Tag Archives: health care reform

Changing the Paradigm of the Emergency Medical Services

 

Can the Emergency Medical Services Evolve to Meet the Needs of Today?

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The emergency medical services (EMS) provide a means of rapid treatment and transportation to definitive care for those people who suffer immediate life-threatening injuries or illnesses (Department of Transportation, National Highway Traffic Safety Administration, n.d.; Mayer, 1980). There are a number of models across the country and the world that are seeking to redefine EMS in a way that is more meaningful in both of its missions, public safety and public health (Washko, 2012). However, financial constraints and overzealous regulations serve only to pigeon-hole EMS into the decade of its birth and refinement, the 1970s, by restricting incentive and growth and limiting the efficacy of directed research and its application towards the much needed restructuring of EMS.

In this brief literature review, I will examine the roots and context of EMS, its mission and current application, as well as possibilities for research, growth, and development. It is important to recognize that EMS is a grand resource for both public safety and public health, especially in light of the growing body of legislation that officials are using to redefine the current health care system within the United States. As we continue to develop EMS, other nations will look to us as they have in the past to adopt and adapt our system for use throughout the world.

A Brief History of Contemporary EMS

There were many forms of organized out-of-hospital medical aid provided throughout history from the biblical good Samaritan to the triage and extrication from the battlefields of the Roman conquests and the Napoleonic wars through the U.S. Civil War and every major war and conflict in U.S. history; however, it was not until the advent of combined mouth-to-mouth resuscitation and closed chest massage (what we know today as cardiopulmonary resuscitation, or CPR), enhanced 9-1-1 for use by the public in summoning emergency services, and the release of a 1966 white paper prepared by the Committee on Trauma and Committee on Shock of the National Academy of Sciences, National Research Council, that we have the EMS system that we are familiar with today (Department of Transportation, National Highway Traffic Safety Administration, 1996). It was about this time that the Department of Transportation (DOT) was given purview over EMS at the national level with the passage of the National Highway Safety Act of 1966.

During the 1970s, EMS had transitioned from mostly untrained funeral home drivers to providers trained by emergency physicians to treat many of the life-threatening scenarios that prevent people from seeking medical attention at hospitals, such as traumatic injuries, cardiac arrest, and many breathing problems. Since this time, there have been a number of concerted efforts and official recommendations by the DOT to augment and improve the delivery model of EMS throughout the country (Department of Transportation, National Highway Traffic Safety Administration, n.d., 1996, 2008). As early as 1996, the DOT published the vision of the future of EMS:

Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net. (Department of Transportation, National Highway Traffic Safety Administration, 1996, p. iii)

Even as today’s emergency rooms, operating suites, and trauma centers throughout the world are overflowing capacity with an increasingly deficient workforce, EMS is expected to answer the call for help as the front-line of a fractured and inefficient health care system (Kellermann, 2006; Mason, Wardrope, & Perrin, 2003; O’Meara et al., 2006; Washko, 2012).

Hampered Efforts

EMS is known throughout the United States as rapid responders in times of medical and traumatic emergencies; however, ever-increasingly, EMS is being used as the front-line alternative to primary care for the non-emergent uninsured and under-insured patient population (Heightman & McCallion, 2011; Washko, 2012). There is a limited number of ambulances, EMTs, and paramedics available at any given moment, which is subject to financial constraints, and non-emergent use of these resources prevents their availability for when a true emergency arises. Secondary to the mission of providing care to the public, EMS is also needed to provide services for fire department and police department operations, such as firefighter rehabilitation at fire scenes and tactical medicine in concert with bomb squads, S.W.A.T. teams, and hazardous materials teams.

EMS resources are costly, and overburdened systems are negatively affected when these resources are misused, especially by those who are unwilling or unable to pay for the services.

Financial Impact

According to the DOT (2008) EMS workforce report, employers reported difficulties in retaining EMTs and paramedics partly due to the inability to raise wages or provide better fringe benefits. The report goes on to show that EMTs and paramedics suffer a wage disparity when compared to other similar public safety ($12.54/hr vs. firefighters: $26.82/hr; police officers: $22.25/hr) and health care workers (licensed vocational nurses and licensed practical nurses: $16.94/hr; respiratory therapists: $21.70/hr; registered nurses: $26.28/hr). In the five years leading up to 2005, the average wage for EMTs and paramedics grew only by $0.29/hr. It is important to note that these numbers do not take cross-trained firefighters and police officers into consideration.

Furthering the concern of wages, as the DOT (2008) report shows, is the lack of growth potential within EMS as most systems lack the ability to provide a meaningful career ladder to the EMTs and paramedics in their employ. These circumstances together create the scenario that EMS is an underpaid dead-end job causing high attrition as most EMTs and paramedics either suffer from burnout, culminated psychological stress from the job, or use the profession as a stepping stone into other health care fields, such as nursing, respiratory therapy, or physician-level medicine.

The DOT (2008) report provides evidence that transport-based reimbursement policies are likely to blame for the unusually low profit margin in EMS (Heightman & McCallion, 2011). The Medicare and Medicaid programs, as well as many private insurers, require documentation that the transport of a patient be medically necessary before they will pay; however, the Medicare and Medicaid reimbursement rates are very low and do not cover the cost of EMS operations. To complicate the matter, EMS providers are mandated by law to provide care to the public regardless of their insurance status or ability to pay (Heightman & McCallion, 2011). EMS is subsidized by either taxes or insurance reimbursement or some combination of the two.

Broad Mission

In addition to providing for the mundane care and transportation of the ill and injured and performing ancillary duties for the police and fire departments as noted above, EMS is tasked with disaster preparedness – preparing for the major incident that is highly unlikely to occur but would be devastating to lives and infrastructure if it does. That is if the EMT or paramedic is employed for an emergency service. Many of the EMTs and paramedics, today, are employed by private ambulance services who transport non-emergent patients to and from skilled nursing facilities and doctors’ offices. The multitude of these EMTs and paramedics are not considered when planning for emergency response schemes.

I consider EMS to be the caulking used to fill many of the fractures and gaps in today’s health care system. If it occurs outside of the hospital, then EMS will take responsibility, yet, they seldom get paid for their actions.

Proposed Solutions

There has been much talk over the past few years regarding the efficacy and efficiency of EMS, and all agree that the current definitive model is inefficient with, at best, questionable efficacy. Washko (2012) describes in detail the number of EMS schemes and their shortfalls. In his article, Washko is correct in stating that transport-based reimbursement policies fail to reward the greater EMS community for their willingness to take on further responsibility within the two scopes of operation: public health and public safety.

Wingrove and Laine (2008) explore the opportunity for training and equipping the most experienced paramedics for a public health centered role delivering community-based care. These community-based paramedics are described as augmenting the traditional emergency responder role with opportunities to direct patients to more appropriate care, such as doctor’s offices and urgent care centers instead of hospital emergency departments when appropriate to their condition. This model was researched recently in Australia with good results, and is now a recommended career path both there and in the United Kingdom (Mason, Wardrope, and Perrin, 2006; O’Meara et al., 2012). In the U.S., EMS professionals feel a responsibility to participate in disease and injury prevention efforts, and research on models that utilize specially-trained paramedics to perform home safety inspections, hazard mitigation, and reduce the risks of injuries to children have proven effective (Hawkins, Brice, & Overby, 2007; Lerner, Fernandez, & Shah, 2009). Hennepin Technical College, in Minnesota, now offers certification in Community Paramedic training when the recommended curriculum is provided by an accredited college, according to Wingrove and Laine.

Other, more immediate (but, arguably, less meaningful) solutions, as Washko (2012) describes, are incorporating operational tactics that better utilize ambulances by attempting to predict call volumes and locations based on historical data, the high-performance model. This, however, creates high-call volume, less resource driven scenarios with ambulances idling on street corners awaiting the next call. As mentioned earlier, attrition is a significant concern in EMS and these tactics are demanding on providers physically and psychologically leading to high incidences of burnout and injury (Department of Transportation, National Highway Traffic Safety Administration, n.d., 2008).

Discussion

The standard operational benchmarks of EMS – response times and mortality and morbidity of cardiac arrest – are antiquated measures and typically distract policymakers when they are considering financial incentives for EMS (Heightman & McCallion, 2011; Washko, 2012). EMS needs to evolve with the changing health care system, and I feel that it is poised, specifically, to help address disparities in health and health care. Using the community-based paramedic model of health care delivery, we can address many public health concerns, provide for public safety, and still maintain the traditional role of emergency responder. The community-based paramedic model will provide an acceptable alternative to the options that lie ahead.

The economics of health care is a reality that must be considered by every EMS operation when approaching growth and change. As long as EMS can fill the gaps in the current health care system, it will be worth the money required to subsidize a robust, well-trained, and well-equipped contingent of emergency medical professionals. In the meantime, though, EMS agencies will have to seek more efficient models that maximize reimbursement while minimizing costs.

References

Committee on Trauma & Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. (1966). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Author.

Department of Transportation, National Highway Traffic Safety Administration. (n.d.). A leadership guide to quality improvement for emergency medical services (EMS) systems (Contract DTNH 22-95-C-05107). Retrieved from http://www.nhtsa.gov/people/injury/ems/Leaderguide/index.html

Department of Transportation, National Highway Traffic Safety Administration. (1996). Emergency medical services: agenda for the future (DOT HS 808441 – NTS-42). Retrieved from http://www.nremt.org/nremt/downloads/EMS%20Agenda%20for%20the%20Future.pdf

Department of Transportation, National Highway Traffic Safety Administration. (2008). EMS workforce for the 21st century: a national assessment. Retrieved from http://secure.naemse.org/services/EMSWorkforceReport.pdf

Hawkins, E. R., Brice, J. H., & Overby, B. A. (2007). Welcome to the World: Findings from an emergency medical services pediatric injury prevention program. Pediatric Emergency Care, 23(11), 790-795. doi:10.1097/PEC.0b013e318159ffd9

Heightman, A. J. & McCallion, T. (2011). Management lessons from Pinnacle: Key messages given to EMS leaders at the 2011 conference. Journal of EMS, 36(10), 50-54.

Kellermann, A. L. (2006). Crisis in the emergency department. New England Journal of Medicine, 355(13), 1300-1303. doi:10.1056/NEJMp068194

Lerner, E. B., Fernandez, A. R., & Shah, M. N. (2009). Do emergency medical services professionals think they should participate in disease prevention? Prehospital Emergency Care, 13(1), 64-70. doi:10.1080/10903120802471915

Mason, S., Wardrope, J., & Perrin, J. (2003). Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emergency Medicine Journal, 20(2), 196-198. doi:10.1136/emj.20.2.196

Mayer, J. D. (1980). Response time and its significance in in medical emergencies. Geographical Review, 70(1), 79-87. Retrieved from http://www.ircp.info/Portals/22/Downloads/Performance/Response%20Time%20and%20Its%20Significance%20in%20Medical%20Emergencies.pdf

National Traffic and Motor Vehicle Safety Act of 1966, Pub. L. No. 89-563, 80 Stat. 718 (1966).

O’Meara, P., Walker, J., Stirling, C., Pedler, D., Tourle, V., Davis, K., … Wray, D. (2006, March). The rural and regional paramedic: moving beyond emergency response (Report to The Council of Ambulance Authorities, Inc.). Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/The%20Rural%20and%20Regional%20Paramedic%20Moving%20Beyond%20Emergency%20Response.pdf

Washko, J. D. (2012). Rethinking delivery models: EMS industry may shift deployment methods. Journal of EMS, 37(7), 32-36.

Wingrove, G. & Laine, D. (2008). Community paramedic: A new expanded EMS model. Domain3, 32-37. Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/NAEMSE%20Community%20Paramedic%20Article.pdf

Paying for Health Care, Today and Tomorrow

Before delving into the substance of this discussion, I must say that my personal beliefs are contradictory to many globalized health care efforts. Penner (2005) discusses some benefits of discussing and comparing health care economics between various nations. However, as we combine efforts to target specific health concerns across the globe, we lose the ability to innovate, promote evidence-based discussion, and promote the sovereignty of each country involved in the global effort. This globalization of health care deteriorates the ability to compare and contrast best practices of various countries. Unfortunately, most of the published works promote an insidious form of social justice and do not address how globalization efforts reduce the sovereignty of nations and people. Huynen, Martens, and Hilderdink (2005) support this deterioration by promoting a foundation for a global governance structure that would lead to better dissemination and control of globalization efforts.

Campbell and Gupta (2009) directly compare some claims that the U.K. National Health System (NHS) has worse health outcomes than the traditional U.S. model. Though Campbell and Gupta provide evidence disparaging many of these claims, they also seem to provide some insight as to the woes the NHS has recently faced and are working to correct. Under a system promoted by Huynen, Martens, and Hilderdink (2005), we would ultimately lose the comparison between nations as to best practices. The U.S. is currently debating the value of nationalizing health care, and similar arguments are arising based on the inability for interstate comparisons of effective and efficient delivery of health care among the various states.

References

Campbell, D. & Gupta, G. (2009, August 11). Is public healthcare in the UK as sick as rightwing America claims? The Guardian. Retrieved from http://www.guardian.co.uk/society/2009/aug/11/nhs-sick-healthcare-reform

Huynen, M. M. T. E., Martens, P., & Hilderink, H. B. M. (2005). The health impacts of globalisation: a conceptual framework. Globalization and Health, 1, 1-14. doi:10.1186/1744-8603-1-14

Penner, S. J. (2004). Introduction to health care economics & financial management: fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.

Pay-for-Performance

Challenges in Developing  Standards

The U.S. health care industry is contemplating the implementation of pay-for-performance reimbursement schemes in order to increase quality and safety in the delivery of health care. Pay-for-performance is a business model that combines reduced compensation for those who fail to meet standards and bonus payments for those that meet or exceed the stated expectations, but the results of such programs, thus far, is mixed (Baker, 2003; Campbell, Reeves, Kontopantelis, Sibbald, & Roland, 2009; Lee & Ferris, 2009; Young et al., 2005). The introduction of pay-for-performance models is primarily to provide relief from other, more extreme, reimbursement models, such as fee-for-service (which rewards overuse) and capitation (which rewards underuse), and with rising health care costs, a diminishing economy, and the increasing number of Americans lacking adequate health insurance, its introduction to the U.S. health care system could not be more timelier (Lee & Ferris, 2009).

The impetus of contemporary pay-for-performance schemes is derived from a report from the Institute of Medicine (2001). This report argued that current reimbursement schemes fail to reward quality in health care and may possibly create a barrier to innovation (Baker, 2003; Young et al., 2005). There are many international supporters of health care pay-for-performance, especially in England where the National Health Service employs pay-for-performance to keep costs under control while attempting to provide for quality and safety in the delivery of primary health care (Baker, 2003; Campbell et al., 2009; Young et al., 2005). However, the adoption of pay-for-performance seems to face many challenges.

One challenge to pay-for-performance implementation concerns the effectiveness in the overall continuity of care. Campbell et al. (2009) conducted an analysis of the effect of pay-for-performance in England and found that, although implementation of pay-for-performance in 2004 resulted in short-term gains in the quality of care, the improvements receded to pre-2004 levels. Beyond the pay-for-performance standards, though, the quality of care in areas not associated with incentives declined. Cameron (2011) reports on a recent study of the effectiveness of pay-for-performance on hypertension – the study shows no improvement in any measure including the incidence of stroke, heart attack, renal failure, heart failure, or combined mortality among the group (Lee & Ferris, 2009). McDonald and Roland (2009) describe these effects on other aspects of care as unintended consequences detrimental to health care quality and safety as a whole.

Another significant challenge to pay-for-performance implementation is ensuring that certain patient populations continue to be able to access appropriate care (McDonald & Roland, 2009). Under some pay-for-performance schemes, practices with a sicker patient demographic (i.e. geriatrics, oncology, neonatology, etc.) will suffer economically despite providing a higher level of care than their counterparts in family medicine or other more generalized practices. Specific concerns address a physicians ability to choose not to treat patients due to their non-compliance with medical orders (McDonald & Roland, 2009). Equity and access cannot suffer under a just reimbursement model, just as physicians with a sicker demographic should not suffer.

Identifying a reliable standard of measure in health care quality proves difficult. Earlier methods, such as those developed by Campbell, Braspenning, Hutchinson, and Marshall (2002), initially appeared sound, but ineffective methods and unintended consequences were soon identified (Cameron, 2011; Lee & Ferris, 2009; McDonald & Roland, 2009). More recent work by Steyerberg et al. (2010) shows that new approaches are on the horizon and that pay-for-performance may still remain a viable scheme, providing the measures and standards are, in fact, legitimate and accurately identify improved quality without detracting from other aspects of heath care. Steyerberg et al. identifies novel approaches to prediction models that may help to standardize measures in pay-for-performance schemes to be more realistic and reliable without causing many of the unintended consequences of earlier plans.

As we become more technologically advanced and find ways, albeit expensive, to cure and treat diseases that until now were intractable, we must address the ethics surrounding the provision of this care as a system of management. By combining the whole of health care into the ethics discussion, we opt to leave no one wanting for care, but we now have to address the problem of paying for the expensive care that we have all but demanded. Pay-for-performance, though not perfect, shows much promise in keeping health care costs manageable. However, we must strive to identify those patients and practitioners that lose out under this system of reimbursement and strive to identify just and ethical means of repairing the scheme. Though, we should first answer the question: is health care a right or a privilege?

References

Baker, G. (2003). Pay for performance incentive programs in healthcare: market dynamics and business process. Retrieved from http://www.leapfroggroup.org/media/file/Leapfrog-Pay_for_Performance_Briefing.pdf

Cameron, D. (2011, January 27). Pay-for-Performance does not improve patient health. Harvard Medical School News. Retrieved from http://hms.harvard.edu/public/news/2011/ 012611_serumaga_soumerai/index.html

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Campbell, S. M., Reeves, D., Kontopantelis, E., Sibbald, B., & Roland, M. (2009). Effects of pay for performance on the quality of primary care in England. New England Journal of Medicine, 361(4), 368-378. doi:10.1056/NEJMsa0807651

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.iom.edu/reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Lee, T. H. & Ferris, T. G. (2009). Pay for performance: a work in progress. Circulation, 119(23), 2965-2966. doi:10.1161/CIRCULATIONAHA.109.869958

McDonald, R. & Roland, M. (2009). Pay for performance in primary care in England and California: comparison of unintended consequences. Annals of Family Medicine, 7(2), 121–127. doi:10.1370/afm.946

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Young, G. J., White, B., Burgess, J. F., Berlowitz, D., Meterko, M., Guldin, M. R., & Bokhour, B. G. (2005). Conceptual issues in the design and implementation of pay-for-quality programs. American Journal of Medical Quality, 20(3), 144-50. doi:10.1177/1062860605275222

Electronic medical records:

The Push and the Pull

Increasing safety and efficiency in medicine can only lead to an increase in health care quality, right? Some might not agree, especially when it comes to the implementation of electronic medical records (EMRs). There is a federal effort to ensure all medical records are in digital format by 2014, and supporters of EMR technology laud their effectiveness at minimizing medical errors, keeping records safe, facilitating information portability, and increasing cost-efficiency overall (The HWN Team, 2009; Preidt, 2009). Unfortunately, many are skeptical of the cost, security, and utility of such systems (Brown, 2008; The HWN Team, 2009; Preidt, 2009; Terry, 2009). These concerns (and others) are dramatically slowing the pace of EMR adoption, especially in smaller private practices where cost is a significant issue (Ford, Menachemi, Peterson, & Huerta, 2009).

Does EMR adoption actually increase safety? As Edmund, Ramaiah, and Gulla (2009) point out, a working computer terminal is required in order to read the EMR. If the computer system fails, there is no longer access to the medical record. This could be detrimental in a number of cases, especially when considering emergency medicine. Edmund, Ramaiah, and Gulla also describe how difficult it can be to maintain such a system. With this in mind, it is plain that as the system ages there will be more frequent outages and, therefore, more opportunity for untoward effects. Further, recent research shows how EMRs enforce pay-for-performance schemes that many U.S. physicians resent. McDonald and Roland (2009) demonstrate that physicians in California would rather disenroll patients who are noncompliant when reimbursed under pay-for-performance models enforced by the EMR software. Declining to treat patients who express their personal responsibility and choice in their own medical treatment cannot improve the effectiveness of safety in the care that they receive.

There needs to be a middle ground. Baldwin (2009) offers some great real world examples of how some hospitals and practices use hybrid systems to ensure effectiveness and quality while enjoying the benefits of digital records. According to Baldwin, there are many concerns to account for when considering a move from an all paper charting system to an all digital system. Many times, these concerns cannot be allayed and concessions between the two systems must be made. Brown (2008) suggests providing a solid education to the front-line staff regarding EMR implementation, and hence, obtaining their ‘buy in’ to the process to create a smoother transition to implementation. However, this does not address the safety concerns. Baldwin’s advice to analyze which processes should be computerized allows a solid business approach to EMR implementation, allowing some processes to remain paper-based if it makes sense to do so.

References

Baldwin, G. (2009). Straddling two worlds. Health Data Management, 17(8), 17-22.

Brown, H. (2008, April). View from the frontline: Does IT make patient care worse? He@lth Information on the Internet, 62(1), 9.

Edmund, L. C. S., Ramaiah, C. K., & Gulla, S. P. (2009, November). Electronic medical records management systems: an overview. Journal of Library & Information Technology, 29(6), 3-12.

Ford, E. W., Menachemi, N., Peterson, L. T., & Huerta, T. R. (2009). Resistance is futile: But it is slowing the pace of EHR adoption nonetheless. Journal of the American Medical Informatics Association, 16, 274-281. doi:10.1197/jamia.M3042

The HWN Team. (2009, March). Electronic medical records: the pros and cons. Health Worldnet. Retrieved from http://healthworldnet.com/HeadsOrTails/electronic-medical-records-the-pros-and-cons/?C=6238

McDonald, R. & Roland, M. (2009, March). Pay for performance in primary care in England and California: Comparison of unintended consequences. Annals of Family Medicine, 7(2), 121-127. doi:10.1370/afm.946

Preidt, R. (2009, December 16). Pros and cons of electronic medical records weighed. Business Week. Retrieved from http://www.businessweek.com/lifestyle/content/healthday/634091.html

Terry, N. P. (2009). Personal health records: Directing more costs and risks to consumers? Drexel Law Review, 1(2), 216-260.

Reducing Philanthropy to Political Commentary

In searching the typical news outlets for stories related to health care reform, be it local or national, I cannot help but notice that health care reform is the news. The factions are split, and the bias is evident. As the news outlets lean more to the left of the political spectrum than ever before, it is almost impossible to research the real issues at hand. Wading through the political views to glimpse a meaningful patient-focused agenda is quite difficult lately.

An article written by Randall Beach (2009) of the New Haven Register focuses on a group of doctors that rely on charity to provide health care to a select adult population who do not qualify for Medicaid and make less than $20,000 per year. Unfortunately, this article, like so many others, reduces philanthropy to political commentary.

Our current health care system is fragmented, and many people believe health care reform is needed (“54% Say Major Changes Needed”, 2009). As Dr. Peter Ellis is quoted, “Our motto is: ‘Health care reform starts at home'” (Beach, 2009, p. 3). It does not make sense, however, to provide Universal Health Care at the cost of our failing economy. Dr. Ellis’ group, Project Access, has secured funding from private sources, including the Hospital of St. Raphael and Yale-New Haven Hospital staff, the Aetna Group, the Community Foundation for Greater New Haven, and the New Haven County Medical Association Foundation. Additionally, 350 local care providers are associated with the project. This is a grassroots effort at helping to care for our neighbors, and as far as I have read, it seems to be a reasonable and responsible attempt to mend some of the local disparities to health care access.

Though I commend Mr. Beach for covering such a newsworthy story, it serves no one to inflame the current health care debates with political posturing by the media. I believe that the recent passing of health care reform will do nothing but create more clutter and complication for us to untangle when we finally have the financial stability to address the issue responsibly and realistically. In the meantime, I, like Project Access, will continue to volunteer my time and medical services to my community.

References

Beach, R. (2009, December 28). Doctors giving health care reform a head start. New Haven Register. Retrieved from http://www.nhregister.com/articles/2009/12/28/news/new_haven/a1_mon_nedoctors_art.prt

54% Say Major Changes Needed in Health Care System, 45% Disagree. (2009, October 2). Rasmussen Reports. Retrieved from http://www.rasmussenreports.com/public_content/politics/current_events/healthcare/october_2009/54_say_major_changes_needed_in_health_care_system_45_disagree

Health Care Reform

In beginning this endeavor, I found it initially difficult to find anything related to health care legislation that I would be inclined to support or oppose in a letter to my Congressman. I tend to rely on the elections in order to convey my political positions. After studying some of the recent legislation, I found that the only premise that interested me was the adoption of The Patient Protection and Affordable Care Act of 2010 and the related Health Care and Education Reconciliation Act of 2010. Unfortunately, attempting to find credible dialogue on the internet regarding these laws is both impractical and near impossible. The special interest groups are leaning to their respective extremes. With commentary not proving trustworthy for factual insight, I relied on the Congressional Budget Office and the full text of the laws to cement my position. Using the aforementioned information in conjunction with Senator Lieberman’s contact information from the U. S. Senate website (http://www.senate.gov), I formulated a letter to him outlining my economic concerns (see Appendix).

I understand the grandeur of the idea of universal health care. I applaud the debates of how best to offer affordable or free health care to ever citizen of the United States. Unfortunately, as a nation, we are not fit in our financial means to proffer such an expensive entitlement. As Goodson (2010) reports, many of the initiatives outlined within the law are not guaranteed to be successful. This at an increased cost of $390 billion over the first 10 years (Elmendorf, 2010).

To ensure that my points were valid, I researched the approval ratings of these laws. According to WashingtonWatch.com (2010), approximately 80% of respondants do not favor the passing of these laws. More scientifically, however, a consistent range of 54 – 58% of Americans favor repeal of the laws, while 63% of senior citizens agree (Rasmussen Reports, 2010).

References

Elmendorf, D. W. (2010, March 20). Manager’s amendment to reconciliation proposal [Letter to the Honorable Nancy Pelosi]. U. S. Congress, Washington, D. C. Retrieved from the Congressional Budget Office website: http://www.cbo.gov/ftpdocs/113xx/doc11379/ Manager%27sAmendmenttoReconciliationProposal.pdf

Goodson, J. D. (2010). Patient Protection and Affordable Care Act: Promise and peril for primary care. Annals of Internal Medicine. Advance online publication. Retrieved from http://www.annals.org/content/early/2010/04/15/0003-4819-152-11-201006010-00249.full

Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152 (2010).

Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148 (2010).

Rasmussen Reports. (2010, May 17). Health care law: 56% Still Want to Repeal Health Care Law, Political Class Disagrees. Retrieved on May 22, 2010, from http://www.rasmussenreports.com/public_content/politics/current_events/healthcare/march_2010/health_care_law

WashingtonWatch.com. (2010). P.L. 111-148, The Patient Protection and Affordable Care Act. Retrieved on May, 22, 2010 from http://www.washingtonwatch.com/bills/show/111_PL_111-148.html

Appendix

Michael F. Schadone
[REDACTED]
Woodstock, CT 06282

The Honorable Joseph I. Lieberman
706 Hart Office Building
United States Senate
Washington, DC 20510

May 22, 2010

Re: The Patient Protection and Affordable Care Act of 2010

 Dear Senator:

 My name is Michael Schadone and I am a nationally registered critical care paramedic working in Northeast Connecticut. I am writing you today because I do not support the recent legislation referred to as The Patient Protection and Affordable Care Act of 2010. I urge you and your colleagues in Congress to repeal this law. I believe that our efforts aimed at improving the economy will, in itself, dramatically reduce the disparities in access to health care.

Under the auspices of a progressive government, our country has seen many times of woe. Bigger government and higher rates of spending have driven our economy into the ground. It was only the idea of smaller government and trust in the American entrepreneur that ever caused unemployment rates to drop to less than five percent. More people gainfully employed means more people with access to affordable health care. Is this not our goal? In Europe, economic systems are collapsing. Many of the countries with universal health care have tax rates approaching 70 percent (including ‘value-added tax’). It is commonly held that suppressing the spending power of the citizenry will surely lead to a collapse of the free market, the basis of our economy. I certainly do not want the United States of America to resemble Greece, Portugal, Spain, or Cuba. We are the Great Experiment, and so far, it is working. I fear, though, not for much longer.

I favor universal health care just as I favor universal education and other entitlements but not at the expense of our country. Improvements to the economy will put us in a position to gain strength and enable us to afford such a sweeping paradigm shift in health care. More importantly, a better economy will allow us to do it properly. I urge you to focus on the economy and repeal this dangerous law.

 Sincerely,

Michael F. Schadone

Freedom vs. Health Care Reform

In the United States, we believe in individual rights, some of which are enumerated in the U. S. Constitution. The right to health care is not one of these. As our country prospers or declines, we may amend our Constitution to ensure more rights or take them away. The question, now, is can we afford health care for all? At this moment, I believe we cannot. Other countries have attempted to provide health care for all of its citizens but are facing economic troubles in spite of 70% tax rates (Clark & Dilnot, 2002). I believe that high tax rates are dangerous to the economy because the people and the government compete in mobilizing the economy; whereas with lower tax rates, the small businesses can drive the economy (U.S. Small Business Administration, Office of Advocacy, 2006).

It is my experience that those who overutilize health care are those who are under-insured (e.g. Medicare and Medicaid) and uneducated about the health care system. Further, it seems that the underpayment of costs by the Medicare and Medicaid programs are driving up the recoverable costs to other payors (Brennan & Mello, 2009). This is why I believe that our health care system is as expensive and inefficient as it is. “The U.S. health care system also spends more on administrative or overhead costs related to health care,” says Garber and Skinner (2008, p. 32), but they attribute this to administrative waste where I conclude that the over-administration is needed to meet the demands of an over-regulated and inefficient payment system.

In conclusion, our health care system is linked to our economy, and improving the economy is the only way to ensure that our health care system improves. By adding entitlements, we are forcing the American people to minimize their financial growth and, thereby, their financial freedom to choose affordable health care.

References

Brennan, T. A. & Mello, M. M. (2009). Incremental health care reform. Journal of the American Medical Association, 301(17), 1814-1816. doi:10.1001/jama.2009.610

Clark, T. & Dilnot, A. (2002). Long-term trends in British taxation and spending (IFS Briefing Note No. 25). London, UK: The Institute for Fiscal Studies. Retrieved from http://www.ifs.org.uk/bns/bn25.pdf

Garber, A. M. & Skinner, J. (2008). Is American health care uniquely inefficient? Journal of Economic Perspective, 22(4), 27–50. doi:10.1257/jep.22.4.27.

U.S. Small Business Administration, Office of Advocacy. (2006, September 28). Small business drives the U.S. economy — represent 99.7 percent of all businesses, employ 57.4 million (SBA No. 06-17 ADVO). Retrieved from http://www.sba.gov/advo/press/06-17.html

Pay-for-performance in EMS?

There has been much discussion regarding reimbursement models for health services, and two main themes have emerged, the historical fee-for-service model and a quality-driven pay-for-performance model (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While many providers argue that the reimbursement level is currently too low to sustain operations (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007), patient advocates cite an overwhelming number of medical mistakes allowing providers to benefit from poorer outcomes leading to increased needs of critical care services which lengthen hospital stays dramatically (Committee on Quality of Health Care in America & Institute of Medicine Staff, 2001; Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While considering more effective designs within our health care system, treatment efficacy, reimbursement paradigms, and patient safety could possibly be used as a foundation upon which to rebuild our health care infrastructure. The Committee on Quality of Health Care in American and the Institute of Medicine Staff (2001) offer “six aims [safe, effective, patient-centered, timely, efficient, and equitable] for improvement that can raise the quality of care to unprecedented levels” (p. 5).

Fee-for-service models, the traditional norm in health care reimbursement, seek to itemize care expenditures based on particular procedures or services rendered to the patient. Though fee-for-service models reward providers for timely, and possibly effective and efficient, delivery of care, it does little to address safe, patient-centered, and equitable considerations.

Financial barriers embodied in current payment methods can create significant obstacles to higher-quality health care. Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions.
(Committee on Quality of Health Care in America et al., 2001, p. 181)

As a paramedic, I am bound to a Medicare reimbursement model that focuses solely on the transportation of the patient and not on the care rendered. For a patient experiencing cardiac chest pain, merely placing them on a continuous ECG monitor and providing transportation to the hospital allows my employer to be paid the same as if I initiated an intravenous line, administered oxygen, aspirin, nitroglycerin, and morphine, and performed serial diagnostic 15-lead ECG readings during the transport. In any case, though, payment is withheld if the patient is not transported. I have to assume that this inequitable reimbursement scheme is replicated across the health care spectrum.

Pay-for-performance models, however, seek to reward the provider for improving the quality of care delivered and “represents an attempt to align incentives in the payment system so that rewards are given to providers who foster the six quality aims set forth in the Quality Chasm report” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 36; Committee on Quality of Health Care in America et al., 2001). Some detractors of pay-for-performance worry that providers serving poor and ethnic communities that have typically poor health and preventative compliance will not benefit from such performance measures. The worry is that the numbers of providers will be lacking in these communities, worsening the communities health outcomes (Nafziger, 2010). Though, “pay for performance is not simply a mechanism to reward those who perform well; rather, its purpose is to encourage redesign and transformation of the health care system to ensure high-quality care for all” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 44). Pay-for-performance focuses on safety, and a search of the literature does not reveal any complicating risk to patients under a pay-for-performance system so long as the system is patient-centric, taking into account the patient population serviced by each provider.

For instance, regarding a certain type of heart attack called a “STEMI”, or ST-segment elevation myocardial infarction, it is beneficial for the paramedic ambulance to bypass the local community hospital and transport the patient to a primary coronary intervention (PCI) facility for a cardiac catheterization. In this instance, the local community hospital is losing potential revenue. Perhaps if the reimbursement model reflected this evidence-based and patient-centered decision and provided a small monetary reward to the local community hospital for allowing the directed care at the PCI center, then mortality and morbidity from STEMI in the community would be reduced and the local hospital would be rewarded for their involvement in the process even if they did not provide any direct care. This is just one instance in the realm of emergency care where pay-for-performance can help to ensure safe, effective, patient-centered, timely, efficient, and equitable delivery of care to the patient.

As both a health care provider and consumer, I would prefer the pay-for-performance model of reimbursement. As a provider, I am a patient advocate, and as a patient, I will, of course, advocate for myself. Pay-for-performance enables provider growth, evidence-based practice, better patient safety mechanisms, and an overall efficient and a more complete and holistic delivery of care.

References

Committee on Quality of Health Care in America (Author), & Institute of Medicine Staff (Author). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff (Author). (2007). Rewarding provider performance: Aligning incentives in Medicare. Washington, DC: National Academies Press.

Nafziger, B. (2010, May 6). Pay for performance could hurt docs who serve poor, blacks and hispanics. DOTMed News. Retrieved from http://www.dotmed.com/fr/news/story/12570/