As I've written in the past about my very antidotal point of view on what is going on in my city since "Obamacare" (better known as ACA) has come into effect.
We are half way through the year now and it is interesting to see how things are going.
The doomsayers said (sayed?) that the economy would collapse as businesses could no longer afford to provide insurance, or would be fined for not providing insurance, or people would not be able to afford insurance and would go broke trying to pay for insurance to stay out of jail. (Yeah, if you did not have insurance you would be thrown in jail by the IRS. Really, that was said)
Well, the economy is kind of [bad word-ie] but has not collapsed. Generally things are slightly better and most people don't feel it is going to get worse, may not get better but not worse. (again, most people)
What we have seen is businesses using ACA as cover for a lot of things. My main employer now charges an automatic $50 a month fee for smoking and you have a limited time frame (that they don't tell you about other than in a foot note) to certify that you don't smoke - you sign a form stating you don't use tobacco and then, if they test you - and you test positive - they deduct the fee retroactively.
UPS non-union salaried workers spouses are no longer covered by the employer plan if the spouse has access to any other plan - to include Medicaid. My County Gov imposes a $100 a month fee if your spouse has access to another plan but does not use it, and they validate your spouses employment. (word has it that UPS will be trying to get the exclusion rule put into the next contract with the Teamsters, and has high hopes as they have given in on this with other contracts in the area)
These employers all blame ACA for requiring them to do this. A small coffee shop chain made the news for telling its employees to have their kids enroll in the SCHIP insurance because it was cheaper for the employer and the employee and the state does not have a change of coverage delay. (a very good argument for single payer, but kind of a scummy way to push it)
Other places have done the math and dropped coverage stating that by doing so, the employee qualifies for the tax breaks in the exchanges and will pay less for insurance. While the reality is the employer saves far more than the "fine" they will have to pay in a few years (that keeps getting waived for wealthy companies like McDonalds which is an issue, I’ll write about that later.)
But what about the effect ON the health providers on the front lines? The Emergency Responders, Paramedics, Emergency Departments? More (very long) after the squiggle.
I started writing this back in the first week of July. I normally write my posts on my phone when I’m between calls on the Ambulance. I can’t do that anymore. I just don’t have time between calls.
Basic Numbers:
We were told by the state that we should expect to see an increase of 70 to 90 thousand people with insurance that did not have it before. Out of a metro area that has 800 to 850 thousand people living in it. Most would be from the Medicaid expansion.
The State has not released numbers for the year yet...well duh right? But they do say between 120,000 and 420,000 now have insurance who did not. (The question is about those who did not have it before from family, spouse, charities, etc vs who has changed insurance) In my work, Paramedic in the lower income section of the city, I can say Medicaid has increased.
Prior to January, about 3 out of 10 Emergency Medical Service (EMS) calls were listed as "Self-Pay", meaning no insurance. Since January I've gone weeks with out selecting "Self-Pay". There are reasons for this, mostly that the State and several Community Groups hit our district hard with adds, registration drives, door hangers, etc. The downtown Hospitals would help people sign up if they stated they did not have insurance. The result was a lot of new Medicaid enrollments.
The State expected this and based off the last expansion they did, the service and Emergency Departments (ED) were warned to expect a 10 to 15% increase in usage on top of the annual growth. We had been seeing a 2 to 3% increase in calls to 911 for the last three years. This year, starting since 1 Jan, of about 14%. At the half way point we are on track to have 9% more calls than last year. It would be higher, but now the 911 service is passing the non-life threat 911 calls to private ambulance companies, taking about 5% of the call volume. (who I feel seem to not have any ambulances available when the call is in the low income neighborhoods but plenty for the wealthy suburbs – as well as charging more for the service while being much more aggressive about collecting too. Another issue to talk about later)
EMS View
I've asked my fellow EMS and they also report a lot, a whole lot, reduction in "Self-pay". We are seeing the predicted increase in calls and usage. This has resulted in longer response times because we are making more calls, even though we have reduced the turnaround time at the ED. Last year the system collected $14.8 million, about 60% of the billed cost. They won't say officially how they are doing this year but the budget forecast was $14.9 million. A number few think is realistic. (granted it was the same increase in collected amount we have been seeing for the last four years, it makes sense to budget on what you know you will see vs the potential you could get) Second hand reports from those who work the billing department is we are approaching 90% collection from bills but are being directed to code Medicaid payments as “intergovernmental reimbursement”. (Some suspect this is to make our service look more expensive and keep us from getting a better contract next year)
But Medicaid does not pay the full bill and we are not allowed to collect from the insured the difference. What this means is the service is not losing as much money on each run, but we are making more runs. This is where the math will have to come in after the year is over to see if we are better off or worse.
(example of how this could be: last year $10,000 was billed, and $6,000 was collected, a short fall of $4,000. This year we have $11,000 billed -10% increase - collect 90% of bills at 75% of billed amount. short fall of $4,475. preformed more work, billed more, and lost more money total but at a slower rate.)
Who is paying?
However, many are starting to question why we bill for 911 service. You don't bill for the police showing up or the Fire department. You pay taxes and that covers the cost. EMS billing in our Metro gov is not added to the budget of EMS, it goes in the general fund. This has raised questions about double taxation of those who can least afford it. (lower income areas have higher use of 911 than wealthy suburbs) But that is another debate.
Hosptials
Because we are seeing more 911 calls, we are taking more people to the Emergency Department...the only place we are allowed to take them by law. So the person who would be treated fine at an Urgent Care clinic 8 blocks away has to go to the ED downtown. The result is we are often backed up at the ED waiting to be triaged. Our ED's are packed. One hospital explained: in 2009 they had an average of 89 patients a day. In 2013 they averaged 101. Since the first of the year it has been 143 a day and they have gone on diversion 7 times this year alone (compared to an average of 3 times a year in past years). We now seldom see the waiting room empty even at 0300 in the morning.
Most of the ED’s are coping, but all are struggling. ACA seems to require more paperwork be done on each person who comes in, more questions asked before they can be put in the computer and assigned a treatment room. We have found one short cut, for the most minor cases, we just let the triage nurse know they can go to the waiting room, and that cuts our time down. Triage can also divert people to “Fast Care” – the urgent care place in the hospital, we can’t but they can.
I think some explanation of the intake process is in order: you arrive at the ED, bring the patient into the ED, go over to registration and give the Social Security number and birthdate, validate the address, name, and insurance. The registration then enters them into the system, prints out a writs band and “stickers” (bar coded). The patient has to sign some forms, then you go to the Triage Nurse, the Nurse has to ask a lot of questions and “officially” the patient has to answer not the EMS who asked the same questions on the way there. Then you get a room assigned. This takes about 20 min.
Now if the patient is dying or seriously hurt, we can short cut right to a Trauma or Cardiac room by calling ahead and the Hospital does all the registration after.
So, 20 min per patient, two triage nurses, five squads at the ED when you arrive, means you are down over 40 min just getting the patient off your stretcher. We have a 30 min limit. Because most triage nurses are willing to short cut as much as possible, we manage to get back in the squad under 30 min over half the time. We still have paperwork to do, and often do that on the way to the next call we picked up from the ED. (Bio clean up often happens while we are waiting for triage, one person stays with the patient, the other goes and cleans up the squad – which is violating procedure because you are not supposed to move a stretcher with just one person even just a few feet.)
In our area we have two major hospital chains, and one minor one. On of the major chains lost over a billion (with a B) dollars last year, so they cut the number of support staff to lower the projected loss this year to “just” $650 million. Now Nurses have to do most of the registration work, clean the rooms for turn over, and restock. They also reduced the number of Nurses from a 1 to 4 ratio to 1 to 5 in the ED. Those hospitals have intake times pushing 50 min, and are going on diversion (not taking patients) frequently. One of the main hospitals in that chain was on diversion for five days out of seven last month, “computer problems” (and several nurses called in sick due to over work).
View So Far
ACA has meant more work for EMS and ED’s. I’ve also heard that it is now harder to get an appointment the same day with doctors offices. We have increased the number of people with the ability to get medical care, but have not increased the number of providers. Our EMS service had its budget frozen last year and cut by 2% this year. The government has capped how many people can be employed in our department at a level much lower than in years past. They are quick to point to our “long down times at the ED” as a reason we don’t need more people. If we could be out of the ED in under 30 min 95% of the time, that would be the same as adding 5 ambulances. If we would get out in 20 min, it would be like adding 12 ambulances. We are also relying on the Fire Department to make calls and provide medical treatment till we can arrive. Which is fine, but many times in a true emergency you need Advanced Life Support (ALS) care from a Paramedic, and the FD has very few of those. (So do we, because they cost more to hire)
The ED’s are busy to swamped, as most of your patients self transport. So for every one that comes in by Ambulance there are four who walked in. Nursing is short, bed space is short, and most hospitals are hoping this is just temporary. Heck our Medical Director told us that we should see a reduction in 911 calls by the end of the year as people get use to having insurance and go to their primary care doc. Even though the State says you will see a small reduction in volume of calls after three years.
But then he won’t put in effect a rule to transport to the nearest appropriate hospital. We have to take the patient to the hospital of choice and if inappropriate explain and try to get them to change their mind. We have had to take people across the county, 30 or more minutes of highway driving, to the hospital they wanted to go to. Passing by five other appropriate hospitals. All because they think the place they are going to is “better”. (and getting upset when they are responsible for their own transport home) ACA discourages the “closest” hospital rule as part of its patient choice freedom, and our MD won’t make the effort to do the work to get it imposed.
It is frustrating to be dragged from your area, across the county, out of the area you are responsible for, for over an hour and half, having to have other squads leave their area to cover yours because someone with abdominal pain dose not want to go to the hospital 12 blocks away because it is not as good as cross county hospital (even though cross county has a higher rate of infection and more malpractice problems)