I'm a Paramedic for a major metro area and as such see the front line of expensive medical care - Emergency Medicine.
I have friends in the EMS world in four other states covering urban, suburban and rural EMS. What i've got to share is an antidotal set of views.
More after the squiggle.
Easy to point to and say "This is working!"
In earlier posts I pointed to some things I had noted of "Obamacare", ACA from now on, that showed it was working. Mostly the spike in the number of 911 calls from doctor offices/clinics. Basically someone goes to the doc not feeling well, and the doc takes a look at them and says "Why did you wait so long!" and calls 911 to take the person to the hospital for immediate medical care (STEMI's, Strokes, AAA's, etc)
In 2013 I made two such calls. In January I made three, February two, March two. In all but one case the person was at their first appointment since getting insurance. If they had not gotten insurance, they would have waited till it became unbearable (or worse). I call that a success for ACA, at least for these people.
Now keep in mind i'm one of 200 EMS providers for 911, and there are several private companies that also do such transfers on contract. I've heard this has happened to my friends also. Now the last two months i've not done any. And that would make rational sense this would do that. Now that they have insurance and have appointments, they are less likely (not completely, some are stubborn) to end up in that situation.
Not so easy to point to
Our call volume shows ACA is working, but not as expected --sort of. At the end of 2013, we were told by the State to expect a 10 to 15% increase in calls (over the 3 to 5% "normal" growth) because our state did the Medicaid expansion. The smartest people in the room in Frankfort stated this would happen because so many more people would have insurance they would not hesitate to call 911 like they use to. And they said this would not go down.
Here and in two other cities, I can say this was spot on. (the other city is in a non-expanded state and they have only seen the normal growth) We were doing daily volume in the middle of winter that we did in the height of summer (our busy season). We have longer waits at the Emergency Departments to transfer care, almost every day are out of squads and have to transfer 911 calls to private companies (who bill the person AND the metro gov).
This has not slowed down. The ER's are telling us they are seeing about the same increase also. The idea that now that the uninsured have insurance will reduce the amount of ED visits is not coming about. Not even over time. I've noted an increase is the "BS" calls. Nothing hard numbers, just more than what we use to get (knee pain from a fall four hours ago, sick kids with the sniffles, abnormal breathing that is not abnormal, etc).
Basically we are seeing 911 being used as a taxi many times. These people know it is not an emergency, and will even tell you they would have taken a cab but they did not have the money. (i'm not talking about the calls where there is not an emergency but the people reasonably thought it was - the person who came off the wagon of 12 years and now has slurred speech unsteady walk and confused behavior - signs of a stroke…or too much alcohol, and the family is panicked.)
This, we are told, is going to be the norm. It won't go down any time soon because the ED is easier to use than to make appointments. Under Medicaid, the ED cost the same as the Urgent Care and the same as making an appointment with a doctor in two days. (The ED is immediate and the Ambulance will take you, Urgent Care is quick but you have to get there on your own, and the doc's office makes you wait for an appointment AND transport yourself)
Our revenue is up. We have fewer unpaid calls. This is good as the number of "Self Pay" ("Screw-U Pay" as we use to call it) has gone down. Now much of that was picked up by the Medicaid expansion - after all most uninsured are low paid workers or unemployed. The people Medicaid was expanded to cover.
This means we will be in a better position to argue for better pay and more employees in the next contract negotiations. It also means the metro taxpayer is not having to shell out $9 million a year for medical care that is not paid for by the user. (more money that can go to parks, bike trails or even filling pot holes. Ha Ha, just kidding about that last one in this city)
The down side of that is the ED's are busy and have relaxed a bit on the diagnostic procedures they do. (we have also) It use to be a patient would say their chest hurt and that would prompt questions about how it hurts, where it hurts, and such to try to rule out the need for a 12 lead ECG and blood work. Because good odds on not getting paid for it. Now, they know they will be paid, so why not slap on some electrodes and just make sure it is not the heart. (yes, this has caught some MI's but most of the time it shows nothing just like the description told you it would not).
We have even changed our protocols to automatic 12 lead's on any (even identified non-cardiac) chest pain. Because they know they will get paid for the service.
The bad side of the Bright Side
We now have to document so much more. This is so billing can better justify the charge, defend against the claim of Medicaid fraud, and comply with ACA regulations. The health care law directed the HHS to establish rules for EMS and Hospitals (and doctors) to follow. Some of these rules are not simple clear straight forward. (legalese gives job security to lawyers)
As such I now face written warnings for not collecting demographics such as Race, Social Security Numbers, next of kin, place of employment, etc. I have to document all medical history the patient can remember - such as the 80 year old who broke their toe when they were in high school. Not just the medically important history. I have to try to get all the medications, dosages, vitamins, frequencies of anything they use and the reason they use it. (not as easy as it sounds when dealing with that 80 year old)
We can't just check off a box showing all is ok with a part of the body, now we have to document that it is ok. When we get to the hospital, we have to give a copy of the report to the nurse who is going to treat the patient, the triage nurse, and one for the doctor. Except we are all electronic records now. Guess what is not allowed to talk to the hospital medical records? (the rules allow for us to upload but not down load, except the tech says it is always a two way street because the rules require us to have access to all the history of a patient.)
This has resulted in a new paper form we have to fill out along with the electronic forms, yeah paperless!
More people have insurance now, we are getting paid more often for the care we give, and we are busier than we have been…ever. I had hopped it would slow down as people got to the doctors and got their chronic problems under control, but five months in, i'm not seeing it. (am seeing more insurance companies demanding proof that a treatment will be beneficial before approving it - such as implanted defibrillators. Which has a new product out called the "Life Vest" by Zoll. It is a mess when it goes off, like two smurffs blew up)