (ACOs), Medicare and Medicaid payments will be tied to these ACO's. These are "groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare/Medicaid patients". And the ACA requires Medicaid/Medicare providers to ensure that a person is not re-admitted with in 30 days for the same issue. (a person with COPD - breathing problem - who gets out of a two day stay at the Hospital, gets admitted to the hospital 28 days later with another bout, could get the Hospital fined for not complying with the Outcome Based Patient Care rules.)
These ACO's will have a lot of power in deciding what treatment and care will be paid for over time. (the origin of the "death panels") Treating a person with a chronic condition over and over in the ED is not Outcome Based Patient Care. A better way would be to make sure they take their daily medication which would prevent their chronic issues from flaring up week after week. But no one is suggesting that doctors be paid to make twice a week visits to these chronic patients. (talk about expensive!)
ACO's also have to ensure that medical records are transferable between area care centers. What is not clear from the regulatory side is does that include EMS? Does ACA require the including of EMS into the ACO's? Some say yes. We are the front line care, the ED on wheels. In an cardiac arrest we can do everything they can do in the ED for the first 20 min. OBPC starts with us, determining that Patient X who just 28 days ago came out from a stay with COPD, is now having a heart attack that is presenting as a bout of COPD would help prevent fines.
Others say no EMS is not allowed to be part of the ACO's. We have no say in how often someone calls us, our care we are allowed to provide is limited and established by the State or Region. We already take a 10% hit to our cost for every Medicaid and Medicare transport (if they approve paying the EMS bill) because their repayment is that much less than our cost. By law we can only transport a 911 call to an ED. So we would not be able to do anything to help OBPC.
Can EMS help lower ED usage and medical costs under ACA?
ACO's doing OBPC should lower costs with out limiting access or feeding the "death panel" lie. I think, and many in the EMS world also, that your Paramedics and EMS systems can do more..IF we are allowed to.
A Paramedic gets paid about $15 an hour as a national average. (on the high end i've seen $25 and the low $10. Please note i'm not talking about Firefighter/Paramedics who get FF pay) A Registered Nurse gets about $33 an hour, between $25 and $46. So your "average" Paramedic (actually we are all extremely above average) costs half as much to send out to check up on people. We also have a better eye for how people are in the non-hosptial environment. (and are more likely to know where an address is as finding them at 0200 in the rain/snow is what we do)
This is called "Community Medicine". Our 911 center could tell you the top 20 people who use 3% of our calls in a year. Yeah, out of 750,000+ people, there are about 20 who every paramedic knows their name, medical history, drugs -prescribed and non, and address. Ten of them would benefit from begin checked up on twice a week to keep them compliant. (IMHO, the other ten are abusing themselves and won't stop unless you strapped them to a bed 24/7/365)
ACO's should be looking to the EMS system for this rather than the higher cost RN's.
Another thing that ACO's should consider is getting laws changed so that EMS can "Treat and Release", "On Site Medical Triage", and "non emergency transport diversion".
Treat and Release would be where the EMS provider treats the person at the site and then clears them from the need to go to the ED. A classic example is the person with "low blood sugar". We show up and they are having trouble responding to questions, standing, covered in sweat and can't swallow. We start an IV, push "sugar" into them (D50) and they come back to normal. Right now by law (in the two states I am currently licensed in and three other states i've worked in), because they had medical treatment, they have to go to the hospital ED to be cleared. We have to do our best to get them to go.
With T&R, they could be cleaned up, IV removed, sign a document that they will follow up with their doctor and we would be back on the street.
On Site Medical Triage is a step beyond the 911 triage. Right now, someone calls 911 and the dispatchers determine the best they can the urgency of the call and try to send the most appropriate care level to the caller. (In our system we have two levels of Ambulance: Basic which is two EMT's who can provide basic level of care, and Advanced which is at least one Paramedic and one other person often an EMT who can provide advanced level of care to include drugs and invasive treatment)
What happens is the 911 center is making a good guess based off a phone call. They are not there. Many times…ok, Most of the time, the caller is inflating the nature of the issue or was not clear on what they needed. Once the Paramedic is on the site, they can better asses the situation.
Here is an example: 911 is called and dispatches an ALS crew to a Sudden onset of Shortness of Breath/Air. We arrive and the person is laying down on the couch, smoking a cigarette. Some quick questions and they explain they "just have not felt well", like they are out of breath if they do anything. (And they told this to the 911 center which erred on the side of caution with the dispatching.) They have a fever, chills, runny nose, and feel tired. It is flu season and they did not get a flu shot.
Right now, we are going to have to take this person to the ED. By law unless they refuse to go and we can't try to talk them out of it. So the medical cost will be an ED visit and an Ambulance transport. Neither is cheep.
OSMT would let us do a check of their vitals, assess their status and then, if warranted, turn down the request to go to the ED by ambulance. (which is what a 911 call is). Making other arraignments for transport would be an option, such as calling a cab. Or explaining that they are not having an emergency right now, but rather a medical condition that could be treated with over the counter medication and scheduling a doctors appointment.
In line with OSMT is non emergency transport diversion. They would go hand in hand. Right now, a 911 call is only going to transport someone to an ED. Not to a dialysis center, doctors office, Urgent Care Clinic, community center. We can't take someone to a mental health center directly, they have to go to an ED.
If we could transport to other locations in a non-emergency roll, we could OSMT a person, then arrange for a diversion pick up. Two EMTs ($9 to $12 an hour) with a van or ambulance that is set up for multiple seated patients could pick up the person in the example above, take them to the Urgent Care or Community Center as well as other people, still be on hand for any emergency with equipment. They could take the person who is on the street, who wants to get back to being compliant with their medication directly to a mental health center. (this has had great success in North Carolina, freeing up many beds in the ED from mental health patients.)
Between 16 and 20% of all calls to 911 are actual Medical Emergencies. (based off a recent study in Maryland. My experience says more like 10% but that is one person's view of the calls I've taken.) 80% of calls are requests for transport for medical care. The person calling wants to receive care for non-life threatening medical issues. This could be for sunburned legs (really happened) to really bad flu to painful productive cough. Each one of those non-emergency calls ties up an ambulance that now can't respond. Being able to divert to lower level of transport would save money.
Please note: i'm talking about 911 calls. Not non-Emergency Medical Transport, this is the person who needs medical supervision or care, but is not an emergency. Such as the recent hip replacement who is going from the hospital to a nursing/rehab center. They need a stretcher with some medical support. They are not going to hop in a car and drive over. But most cities and states use private non-government/non-volunteer companies for this.
Over the long run, i'm expecting the following in EMS because of ACA.
First more doctors to ED calls for the next several months.
Next, more calls and fuller ED's.
Then more lectures from management about how important it is that we gather this demographic and insurance history is.
Next, more non-medical information that is mandatory to collect.
Then a better bargaining position for EMT's and Paramedics to get better pay and work conditions.
Will be able to work with ACO's and do some of what I suggested? Don't know, I hope so.
I'm sure some people reading this will say "my state does not requirer X or Y" And you might be right. The Journal of Emergency Medical Service often gets great articles that advocate doing Y or X only to find out that in 29 states you would go to jail. (or lose your license for breaking the rules)
I'm sure some with think i'm making up these examples or numbers. I will use the defense that this is what i've seen. (Others will chime in with even worse examples they have had. EMS is full of cases of medical WTF's) I don't claim this is 100% correct for my area. This i my POV from what i've seen. Take it for what that is worth.