EMS Refusals, ER Losing Money?

[Bieber]

So, this topic isn't so much about whether or not EMS can safely refuse patients (the jury's still out on that one, but seems to indicate that additional education will be required), but rather about whether or not it will actually come to pass. It seems like most of us in the field realize that the current system is broken, and that EMS transport to the ER does not provide cost-effective, evidence-based care to our patients... On the other hand, it seems like I've been noticing more and more people within the EMS community suggesting that even if this is the case, the idea of an evidence-based, cost-effective EMS treat-and-release or release-and-refer model might face another major obstacle... namely, physicians.

Obviously while avoiding unnecessary transport and referring more of our patients to a more appropriate avenue of care might be good for our patients (and their wallets), it would also mean that ER's and ER staff (physicians, nurses, techs) would also be losing money. I'm not sure about your own systems, but I know one of the hospitals here locally is notorious for upgrading just about any patient to a trauma alert, regardless of what EMS's assessment findings are (I literally had a nurse straight up ignore me when I told her that a patient suffering a posterior rib fx from a fall had no injury to his scapula, and she went on and upgraded him to trauma for "scapular pain"). This to me makes me think that at times the hospitals are more interested in making money than giving the patient evidence-based (or even assessment based) care, and I know trauma systems across the country have started to take criticism for their tremendous costs.

I guess my question is, even if EMS can safely demonstrate the ability to treat, will we face opposition from the rest of the emergency medical community that stands to lose a lot of money if patient numbers drop? Could the risk of losing that money lead to ER physicians and nurses working to make EMS incompetent to refuse/treat-and-release, even if we can become capable of it?

Other thoughts?

[paramedicmike]

Sometimes patients are upgraded to trauma simply because the trauma center needs the numbers to maintain their trauma status. It happens around here all the time. The docs freely admit it... well... to us anyway. It used to drive me crazy that isolated orthopedic injuries were upgraded to trauma upon arrival at the hospital. But once I came to terms with the idea that it was the hospital and not that they weren't listening to me I got over it.

As far as patient numbers declining and income dropping from increased EMS refusals or similar, I think you might be overestimating just how many people come in to the ER via EMS. I really don't think an increase in EMS obtained refusals would impact the bottom line of a hospital ER. Admittedly I don't have solid numbers. But two ERs at which I interviewed recently routinely see between 200-400 patients per day the vast majority of which are walk ins.

Another thing to consider, and I don't have even anecdotal numbers on this, would be how many of the people we bring in actually pay their bills. Is it reasonable to think that by reducing the number of transports of people by obtaining refusals (or refusing transport) that the hospitals could actually save money by not expending resources on people who wouldn't pay otherwise? I don't know. It would be interesting to research.

Good questions.

[ERDoc]

Nurses and techs are salaried by the hospital so this will have no effect on their income. As for the hospital, it doesn't matter how it is coded when the pt arrives. There are certain requirements to bill certain levels of care and this depends on the physician. Billing is a complex entity and it does not matter if someone simply says, "Hey this is a trauma code." As for the ER physician, it depends on how they are employed. Some are hospital employed and salaried so it will not effect them. Those of us who are a part of a contract group get paid by what we bill. I'm not too worried about it because we can't keep up with the volume we have now, so losing a few people might not be a bad thing. Just because EMS doesn't bring them, doesn't mean they aren't coming to the ER anyway.

[Kiwiology]

The notion that Physicians would oppose such a model because they might loose some money on it is quite, ok lets be honest, extremely extremely aquared by elventygadzilliotybillion, perturbing

[kurigerb21]

Nurses and techs are salaried by the hospital so this will have no effect on their income. As for the hospital, it doesn't matter how it is coded when the pt arrives. There are certain requirements to bill certain levels of care and this depends on the physician. Billing is a complex entity and it does not matter if someone simply says, "Hey this is a trauma code." As for the ER physician, it depends on how they are employed. Some are hospital employed and salaried so it will not effect them. Those of us who are a part of a contract group get paid by what we bill. I'm not too worried about it because we can't keep up with the volume we have now, so losing a few people might not be a bad thing. Just because EMS doesn't bring them, doesn't mean they aren't coming to the ER anyway.

I couldn't possibly agree more. Maybe when you look at the administration which can get money hungry, but in general, most ER's I know would actually be okay with the idea of having a few patients not come in. Granted, this may be different for the contracted physicians, I'm not sure if I've worked with any or not, I've never asked, and most of the time when test are being over done, it's because they come from, say, a Level 1 trauma center, and are adjusting to a less acute facility, it's not been about the money. This is why I love Emergency Medicine (for the most part), volume isn't a huge crisis (stupidity makes sure we have job security!), and it's VERY rare that I hear a physician say, "Well, I'd like to do this test, but I'm not sure if insurance will cover it".

Terrific topic to initiate a conversation about! All, and all....if we could come up with a way that we, as EMS could safely determine if patient's need transported (though, let's get real, 9 times out of 10, our guess is pretty accurate, even if we can't voice it), I think it would actually benefit Emergency Departments. Like, on Christmas Day, when a tonsillitis occupied an ALS crew, and took a room in an ER who's numbers broke an all-time record that day...that's a situation where if EMS could refer instead of transport, it would just make everything better (The crew ended up having to call mutual-aid for a chest pain, which ended up coming to the hospital as a cardiac arrest, because they had to transport a tonsillitis.)

[Chief1C]

I often compare hospitals with pharmacies. I do third party EMS billing. Ever go into a large chain pharmacy, and notice they sell first aid supplies in individual amounts, like $1.50 for ONE 4x4.. and similar. That way, when someone on Medicare or etc, buys it insurance pay, they get 1/3 or such back and still make money. I say that often hospitals go out of their way to make a buck, when its not necessary.

I have a lot of elderly, low income folks that refuse ALS b/c they don't want the bill. Typically, the local ALS has the most outrageous bills I've ever seen, often several hundred to a thousand more than some of the urban services. I took a patient in, diabetic/fall victim was the dispatch, fell *against a chair, to the carpeted floor. Had a skin tear, that was the only complaint, wanted to be checked out. Didn't want a paramedic, didn't want a board, didn't want anymore than a friendly ride. Conscious, alert, oriented, not confused. Great, lets go, nice ride in the country.

Get to the ER, give my report to the nurse, we're standing there waiting for the insurance sheet.. and the bells go off, Trauma Alert, ETA Now. Here comes our patient, they were all ranting, fall victim on blood thinners.

Like.. I literally just answered your questions. Does the patient take blood thinners? Patient takes one 81mg baby aspirin every Tuesday morning (why Tuesday?), other than that, No prescribed blood thinners, only history is diabetes controlled with (stated meds). ER Doc gets in my face and says - This patient needs the trauma service, all fall victims on blood thinners need to be screened for head bleeds. I said But the patient doesn't take any blood thinners, and didn't hit anywhere remotely near the head. Patient against a chair and bumped the leg. There are no blood thinners on the meds list, they gave us a bag of meds, none in there, patient denied taking any, patients spouse stated the patient didn't take any. I always ask that if the call is for a fall victim, no matter the age. He said that patient takes Aspirin. Yeah, once a week. I took four for a headache this morning, maybe I should be trauma alerted by (pointing at a hott resident) that one? Aside from that, the patient had no symptoms/signs of a head injury, bleed, cva, et al.

I seriously almost slapped the doc. He either needed a vacation, or a piece of @$$. Way too uptight.

[mikeymedic1984]

Base your decisions, plans, and goals on what is best for the patient from the EMS perspective, let hospitals worry about their profit or lack thereof. When was the last time your local hospital ever did anything internally that helped the external EMS community ?? They run their company based on what is best for their organization and patients, you should do the same.

[Just Plain Ruff]

Hey 1chief, my dad bumped his head and opened a recently closed lac post cancer removal on the top of his head. NO Loc, no dizziness. We go to the local Er and they get into a debate on whether he needs a head CT. My father and I decide against it. The ED PA decides against it as well. The ED Doc comes in and asks same questions and then recommends the CT head. He then says that since he bumped his head hard enough to cut the skin that we needed to consider a transport to the nearest trauma center for workup as well. We said NO much to the Doc's chagrin.

So no head CT, no transfer.

I didn't hold it against the ED doctor staff because they were just "following" protocol.

In the end, the decision to close the wound was not made because it was not a closable wound they said, 2 days later the wound looked wonderful, no additional bleeding and 5 weeks post ER visit the wound is nearly healed.

Had we have gone to the trauma center like we started out going to, I'm sure the trauma team would have been called in and we would have been there forever, all based on a small 1/2 inch cut on my 76 year old father's head.

[Chief1C]

A victim of a walk-in "trauma alerting", it is not a pleasant experience, especially when you know about 60% of what they're doing is not necessary. Walk in (dressed nicely and fully alert) expecting about a $2,500 bill, walk back out (dressed in scrubs with a bag of shredded clothing and slightly dazed from "something to help me relax") - four hours later,.... I signed out, AMA of course, because they wanted to keep me overnight for observation. What did I have to show for a $13K bill? A cheap little arm sling and 30 800mg Ibuprofin. I should have stayed home, a crew member already had it nice and snug in a sling/swath anyway.

In fact, if I wanted to be a dick, I'd consider it borderline assault or a near Cobra violation. I was told if I didn't allow it, then the ER doc wasn't touching me. Some folks came in, and bitched at the guy that drove me b/c I wasn't boarded. Like, wtf, we came in a car, not the ambulance. There wasn't even an ambulance involved, it was a freak accident, and just happened to be in the company of my buddies - which namely consist of other providers.

They put a collar on me and put me on a board; moved me to another room where it was taken off three minutes after they cut all my clothes off.. Then when I questioned it, they considered that I may have a head injury, and I could possibly be combative.. so they dosed me with Diazepam.. in one of the two IV's they started. I had an abrasion to the scalp, and I only went b/c I thought my arm was broken, from being struck by an object. There was no blood loss, my vitals were fine, I had no loss of consciousness, no swelling around the abrasion, it was just a small rub mark, that didn't even bleed. Head to toe, I had arm pain. My chest was fine, my abdomen was fine; and I certainly could have pissed in a cup, and removed my clothing prior to the onslaught. I haven't been able to find another pair of ambulance boxers since then, so I sewed them back together. Call them my trauma shorts

Edited January 22, 2013 by Chief1C

[Just Plain Ruff]

Hey 1chief, my dad bumped his head and opened a recently closed lac post cancer removal on the top of his head. NO Loc, no dizziness. We go to the local Er and they get into a debate on whether he needs a head CT. My father and I decide against it. The ED PA decides against it as well. The ED Doc comes in and asks same questions and then recommends the CT head. He then says that since he bumped his head hard enough to cut the skin that we needed to consider a transport to the nearest trauma center for workup as well. We said NO much to the Doc's chagrin.

So no head CT, no transfer.

I didn't hold it against the ED doctor staff because they were just "following" protocol.

In the end, the decision to close the wound was not made because it was not a closable wound they said, 2 days later the wound looked wonderful, no additional bleeding and 5 weeks post ER visit the wound is nearly healed.

Had we have gone to the trauma center like we started out going to, I'm sure the trauma team would have been called in and we would have been there forever, all based on a small 1/2 inch cut on my 76 year old father's head.

And the only reason we were going to the trauma center was that is where my dad's oncologist is on staff.