As colossal self-interest groups and lobbyists battle over health-care reform, I'm reminded of the inscription on the Statue of Liberty:
“Keep, ancient lands, your storied pomp!” cries she with silent lips. “Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, tempest-tossed to me. I lift my lamp beside the golden door!”
The verse from “New Colossus,” a sonnet written by Emily Lazarus, is a reflection and celebration of a new-found democracy. In those revolutionary times, the Federalists argued that government breached the social contract and was in need of replacement.
Once again, we find ourselves questioning the government's ability to deliver service.
The titans of the health-care industry, some pharmaceutical manufacturers and the great hospital chains all are lining up against the concerted effort to bring real change to a health-care system that we, as fire and EMS providers, have seen crumble over the last 10 years. Those who serve in the urban areas long have been aware of the “huddled masses” created by the lack of medical, social and mental health services.
The rework of the nation's health-care system is important to fire-based EMS, as we are providers at some level in almost every community. We are the country's medical safety net, and any changes will affect our service delivery.
Look at your own department's health-care expenses, and you will find that they are a significant cost of doing business. And as many states' legislation regarding cancer presumption forces cities and counties to provide support to afflicted firefighters, these benefits will be under constant attack as health-care costs increase. To comply with those mandated benefits, money surely will be diverted from non-mandated items such as training, equipment and staffing.
But there are legitimate concerns regarding the money supply. Companies continue to move their factories abroad, eroding the middle class and reducing the common person's ability to purchase a home and thus pay the property taxes that fund public safety.
There are some indications that any national health-care plan would have the same low reimbursement rates as Medicare and Medicaid. Can private-ambulance companies remain profitable in an environment that has more people insured, but who are paying at the levels set by Medicare? Will the volume of minimally insured people make up for the lowered reimbursement rates? Will the private insurance companies be forced to reduce their reimbursement to compete with a national health-care plan? This is going to put tremendous pressure on the ambulance industry to cut costs and reduce service charges.
In many areas, a two-tiered system already allows for fire-based EMS (the public system) to handle the more expensive emergency work and private ambulance (the private option) to handle the less acute or optional transports. Years ago, the public-utility model concept promoted economies of scale by having a paramedic unit take non-emergency calls while waiting for more serious ones. The paying non-emergency transports were supposed to subsidize the more costly emergency work.
But a jurisdiction that has an urgent-care or for-profit clinic will tell you that this system fails. A request for a non-emergency transport for someone who has been sitting in the clinic for hours often is rung up as an emergency anyway.
Should every call in the 911 system get an expensive advanced-life-support resource? Those non-emergencies barely cover the cost of the emergency work, which will be exacerbated as more people lose their insurance. While emergency calls are declining slightly, the acuity or criticality of calls is increasing, as people are waiting until the last minute to seek help or have been skipping pills to save costs.
Congress is trying to push several bills to help contain any hemorrhaging the ambulance industry might experience, as the new health-care plan tries to re-appropriate money from Medicare funding. H.R 2443 and Senate Bill 1066 both entitled, The Medicare Ambulance Access Preservation Act of 2009, amends Title XVIII of the Social Security Act (Medicare) and seeks to increase ambulance rates by 6% permanently for ground ambulance services furnished on or after Jan. 1, 2010. Another bill, H.R. 1915, seeks to amend the Medicare rules to provide expanded coverage for paramedic-intercept services and make the reimbursement mandatory. Both bills were introduced in the spring, but neither have made much progress.
Billions will have to be found to cover the cost of the new health-care plan, which will mean draconian cuts or strict enforcement. Fire chiefs should expect scrutiny over ambulance billing and beware of any “upbilling” or billing for ALS services when it does not meet the criteria. Just because a paramedic is on scene does not make it an ALS call under Medicare billing rules.
People in Canada, France and other industrialized countries don't wait for an ambulance. True, a non-emergency knee replacement might be delayed for a month to wait for an opening, but emergency- and immediate-care needs are met in a very timely fashion with the most appropriate technology. Pain control, safety designs, and coordination of services are far more developed than in the United States. Take for instance the use of continuous positive airway pressure (CPAP), which has proved to be a benefit to the patient. Many services are unwilling to incur CPAP costs without reimbursement. Fire departments like Houston's have been able to deploy it to the street after having it provided by a hospital. In this case, the hospital figured out that if EMS deploys CPAP, it reduces the confinement time of a patient with congestive heart failure below that which was authorized by Medicare. In other words, while Medicare pays for hospitalization of the patient for 3.2 days, CPAP reduces the hospitalization time to 1.2 days and eliminates the need for intubation, so the hospital clears two days of pure profit.
If you are against socialized medicine, you need to look in the mirror. That is exactly what fire-based EMS is. We respond regardless of insurance or payment status. We have every incentive to do what's right for the patient because they collectively, as taxpayers are the ones paying our salary. Our role as the gateway to the health-care system should stand out like the Statue of Liberty's torch. The words on the pedestal reflect this country's core values and it's a mission to which fire-based EMS has long been accustomed.
Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.
