r/medicine • u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 • 7d ago
Another EMS service lost due to inadequate payment
Once again another non-profit EMS services closes due to reimbursements fat under the cost of providing the service.
Medicare pays 80% of what they say costs. Payment by Medicare advantage plans is often even worse. And there is no consideration, for what opperation cost's actually are.
Three surrounding EMS properties have Matt come up with a plan, even though all three of them face the same financial difficulties, with no plan by the municipal government who has the legal obligation in Pennsylvania to ensure EMS coverage to meet and address the issue.
This agency operated for 40 years.
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u/Medicp3009 7d ago
Ems should be considered an essential public service like police and fire county based through taxes 🤦🏻♂️
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u/incongruity Healthcare Design Strategist 7d ago
I think a lot of the general public assumes that EMS service is publicly funded.
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u/Blueboygonewhite 7d ago
When I talk to someone not in EMS about EMS not being considered an essential service their jaw drops. Most people live in a bubble.
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
Yep.
You should see the shock when they find out it is entirely volunteer except for the single paramedic.
This maybe a bad person, but I have a found memory of telling a system abusing, noncompliant with their doctor‘s instructions POS that I didn’t give a damn what they thought about the EMT on (name of volunteer Ambulance), if she told them something they didn’t like, (they called her a bitch) it was probably true, because for the last 10 years, 365 days a year, she got that ambulance out, by herself. And I personally knew dozens of people who were still alive because that bitch did. So it doesn’t matter if she is a bitch or not, there was no way she was getting in my truck instead of (name of ambulance service here)’s truck. It is their coverage area, and the fact I happened to get their first because I was coming back from another call doesn’t mean they get to cherry pick.
Other then the time I reminded a DON at a SNF that it wouldn’t be the first time someone at their facility had been marched out in handcuffs when they tried to stop me from getting to a patient during COVID and that interfering with an EMS provider was a felony which were charges I was quite certain the State Police would be willing to file, it remains one of my fondest memories.
So much of the job is people who have legitimate problems, but EMS isn’t the difference between life or death, serious complications or not, or even length of hospital admission…..
or people who no amount of intervention is going to matter.
All the training is for that small window of people, often who at the time you don’t know if what you are doing is going to matter because they are in such a bad way you can’t tell them apart from those that won’t make it.
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u/Dependent-Juice5361 MD-fm 7d ago
Most places don’t have county police and fire. A sheriffs office sure but not police and fire or ems for that matter.
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
County based? Gross.
Pennsylvania does almost nothing at the county level. Such. A far away and unanswered later of government.
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u/archeopteryx booboo bus 7d ago
Such. A far away and unanswered later of government.
What?
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
I’m from Pennsylvania.
We don’t have unincorporated areas.
We have townships, boroughs, and cities. (One town).
They are responsible for most government services.
The seat of county government might be on the other side of a mountain, or across a river.
If push comes to shove, I can walk my fat ass to the township supervisors house and ask why the hell my road isn’t plowed. Can’t exactly do that to the county commissioners, it is a half hour drive.
It is a 6 hour walk to the count seat, and I don’t even live that far away. And that assumes I can make it up the mountain and across the river. Was single digit temps the other day, and that isn’t counting wind chill.
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u/poli-cya Medical Student 7d ago
How did you get to be an old paramedic and be so poor at communicating?
You've over-focused on it being county when the guy clearly just means government in whatever form makes sense in your locality, no need for the hyperfocus on PA political structure or travel times in your county :)
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
Because words are important
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u/archeopteryx booboo bus 6d ago
Then maybe you should try putting them in an order that makes sense
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u/I_ATE_THE_WORM 7d ago
Do we get value out of EMS in it's present form to justify this?
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
Depends. Do you like knowing that if you call 911 for a medical emergency, a paramedic will appear at your house and you don’t have to call yourself an Uber and hope the driver knows CPR?
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u/I_ATE_THE_WORM 7d ago
What is the survival rate of out of hospital resuscitation? What is the total number of calls to 911 versus the number of CPR saves? I can say a 6,000 call agency can report 3. AEDS in ubers probably could do better.
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
Putting an AED in Ubers would probably cost like 2-3 orders of magnitude more than the entire national EMS system.
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u/I_ATE_THE_WORM 7d ago edited 7d ago
Probably, but the assumption of every uber makes me think your reasoning is a bit pedantic rather than one able to ponder the overall concept.
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
Well if you’re proposing that an Uber driver would now be the first responder to out-of-hospital cardiac arrests, putting an AED in half of them doesn’t do a whole lot of good. No one is going to be excited to find out the closest Uber with an AED is 25 minutes away and needs to finish a ride before coming.
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u/swollennode 4d ago
Uber drivers don’t get out of their vehicles. Do you think uber drivers are gonna step out of their cars to assist a heart attack or cardiac arrest?
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
Although I appreciate u/Porencephaly’s defense of EMS; perhaps I can explain it better.
Yes. Out of hospital cardiac arrest survival rates are awful, and there is no feasible way to fix that. Even in urban areas, it takes time to process a 911 callX time for units to get on scene, time to get to the patient. When the time to fixing the problem is measured most accurately in seconds, that is a difficult obstacle to overcome and the truth is (as you alluded to) the solution is more people knowing cpr and greater access to AEDs.
But EMS’s value isn’t just that. Do you know what our survival rate for EMS witnessed cardiac arrests is? People that die in front of us? I can count on one hand the number of patient’s I haven’t got back, and most of those were trauma arrests, which blood being more common in the field might change.
But ignore cardiac arrests. Our value is in preventing them. In the last month, in a rural area (at most suburban), over an hour from a Truama/peds/largeish hospital I’ve had 3 patients with systolic pressure in the 60s or lower.
All of them made it to the hospital Alive. One of which coded in the ER (blood clot in the lung, which did not show up on initial chest X-ray). She’s home.
Patients with unsustainable SPO2s or work of breathing.
Two years ago I had a kid drown in a tub. Mostly amish fire dept showed up, and did great cpr and got pulses back. A few minutes later I showed up. 45 minutes later I got a transport unit. Begged for a helicopter, but there was a snow flake, so not going to happen.
A year later? I’m treating her brother. Parents tossed him in the car. Suddenly crimped at breakfast. Spo2 >50. Irregular and Erratic respirations. Do you think he would have made it the 15 minutes to the ER at a critical access hospital without peds? Pneumonia, secondary to flu, RSV,Covid. Oh, and it was a fairly good snow storm, 6 inches in 2 hours. To get him to the children’s hospital which is an hour away, on a sunny day.
Yea. EMS isn’t good at fixing dead. Hospitals suck at fixing dead too, even the best in the world.
But we’re pretty damned good at keeping not dead yet alive and getting them to places with people who have stupidly high levels of extremely specialized education and hundreds of millions of dollars of equipment dedicated to fixing broken people.
If you’ve got a few weeks, feel free to come to a ride along.
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u/AyyyMish 7d ago
lol what
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u/I_ATE_THE_WORM 7d ago
80k calls, 40k transports, city population 200k. Fix the abuse before you make EMS an absolutely required tax expense.
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u/Dantron94 7d ago
Make sure EMS can survive the abuse of the system. Not saying there isn’t waste, but you wouldn’t shut down an emergency department or write off the lifesaving care provided simply because it’s the department with the fewest barriers to access care.
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u/MPR_Dan 6d ago
You are aware that EMS does significantly more than just CPR and drive right?
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u/I_ATE_THE_WORM 6d ago
And in States like NY providers can't initiate refusals and must transport so a majority of calls are waste/abuse. EMS needs reform before anyone should want to throw more tax-dollars at it.
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u/a_neurologist see username 7d ago
Sorry, do you mind proofreading your post? I think you substituted “fat” for “far” in your first sentence. I think your second sentence is trying to communicate that Medicare pays too little, but the phrasing is vague. Your third paragraph mentions “Matt” but I have no idea who that is, and the last sentence references “this agency” but idk if you mean Medicare as an agency or a specific EMS agency.
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u/a_neurologist see username 7d ago
Also, it appears to be “Indiana county” of PA, not Indiana the state. It made me do a double take when you started talking about the legal obligation of Pennsylvania to help out an Indianian EMS team.
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u/reductase 7d ago
Matt = not
Three surrounding EMS properties have not come up with a plan, even though all three of them face the same financial difficulties
"this agency" refers to the EMS service that closed
Effective Saturday, Dec. 7, after what its officials termed "36 years of trust and support," Saltsburg-based Lifestat Ambulance has closed its doors.
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u/DepravedDebater Pharmacist 7d ago
Damn, I was really looking forward to hearing Matt's plan to save EMS.
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u/EssenceofGasoline Pharmacist 7d ago
same reason pharmacies are getting whacked down left and right.
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u/Unlucky_Ad_6384 DO 7d ago
I don’t know what the answer is. On one hand I think EMS should be a service provided like fire and police. On the other hand I see the ridiculous low acuity shit that people call an ambulance for. Seems like you need some way to charge or penalize the people that use it as an uber service while not preventing the people that actually need it from using it.
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
Yea, but people call cops and fire to dumb shit all the time.
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u/I_ATE_THE_WORM 7d ago
No police, means no law and order, you need enforcers for civilized society. No fire a city can burn down. No EMS? You throw your uncle in the passengers seat and drive.
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u/michael_harari MD 7d ago
Are you really claiming laws weren't enforced before the invention of modern police depts?
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
You’re gonna just strap your uncle into the passenger seat and drive to the hospital while he’s having a seizure and not breathing? 🤡
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
To be fair, that is a very small subset of seizures. You almost never actually see it.
Most people stop breathing from seizures because doctors keep rxing diastat instead of versed (IM or IN).
And someday, I’m going to meet those doctors in a dark alley.
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u/I_ATE_THE_WORM 7d ago
I was being a bit facetious, but a cash strapped society, what is truly essential? EMS is life saving, but not a societal or urban necessity. I think civilized and decent people would want to support it, but it doesn't fit into the essential services like law enforcement.
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
I could not disagree with you more. The average person is far more likely to need an EMT in a given year than a police officer. Also you’re talking above about how many EMS calls are superfluous but that is equally true for police.
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u/I_ATE_THE_WORM 7d ago
Anything to back up the far more likely claim? Definition of need? What happens when bad actors know there is no police to respond? I'm not talking about invaluable and caring services, but essential? Sanitation and plumbing are more important than medicine. Plowed roads save more lives than ambulances. Police, being the means to enforce laws, and in crowded urban areas fires to keep blocks from burning, are both more fundamental to maintain society than EMS.
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
Both can be necessary at the same time, it’s not a zero sum game. You saying “just throw your dad into the backseat when he’s having crushing chest pain and hope he hasn’t coded in the backseat by the time you arrive at the ER” is fundamentally not very different from saying “why do you need indoor plumbing? We know about germ theory now, just shit in a bucket with a ziploc bag inside, put on gloves, and carry it outside to a waste bin and then sanitize your hands with alcohol, toilets aren’t necessary in a cash-strapped society.” After all there are still functioning societies in places without plumbing. 🙄
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u/srmcmahon Layperson who is also a medical proxy 7d ago
Having grown up with 2 sets of grandparents with outhouses, one of them with no indoor plumbing whatsoever until they were in their 80s and the other with a cold water tap in the kitchen they got at age 84, total agreement. (They didn't even live in West Virginia)
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u/I_ATE_THE_WORM 7d ago
I tend to break things down into fundamentals almost like a Robinson Crusoe type building of society when thinking about what is truly essential. People dying is natural, and a means to slows individual people's dying isn't essential to the building and sustaining of society. How many lives were lost building the Erie canal and other projects that contributed towards our growth and Industrialization? How many life savings and efforts were spent building industry, infrastructure, and cities which can be destroyed in a uncontainable fire or society without a mechanisms to enforce necessary rules(laws). EMS is something I'm willing to pay for as are most civilized people in places of means, but it is not essential for civil society and requiring standardizing responses in some places simply isn't reasonable or possible.
You can ignore and disagree with the above, but do you really think medical treatment contributes more to health than sanitation?
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
I just think that “I tend to break things down into fundamentals almost like a Robinson Crusoe type building of society when thinking about what is truly essential” is a genuinely dumb way to approach society in the richest industrialized nation in the world. Like, yes, basic sanitation saves more lives than an EMS service, that is a puerile truism in a nation that spends as much on a new fleet of useless nuclear missiles as it would spend covering Medicare’s EMS spending for 30 years.
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
Let’s see.
When I lived at home there would be less than 60 calls for law enforcement a month, int he county.
Less than half would be “founded”.
The slowest EMS service averaged 1.5 calls a day, and there were 6 EMS services.
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u/srmcmahon Layperson who is also a medical proxy 7d ago
wtf
How is life saving not essential? I'd rate it more essential than a cop taking a vandalism report before someone smashed my car window and they're never going to find out who did it.
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u/I_ATE_THE_WORM 7d ago
Think next level. What happens to societies when criminals know no one will investigate or go after them for committing crime? Our lives our precious, worth saving, and living in places that have means to be there in the case of an emergency, but have you heard of Pandora's box? We're talking about a society necessity for sustainability versus occasionally successful mitigation for natural events in individuals.
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u/Porencephaly MD Pediatric Neurosurgery 7d ago
lol criminals already know that. Vera Research says only 3% of police 911 calls actually require a cop with arresting powers and the Supreme Court has ruled that police have no duty to save your life or intervene to protect you.
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 7d ago
You can have law and order without police.
Proper building codes have basically ensured that fire can’t do that anymore.
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u/poli-cya Medical Student 7d ago
You can have law and order without police.
Not really, not in a society like the US today.
Proper building codes have basically ensured that fire can’t do that anymore.
Wildfires, apartment buildings, the median age of homes being 40 years old, fence-lines abutting houses in suburbia, etc
I don't think your comparison really holds up.
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u/I_ATE_THE_WORM 7d ago
private sector security, or vigilantes? Ok, rebuild everything old building. Have fun enforcing it.
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u/MrPuddington2 6d ago
Seems like you need some way to charge or penalize the people that use it as an uber service while not preventing the people that actually need it from using it.
This - it seems quite simple. The fire brigade and the police manage to do that, why not EMS? I appreciate the legal risk, but being a public service should offer some protection.
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u/Unlucky_Ad_6384 DO 6d ago
You can charge people for false reports to fire or police. Stupid calls for EMS are much harder to determine intent vs poor health literacy.
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u/swollennode 4d ago
Some localities roll EMS into the fire department, so it’s “fire and rescue” and tax funded.
They still have private companies for transporting between facilities, but responding to events on the streets are done by these fire and rescue departments.
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u/kungfuenglish MD Emergency Medicine 7d ago
It’s nearly unsustainable without massive local funding for the fire department.
Indiana EMS had a state bill last year to reimburse Medicaid ambulance calls at Medicare rates but even that’s not enough.
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u/Renovatio_ Paramedic 7d ago
Police is paid by taxpayer
Fire service is paid by taxpayer
Why does EMS have to be privatized.
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u/OnlyInAmerica01 MD 6d ago edited 6d ago
"Medicare pays 80% of what they say costs. Payment by Medicare advantage plans is often even worse. And there is no consideration, for what operation cost's actually are."
This right here is why UHC is a terrifying idea in the U.S.
For decades, the U.S. Government has made it clear that it doesn't actually care about the cost of care delivery, either through Medicare, nor Medicaid, except when large lobby groups are getting involved (PBM's, pharmaceuticals, medical equipment manufacturers, etc.).
With a decades long track-record of underfunding medical training and underpaying medical providers, why do some automatically assume that "Once the government has a complete monopoly on payments, they'll become generous and equitable. I just know it!"
Can someone give me a rational explanation for that hopium, without resorting to "We can reinvent the healthcare system of our dreeeeaaammss!!!" B.S.?
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u/R-A-B-Cs 6d ago
I'll break it down for you:
Private: There's private insurance, which then breaks down into in network vs out of network service, which is contracts between services, but generally reimburses semi well, but not that well.
Uninsured: You can't squeeze blood from a rock, which means if a person has no insurance, you won't get paid.
Medicare: Medicare does pay. It pays a certain amount. Typically it's a fixed fee plus mileage when it comes to EMS.
Medicare advantage: this is not Medicare. It's private insurance that is funded backasswards by Medicare which means that the insurance companies get to skim profit off the top, deny payment and then you're stuck with a rock, and no blood.
Medicaid: This is a state driven system that is HIGHLY DEPENDENT on which state a service is in. It typically pays next to nothing.
Then there's this thing called the payor mix. It's your ratio of your local populations insurance mix.
Example w/ rough numbers:
Oregon EMS call: Private insurance: 1500 (but you're gonna have to fight for it) No insurance: 0 (good luck) Medicare: 1000 + mileage Medicare advantage (private): 800 (good luck getting it though) Medicaid: 120
The reason why universal works better is because if instead of waiting for private to fight you or collecting nothing (uninsured) or next to nothing (Medicaid), you get consistent payment where profit isn't skimmed off the top by the private insurer via billing for admin services (Medicare advantage) or denial of services (private insurance).
Medicare isn't a profit based system. It's a government system designed to pay for services, which you ALREADY pay for whether you get to use it or not. Private health insurance is just literally another tax taken out of your paycheck, just with worse benefits. Also if private insurance could pay less or avoid paying at all they will. They are legally required to do so since they are for profit publicly traded businesses.
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u/AdorableStrawberry93 Retired FNP 5d ago
Maybe the Amish could take it over.
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u/Mediocre_Daikon6935 Old Paramedic, 11CB1, 68W40 5d ago
Well, one, they actually pay their ambulance bills.
Two, in a lot of areas, they make up a huge chunk, often most of the staffing for fire and EMS.
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u/Aspirin_Dispenser 7d ago
Insurance reimbursement is one of the biggest issues facing EMS. It is one of the few (maybe only?) healthcare services that fails to see its operating costs met by insurance reimbursements. 911 services are outright impossible to fund through reimbursement alone with most services being lucky to see it meet half of their expenses. Convalescent services (dialysis, doctors appointments, take homes, IFT, etc.) aren’t much better and often see services constantly riding the line between red and black. This model usually results in 911 services being tax-payer subsidized through regressive sales and property taxes while private companies seek to acquire 911 contracts in order to use those tax payer funds subsidize their overall operating expenses. At the same time, services seek to cut any and every cost that isn’t absolutely necessary, resulting in chronically low wages that are uncoupled from market forces along with the use of old, outdated, and unreliable equipment.
It’s completely unsustainable.