Bear with me for a minute here folks. This is long, but important.
I’d like to talk for a bit about the EMS 2.0 movement and US healthcare reform, a subject that I haven’t brought up for a while but that is still very important. EMS 2.0 hasn’t slowed down, and you may recognize a lot of the ideas that the concept shares with other EMS improvement labels gaining a lot of ground these days. I’m very happy for that fact. EMS 2.0 is a concept of overall improvement within the profession, not simply a cause to be championed as its own label. Whether you call it Mobile Integrated Healthcare, Community Paramedicine, or Healthcare Reform, there is improvement out there that is making EMS better. That’s what we want.
Time for a quick disclaimer: I don’t usually talk politics on this blog. That’s because I believe people are getting way too involved in supporting their own favorite political teams these days. Because of this, I believe that some people are only listening to narratives that affirm their own personal confirmation biases and aren’t fully considering some good ideas based on their merit. I know that I’m not going to change your team of choice, and I’m not attempting to try here.
With that said, whether you are the Affordable Care Act’s biggest fan or believe that it is a governmental overreach that will be ineffective at best. I don’t believe that there isn’t anyone out there who doesn’t think that the US healthcare system couldn’t be improved. We all have goals and differ on our ways to achieve them but I believe our similarities may outweigh our differences. We might realize that if we took the time to actually listen to ideas and stopped trying to shout over the folks who carry around a different label.
RecentlyÂ a story popped up all over the Internet about a Middle School student in Pennsylvania who did a science projectÂ showing how everyone from his local school to the federal government could save staggering amounts of money simply by changing the font they use in printed documents. The change of fonts, from Times New Roman to Garamond which uses less ink, is minuscule when looked at in terms of a single printed document but snowballs into millions of dollars worth of ink at scale. The student calculated that the change could save his school district roughly $21,000 per year and that the US federal government could save somewhere around $370 million. That’s hardly pocket change.
I have no idea who the author of this next anecdote is and therefore no way to verify its accuracy, but it sounds extremely plausible to my ears. Keep in mind the difference changing font sizes makes as you read it:
A toothpaste factory had a problem: Due to the way their production line was set up, sometimes empty boxes were shipped without the actual toothpaste tube inside. Now, People with experience in designing production lines will tell you how difficult it is to have everything happen with timings so precise that every single unit coming off of it is perfect 100% of the time. Small variations in the environment (which cannot be controlled in a cost-effective fashion) mean quality assurance checks must be smartly distributed across the production line so that customers all the way down to the supermarket won’t get frustrated and purchase another product instead.
Understanding how important that was, the CEO of the toothpaste factory gathered the top people in the company together. Since their own engineering department was already stretched too thin, they decided to hire an external engineering company to solve their empty box problem.
The project followed the usual process: budget and project sponsor allocated, RFP (request for proposal), third-parties selected, and six months (and $8 million) later a fantastic solution was delivered on time, on budget, high quality and everyone in the project had a great time. The problem was solved by using high-tech precision scales that would sound a bell and flash lights whenever a toothpaste box would weigh less than it should. The line would stop, and someone had to walk over and yank the defective box off the line, then press another button to re-start the line.
A short time later, the CEO decided to have a look at the ROI (return on investment) of the project: amazing results! No empty boxes ever shipped out of the factory after the scales were put in place. There were very few customer complaints, and they were gaining market share. ‘That was some money well spent!” he said, before looking closely at the other statistics in the report.
The number of defects picked up by the scales was 0 after three weeks of production use. How could that be? It should have been picking up at least a dozen a day, so maybe there was something wrong with the report. He filed a bug against it, and after some investigation, the engineers indicated the statistics were indeed correct. The scales were NOT picking up any defects, because all boxes that got to that point in the conveyor belt were good.
Perplexed, the CEO traveled down to the factory and walked up to the part of the line where the precision scales were installed. A few feet before the scale, a $20 desk fan was blowing any empty boxes off the belt and into a bin. Puzzled, the CEO turned to one of the workers who stated, “Oh, that!One of the guys put it there cause he was tired of walking over every time the bell rang!”
A few years back,Â I wrote a long-winded article comparing EMS providers to sporks, but after reading the above anecdote I’d like to add that EMS providers are also very much the $20 desk fan of the healthcare system.
At least we could be.
Two somewhat recent ambulance calls I responded to provide perfect examples of how this might work. Details, of course, have been changed to protect privacy.
The first call was for a young male patient whose mother called 911 saying her child was having difficulty breathing. We responded non-emergent as per the dispatch code and arrived to find the patient and his mother waiting for us outside of their apartment complex. They both started walking up to the ambulance as we arrived. The kid walked up to us without any problem.
I invited the both of them into the back of the truck so I could get a better look at the patient. He looked fine at first impression and I performed a thorough assessment on him to make sure. He had recently been diagnosed with asthma and was newly under a physician’s care for it. His mother had called the new physician’s office before calling 911 to ask for advice and they had told her to call an ambulance because she mentioned her son was having difficulty breathing. That’s where we came in. Mom apologized for bothering us by calling 911 but I assured her that we were always happy to come out and take a look. We looked and found that the patient wasn’t having an acute asthma attack but was probably experiencing an upper respiratory infection of some sort. I checked him out very thoroughly and determined him not to be in any immediate danger. That’s when I started talking options.
First and foremost, we’re an ambulance and we’re obligated to take anyone to the hospital who asks us to do so. As such, I offered that as the first option and would have been happy to transport the patient if his mother wanted me to. I did however mention, that while I was not a physician and had no legal authority to give her the option of going to an urgent care center or to the patient’s personal physician’s office, I wouldn’t protest if she chose to do that. The patient’s mother asked that since her husband was expected to be home in about ten minutes if they could just take their son to the local urgent care center down the street. I told her that I believed there to be minimal danger in her doing so and assured her that she could call 911 at any time should there be any problems.
The patient’s mom chose the second option, so instead of transporting her son to the hospital by ambulance for hundreds of dollars and then having the patient treated in the Emergency Department for thousands of dollars, she elected to take the patient herself for a negligible cost and have the patient seen in the Urgent Care for about a hundred bucks or so. Her insurance company saved a great deal of money because of her choice, but of course since our ambulance service only gets paid for transporting patients we took a loss and received no revenue.
The second patient was a twenty-something female who was playing sports and fell. When she fell, she experienced immediate, severe pain to her left knee. We responded and found no injuries other than an obviously displaced left patella (kneecap). It was a lateral displacement,Â which is an injury easily treated by simply reducing the displacementÂ and taking it easy for a few days, unlike a medial or other kind of patellar displacement which usually requires further intervention.
If you’re not familiar with a patellar displacement, let me tell you that they are exceptionally painful for the patients who experience them. They’re also common in younger female patients who are active in various types of sports. These things hurt immensely until the kneecap is put back into place. Luckily around 40% of these injuries go back into place on their own and the others can be easily reduced with a simple procedure. Athletic trainers in most areas do this all the time and then refer the doctor to an orthopedist or physical therapist for follow-up care.
However I couldn’t use any of that knowledge. As a paramedic, my scope of practice does not allow me to reduce any type of dislocation. My treatment was limited to splinting the extremity in place, carefully supporting it, administering intravenous pain medication, and transporting the patient to an Emergency Department so they could pop it back in.
When we arrived, the physician had it popped right back into place within 5 minutes of our dropping her off.
In this second call, we ended up transporting the patient at the cost of several hundred dollars. It was an ALS call because of the IV pain medication, which added to the patient’s cost. Then the ED charged her a few thousand dollars for the treatment, x-ray, and other care. The only so-called benefit to this situation is that our ambulance service earned some money with which to continue paying my salary. So there’s that. I do enjoy being able to earn a living.
Both of these calls are illustrative of the need for a change in font or a $20 desk fan. The first call was much cheaper for the patient and the overall healthcare system because the patient safely went to an appropriate level of care after being triaged by a clinician, but our ambulance service ate the loss because we couldn’t charge anything for the service it cost us money and resources to provide. That’s an unfair loss for both our service and the taxpayers who support us to take.
The second call was also a loss, because we were prevented by government regulation from providing the appropriate service, which would have been to attempt to reduce the fracture and then triage the patient to orthopedic care apart from the emergency healthcare system, even though in this case our service was able to bill for the costs of providing our care.
This whole “Healthcare Reform” thing is crying out for a $20 desk fan, and EMS 2.0 is that $20 desk fan. While the costs saved to the system and to the individual patients don’t look like they’re extremely important, the savings and improvement to care when taken to scale would be staggering.
We need to be able to change the rules we follow and find the best solutions using the eyes of the people actually on the line, a bottom-up approach if you will. The top-down approach mandated by government in this age of federal healthcare reform isn’t always the best choice and will, in my opinion, only make the system more complex and costly. Everyone needs to be involved.
If you’re an EMS provider, start looking for solutions. If you’re a politician, start asking us for those solutions. If you’re a reporter, please start publicizing EMS 2.0. We can change the system immensely for the better from the bottom up if someone would simply ask us to the table.
For more on this, check out:Â Are we the Gatekeepers to the Emergency Healthcare System?Â And for more about changing the rules of the game, seeÂ The Houston Medicare Problem, Formulating Better Instructions on Paying for EMS.