Tuesday, May 27, 2008

The Ambulance Business is Changing

As you may know, I'm a fairly busy EMT. I'm also currently the president of a volunteer ambulance corps that has about 100 members and gets about six calls every day. I've been a medic since 1999 and covered about 2,000 calls since then. It's mostly routine for us, but I and my partner often make a stressful situation much more bearable for the people we serve . In recent years, however, the ambulance business has changed a lot and not always for the better.

The first change was the gradual increase in the number of calls coded for paramedic support. Paramedics are highly trained emergency medical providers, and they get paid. What they do is called "advanced life support", which includes cardiac monitoring, invasive breathing support, and administration of powerful drugs ususally via IV. They can also do heart pacing and other cool things. The thing is, their specialized skills are required only in potentially life threatening situations. The great majority of patients simply need a ride to the hospital, or some oxygen, or to have their broken bone stabilized prior to being transported. But paramedics are being dispatched on many more calls than previously, partly because there are more of them and partly as "defensive medicine". EMT's are going the way of the dinosaurs, since they run fewer and fewer calls on their own and often stand by while a paramedic performs unnecessary procedures on a patient.

You may say, "This is great!". You get a more qualified person to help you when you're sick or hurt. That part is true. The other side of the coin, however, is that you get a much bigger bill for ambulance services. The company that employs the paramedic is going to charge you (or your insurance) about $400-$500 for 15-20 minutes of monitoring you on the way to the hospital, whether you really need it or not. EMT's, on the other hand, are pretty well trained to evaluate symptoms and determine whether or not a paramedic is needed. We are much less expensive, or even free of charge, like me. But we are being pushed out in favor of much more costly professionals. I may ultimately stop doing this work because cases I used to handle without incident are now being coded for paramedic involvement. The patients are seldom any better off, but they pay a lot more and I get bored.

The second issue involves reporting requirements. When I started we had one version of a written report. A few years later we got a new report form, much improved in my opinion, with lots of check boxes for what we found and what we did for the patient. Recently we have gone to computer input of our reporting - we have laptops on the ambulances and we can access the software from any internet computer. Completing this computer-based reporting (about 8 screens worth) takes at least 30 minutes per call - after the call. We once were able to come back to the base, write one or two more things on our mostly completed paper-based reporting, and be done. Now we need 30 minutes to finish the call on the computer. If we get three calls in quick succession, we get to do 1.5 hours of keypunching when we finally get home to the base. That stinks! Worse yet, it's hard to see whether this adds anything of value to what we've already done. Why should a volunteer have to put up with this?

This tirade is aimed at those who think that more is always better. It's not. Life is all about trade-off's. "More" costs more. "Is it worth it" is seldom asked. In my view the cost of living in America is going up in many cases simply because that simple question is not being asked or answered. There is little doubt that many more paramedic jobs, paying from $15-25 per hour, often with benefits, are being created. Also, electronic reporting provides a great mass of data about ambulance calls. But are these things really improvements? In my view, we pay a hidden tax by being provided with more qualified care than is necessary or requiring ambulance personnel to spend more time preparing a report than they just spent taking care of a patient.

Am I the only one who feels this way? No. My own physician complained bitterly about his own computer-based reporting when I last visited him, and I know he's not allowed to do simple procedures that my family doctor routinely performed 50 years ago. The medical profession is being overwhelmed at all levels by the bureaucracy and defensive medicine.

If we are ever going to have an excellent and efficient national health care system, those who implement it will have a lot of choices about where the money gets spent. If they opt for defensive medicine at every level, which seems to be the trend, health care will bankrupt our country. Think of an agency like the boneheaded Homeland Security agency for health care - bureaucracy in triplicate and job #1 for everyone is to cover their "behind". Sanity is needed, but government seldom has it. So, a fine volunteer agency like mine has experienced people with great records pissed off and ready to quit because government is getting overly cautious and intrusive. Is this the America of self-reliance and freedom, or is this the coming America of the bureaucrats?


ThomasLB said...

I think businesses in general are trending toward too much paperwork. It's how middle management justifies its existence.

When I first worked at Du Pont twenty years ago or so, you could buy something simple like a valve and just put down the company and model number on the form. A few years later we were basically copying over all the information in the catalogue- all so our manager could look important walking around with big reams of data under his arm.

The designers used to keep track of a project using 3x5 index cards. When I left, the database had 256 fields for each and every item- and they wanted more, but at the time that was the upper limit the program allowed!

Dave said...

Another problem with medicine is the payment system. I used to go to an internist every six months. He would come into the room say hello, prod and pound a bit and then tell me I was due for a test or two. The reason? My insurance would pay for that the test(s). Were they medically needed? No.

He and I parted ways.

My dentist referred me to an endodontist (?) to determine if I needed a fairly major procedure on my gums. He determined that I did. When it turned out that my insurance wouldn't pay for it, he magically decided that a less invasive and less costly procedure that my insurance would pay for was necessary. We also parted ways.

Neither example is "defensive medicine" rather it is greedy medicine.

Lifehiker said...

My teeth (I still have them all) have food-catching gaps due to periodontal work recommended by a dentist who was colluding with a periodontist. I was the sucker who trusted "professionals".

I agree with Dave. We are at risk from both bureaucrats and greedy medical providers.