Ambulance Abuse?

[Dustdevil]

http://www.wgrz.com/news/local/story.aspx?...29&catid=37

You Paid For It: Ambulance Rides, Health Care Reform

Posted By: Andrew Pierrotti Posted By: Michael Wooten 38 mins ago

If it's a medical emergency, Erie County 911 will respond, but there is one address many of its dispatchers know by heart.

They find Scott Graham usually waiting at that Buffalo address for his ambulance several times a week.

"Sometimes two times a day," Graham told 2 On Your Side. He suffers from Sickle Cell Anemia, a blood disorder. If left untreated, it can block blood flow to limbs and organs.

"It feels like somebody shooting me with battery acid, and I'm stepping on razor blades, and I'm having a heart attack at once," he said talking about the pain the disorder causes.

Graham doesn't have a job, insurance or car. So, when he feels bad, he doesn't call a cab. He calls 911 to have an ambulance drive him to the hospital.

A 2 On Your Side investigation found that from January 2006 to May of this year, Rural Metro Ambulance picked him up 603 times.

Medicaid picked up the tab for each ride, costing taxpayers at least $118,158.

Graham estimates he's requested even more rides. "I'd say about a thousand times."

Rural Metro and Erie County chose not to respond on camera about Graham's case. The county follows the same rules most emergency systems follow across the country. If you call, they must haul you to the hospital, no matter what your call is about.

Graham says he requests an ambulance because he can't see his doctor as much as he needs. He also says he gets help quicker by arriving in an ambulance rather than by cab.

2 On Your Side contacted Medicaid to have them look into the number of times Graham used an ambulance. Medicaid appeared more interested in how we got the information, rather than how much it cost taxpayers to pick him up.

Medicaid fraud and abuse costs $60 billion each year nationwide.

2 On Your Side contacted our lawmakers to discuss how to lower that number.

"As we look at health care reform," Senator Kirsten Gillibrand (D-NY) said, "we should also look at oversight and accountability for those programs to make sure that people aren't abusing the system."

Gillibrand says cracking down on abuse should be part of the major health care reform going through Congress to force more oversight.

Take Mr. Graham's case. His trips cost Medicaid $118,000, but the government reimbursements are low. In fact, most ambulance companies lose money, up to 30% or more, when they transport Medicaid patients, because the government simply does not pay the full cost. Therefore, Mr. Graham's actual cost to the ambulance company and to the health care system in general, is much more, as high as $360,000.

Erie County Executive Chris Collins, a Republican, says government is not the answer to limiting that type of alleged abuse and waste.

"Fundamentally, inherently I think the private sector is better able to do anything and everything compared to government," Collins said.

Instead, Collins said the solution is insurance that is private and not public.

"Would the type of reform that you're suggesting here be able to crack down more on this type of fraud?" asked 2 On Your Side's Michael Wooten.

"I'm actually talking about the basic design of the program in New York," Collins said. "where fraud is something we have to look at everyday. But the actual larger cost is the actual design of the program and the fact that we took the entire menu and said we'll provide it all."

Gillibrand disagrees.

"Bottom line then, expanded government-run health care can be efficient you believe?" 2 On Your Side's Michael Wooten asked Gillibrand. "Absolutely," she responded. "Talk to your mother. Talk to your father. Talk to someone who has Medicare. They're pretty happy."

Currently, New York has a dubious distinction of having the highest Medicaid costs in the entire country, about $2,300 per person. Collins said if we had a system similar the one in California, which does not provide as much care, we would save enough money to completely eliminate the county property tax.

[fireflymedic]

Hey give 'em credit, at least they picked someone with a legitimate medical problem which is better than the vast majority of B.S. runs that we pick up. There's more than a few I've picked up that had nothing wrong with them, they just wanted a ride to town to the ER for some B.S. complaint so they could go to the liquor store and get a cab voucher home. The stopping of the hospital issuing cab vouchers helped, but unfortunately also hurt those who truly needed it - someone always has to pay for others stupidity sadly. Too bad they don't have the option of diverting to an urgent care clinic or the health clinic. You call we haul will kill us all.

[Kaisu]

I'm going to sound like a broken record here, but if the educational requirements of EMS and thus the scope of practice were increased, then we could triage these patients to the appropriate care. That would mean a realignment of current practice to serve the public, as opposed to the vested interests that put a stop to these types of measures each and every time. Are our public officials really so in the dark about what this is all about? Has no one told them?

[mobey]

At one point our hospital's ER was closed due to an infectious disease. As EMS responders we were mandated to assess the patient, and, if we thought it was appropriate, call the MD and recieve orders to cancel. We would then call the clinic and an appointment was made based on urgency.... Usually the next day.

There were about 30% less transports in that 2 week span.

Although it would not work in a chronic pain type call such as in this article, it is a start.

I'm going to sound like a broken record here, but if the educational requirements of EMS and thus the scope of practice were increased, then we could triage these patients to the appropriate care.

I don't know if education is truly the problem. I like to think the majority of ALS providers can triage appropriatly.

I think the problem lies in the liability, and financial politics.

I know my boss used to get ticked off when we did not transport, and could only bill for a responce and not a transport.

[cosgrojo]

I'm going to sound like a broken record here, but if the educational requirements of EMS and thus the scope of practice were increased, then we could triage these patients to the appropriate care. That would mean a realignment of current practice to serve the public, as opposed to the vested interests that put a stop to these types of measures each and every time. Are our public officials really so in the dark about what this is all about? Has no one told them?

While I agree with your stance on education, I don't think that it would really allow us to ignore patients request to go to the hospital. If that were the case, then RN's and MD's would have the right to turn patients away at the door shortly after triage questions. But they have to let them in, and so do we. If you work in a system that allows hospitals to kick you out before receiving care, then we obviously don't work in the same system. Everyone has the "right" to receive medical care, whether they need it or not... unfortunately.

[VentMedic]

I don't know if education is truly the problem. I like to think the majority of ALS providers can triage appropriatly.

Several studies in the U.S. say differently.

Can paramedics using guidelines accurately triage patients?

http://www.ncbi.nlm.nih.gov/pubmed/11524646

CONCLUSION: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.

Can paramedics accurately identify patients who do not require emergency department care?

http://www.ncbi.nlm.nih.gov/pubmed/1238560...ogdbfrom=pubmed

CONCLUSION: In this urban system, paramedics cannot reliably predict which patients do and do not require ED care.

Can paramedics safely decide which patients do not need ambulance transport or emergency department care?

http://www.ncbi.nlm.nih.gov/pubmed/1238560...ogdbfrom=pubmed

CONCLUSION: Paramedics cannot safely determine which patients do not need ambulance transport or ED care.

Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport.

http://www.ncbi.nlm.nih.gov/pubmed/1090564...ogdbfrom=pubmed

CONCLUSIONS: From 3% to 11% of patients determined on scene not to need an ambulance had a critical event. Emergency medical services systems need to determine an acceptable rate of undertriage. Further study is needed to determine whether better adherence to the protocols might increase safety.

Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols.

http://www.ncbi.nlm.nih.gov/pubmed/1164258...ogdbfrom=pubmed

CONCLUSION: These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.

Prospective determination of medical necessity for ambulance transport by paramedics

http://www.ncbi.nlm.nih.gov/pubmed/1458210...ogdbfrom=pubmed

CONCLUSIONS: Paramedics and emergency physicians agreed that a significant percentage of patients did not require ambulance transport to the emergency department. Despite only moderate agreement regarding which patients needed transport, the undertriage rate was low.

Can paramedics using guidelines accurately triage patients?

http://www.annemergmed.com/article/S0196-0...5311-2/abstract

Conclusion: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.

This was an interesting study that was referenced by one of the others. The stats it shows reflect the areas of interest of the Paramedic and they are not always the ones that can make for a provider who is knowledgable in many areas that are required to determine appropriate deposition of a patient. Trauma is a leading interest while medical conditions are not. As well, JEMS is the most popular journal which is not surprising but disappointing.

http://www.acep.org/workarea/downloadasset.aspx?id=4814

[CBEMT]

A 2 On Your Side investigation found that from January 2006 to May of this year, Rural Metro Ambulance picked him up 603 times.

That's it?

603 trips in 3 years wouldn't even get him into the top 10 here.

As well, JEMS is the most popular journal which is not surprising but disappointing.

http://www.acep.org/workarea/downloadasset.aspx?id=4814

I'm surprised. I would've thought it was Firehouse.

Edited August 1, 2009 by CBEMT

[tniuqs]

It appears that "debate" on Health Care Reform in the US is the underlying theme in this news article not abuse of ambulance nor can Paramedics triage (besides in the UK this is very effective modern means of delivery) google Super Medic and or what has been occurring offshore oil platforms world wide for a decade, triage in the field and delivery of health care in the field can be accomplished its a matter of education in the system, sorry to disagree Vent but this is an area where education can resolve many issues from urgent visit to ER to deferral to a GP office visit the next day.

In mobey and my hood this is going to happen ... legislation has been tabled to accomplish this "Out of Hospital Delivery of Primary Care", no studies just yet in Canukistan.

"Sometimes two times a day," Graham told 2 On Your Side. He suffers from Sickle Cell Anemia, a blood disorder. If left untreated, it can block blood flow to limbs and organs.

"It feels like somebody shooting me with battery acid, and I'm stepping on razor blades, and I'm having a heart attack at once," he said talking about the pain the disorder causes.

This raises the question ... is the transport system the failure or abused or is it the failure of the Health system to provide continuing care for a legitimate illness.

When I was working the road I actually enjoyed the Frequent Flyer's Clientèle always a good joke to be had, no point in whining, and Quoting a Triage RN .... did you need directions to "B" side ? ..... (in the event of yet another urine pants filled Paulette )

cheers

[VentMedic]

It appears that "debate" on Health Care Reform in the US is the underlying theme in this news article not abuse of ambulance nor can Paramedics triage (besides in the UK this is very effective modern means of delivery) google Super Medic and or what has been occurring offshore oil platforms world wide for a decade, triage in the field and delivery of health care in the field can be accomplished its a matter of education in the system, sorry to disagree Vent but this is an area where education can resolve many issues from urgent visit to ER to deferral to a GP office visit the next day.

The system in the U.K. also utilizes a nurse in some areas.

I am not anti-education. However, we now have too many in this profession who did not invest but the bare minimum (500 - 1000) hours to become a Paramedic and then have little interest in maintiaining what skills they do have. As well, the areas where the U.S. Paramedics are the weakest or display the least interest is medical issues. If all the patients to triage were trauma or "exciting" then they might show some ambition towards learning more. And yes I do fault the FDs are now making every FF become a Paramedic while utilizing their own PDQ mill or some other 3 month wonder mill. Right now we do have a considerable number of people wearing a Paramedic patch who have no interest in medicine or patient care and will not be the best judge of who deserves medical attention at the ED. It will be more of a "personality contest" rather than something based on a medical assessment. Some fail to put their attitudes in check when they get a call to a familar address or "one of those" neighborhoods with "those kind" of people. Look at the studies with MI patients. There is enough concern out there that some aren't getting assessed or taken seriously because of their gender or race.

[HERBIE1]

Several studies in the U.S. say differently.

Can paramedics using guidelines accurately triage patients?

http://www.ncbi.nlm.nih.gov/pubmed/11524646

CONCLUSION: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.

Can paramedics accurately identify patients who do not require emergency department care?

http://www.ncbi.nlm.nih.gov/pubmed/1238560...ogdbfrom=pubmed

CONCLUSION: In this urban system, paramedics cannot reliably predict which patients do and do not require ED care.

Can paramedics safely decide which patients do not need ambulance transport or emergency department care?

http://www.ncbi.nlm.nih.gov/pubmed/1238560...ogdbfrom=pubmed

CONCLUSION: Paramedics cannot safely determine which patients do not need ambulance transport or ED care.

Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport.

http://www.ncbi.nlm.nih.gov/pubmed/1090564...ogdbfrom=pubmed

CONCLUSIONS: From 3% to 11% of patients determined on scene not to need an ambulance had a critical event. Emergency medical services systems need to determine an acceptable rate of undertriage. Further study is needed to determine whether better adherence to the protocols might increase safety.

Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols.

http://www.ncbi.nlm.nih.gov/pubmed/1164258...ogdbfrom=pubmed

CONCLUSION: These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.

Prospective determination of medical necessity for ambulance transport by paramedics

http://www.ncbi.nlm.nih.gov/pubmed/1458210...ogdbfrom=pubmed

CONCLUSIONS: Paramedics and emergency physicians agreed that a significant percentage of patients did not require ambulance transport to the emergency department. Despite only moderate agreement regarding which patients needed transport, the undertriage rate was low.

Can paramedics using guidelines accurately triage patients?

http://www.annemergmed.com/article/S0196-0...5311-2/abstract

Conclusion: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.

This was an interesting study that was referenced by one of the others. The stats it shows reflect the areas of interest of the Paramedic and they are not always the ones that can make for a provider who is knowledgable in many areas that are required to determine appropriate deposition of a patient. Trauma is a leading interest while medical conditions are not. As well, JEMS is the most popular journal which is not surprising but disappointing.

http://www.acep.org/workarea/downloadasset.aspx?id=4814

Looking at the first few studies, it was clear the sample sizes were exceedingly small- statistically insignificant if someone was trying to suggest that prehospital triage is large scale problem. Certainly these studies cite a problem within those particular systems, but I fail to see proof it is a widespread issue. As for trauma- much of what we do(treatment, proper mode of transport, appropriate facility, etc) is supposition based on MOI, not necessarily direct evidence. We assume the worst and let the hospital and their advanced training and diagnostics rule everything out- as it should be.

If there was a nationwide study, with an appropriate sample, that bridged all types of EMS provider systems, I would be more apt to believe the results.