Brandon O
Puzzled by facies
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We've all probably heard this stuff discussed to death, but I just attended a lecture that summarized the ACA changes along with some proposals for filling in the gaps that made 10000% more sense than anything else I've heard. It really resonated with me, answered many of my objections, and got me excited -- I thought I'd summarize it here. This is from Bill Kinch in the Boston area, a longtime medic who's been working to establish programs like this for a number of years. He's helped set up portions of these ideas in multiple states/countries and is aggressively continuing to develop them on several fronts.
So the problem now is that we're set up to treat acute emergencies (EMS + ED) and manage chronic illness in a scheduled fashion (make a PCP appointment in six months), but not unscheduled non-emergent illness, which makes up most of our volume. You can't get your PCP and there's no other option, so you use the ED, maybe via ambulance, which costs a ton and is terribly inefficient, because it's not set up for that. So instead, how about this?
1. You call 911, and a careful, rigorous EMD process establishes that your complaint is not life-threatening and emergent (cardiac arrest, stroke, major trauma, etc.). If it is, the EMS system is activated per normal. If not, they kick the call to a secondary communications center.
2. There your basic info is taken, which brings up your demographics (system integration is needed here), including your ACO -- meaning the coalition of PCP, hospitals, paramedicine providers, insurers, etc. that are responsible for your care. If possible you'll stay within that system.
3. A nurse interviews you, answering any questions as needed, and determines what needs to happen to address your problem.
4. The communications center can then dispatch the best resource, which may be: a non-emergent ambulance; a chair car; a passenger (livery) vehicle; a social worker; perhaps a midlevel-type practitioner; or nothing. You can be transported to the ED, an urgent care center, the pharmacy, directly to psych facilities (upgraded for acute assessment, including medical clearance), or wherever's best.
5. Advanced paramedics (call them what you want), which could simply be drawn from the standing pool of emergency ambulances while they're sitting around, or midlevel providers, could perform most screening and treatment on scene. Successful pilots have been made with point-of-care labs, suturing, casting, portable x-rays, and appropriate medical therapy all in a van and operated on scene (or with tele-consultation). Labs or radiography could be obtained and analyzed in a timely but not emergent fashion (come back in a few hours). Follow up is always possible since the pool of clinicians, particularly if you train all your ambulances at this level, is always available during their downtime. They can also perform proactive visitation, check up on recent discharges, and refer out for home safety or social needs.
6. Fee-for-service is gone, so we're not paid to transport, the hospital isn't paid per test or procedure, physicians aren't paid per patient load. Instead a chunk of money is given to the overall ACO to care for each patient, modified according to resource utilization and outcome. If patients get sick and do badly, everyone gets less money. If unnecessary resources are used, you're penalized. Patient only needed a cab ride, but you sent a paramedic? Tough, we're only paying you for the cab. Patient wanted the ambulance? Tough -- they don't dictate their care, they dictate their problem, the system determines the response. (If they insist on getting SOMETHING even if they need nothing -- true system abusers -- they probably get a cheap transport of some kind, but that's hugely less impacting than always getting an ambulance.) Eventually everyone should be insured; if you call for help and you're not in an ACO, you're placed in a temporary medical "home" and eventually assigned to a PCP and ACO, which will follow you in the future.
7. Liability and tort reform would have to be part and parcel. Since every patient isn't coming to the ED to get worked up in every imaginable way -- and even if they do come, physicians are discouraged from practicing that type of medicine -- we have to accept that there will occasionally be missed badness. This can be managed by smart screening at every level, and probably by accepting the retention of a certain degree of paranoia for really tricky cases (such as chest pain).
8. EMS education would obviously need to be improved, which may be tricky since although the rest of this can be driven from the top-down via government, there's no real federal EMS boss. However, if reimbursement starts to require it, and the demand exists, presumably educational pathways will develop. Providers may be happier, since they're being utilized more appropriately, and making more money. ED folks will be happier due to less crowding and more true emergency medicine.
9. In short: reimbursement, liability, and education all need to develop together. However, the overall model seems sound.
Thoughts?
So the problem now is that we're set up to treat acute emergencies (EMS + ED) and manage chronic illness in a scheduled fashion (make a PCP appointment in six months), but not unscheduled non-emergent illness, which makes up most of our volume. You can't get your PCP and there's no other option, so you use the ED, maybe via ambulance, which costs a ton and is terribly inefficient, because it's not set up for that. So instead, how about this?
1. You call 911, and a careful, rigorous EMD process establishes that your complaint is not life-threatening and emergent (cardiac arrest, stroke, major trauma, etc.). If it is, the EMS system is activated per normal. If not, they kick the call to a secondary communications center.
2. There your basic info is taken, which brings up your demographics (system integration is needed here), including your ACO -- meaning the coalition of PCP, hospitals, paramedicine providers, insurers, etc. that are responsible for your care. If possible you'll stay within that system.
3. A nurse interviews you, answering any questions as needed, and determines what needs to happen to address your problem.
4. The communications center can then dispatch the best resource, which may be: a non-emergent ambulance; a chair car; a passenger (livery) vehicle; a social worker; perhaps a midlevel-type practitioner; or nothing. You can be transported to the ED, an urgent care center, the pharmacy, directly to psych facilities (upgraded for acute assessment, including medical clearance), or wherever's best.
5. Advanced paramedics (call them what you want), which could simply be drawn from the standing pool of emergency ambulances while they're sitting around, or midlevel providers, could perform most screening and treatment on scene. Successful pilots have been made with point-of-care labs, suturing, casting, portable x-rays, and appropriate medical therapy all in a van and operated on scene (or with tele-consultation). Labs or radiography could be obtained and analyzed in a timely but not emergent fashion (come back in a few hours). Follow up is always possible since the pool of clinicians, particularly if you train all your ambulances at this level, is always available during their downtime. They can also perform proactive visitation, check up on recent discharges, and refer out for home safety or social needs.
6. Fee-for-service is gone, so we're not paid to transport, the hospital isn't paid per test or procedure, physicians aren't paid per patient load. Instead a chunk of money is given to the overall ACO to care for each patient, modified according to resource utilization and outcome. If patients get sick and do badly, everyone gets less money. If unnecessary resources are used, you're penalized. Patient only needed a cab ride, but you sent a paramedic? Tough, we're only paying you for the cab. Patient wanted the ambulance? Tough -- they don't dictate their care, they dictate their problem, the system determines the response. (If they insist on getting SOMETHING even if they need nothing -- true system abusers -- they probably get a cheap transport of some kind, but that's hugely less impacting than always getting an ambulance.) Eventually everyone should be insured; if you call for help and you're not in an ACO, you're placed in a temporary medical "home" and eventually assigned to a PCP and ACO, which will follow you in the future.
7. Liability and tort reform would have to be part and parcel. Since every patient isn't coming to the ED to get worked up in every imaginable way -- and even if they do come, physicians are discouraged from practicing that type of medicine -- we have to accept that there will occasionally be missed badness. This can be managed by smart screening at every level, and probably by accepting the retention of a certain degree of paranoia for really tricky cases (such as chest pain).
8. EMS education would obviously need to be improved, which may be tricky since although the rest of this can be driven from the top-down via government, there's no real federal EMS boss. However, if reimbursement starts to require it, and the demand exists, presumably educational pathways will develop. Providers may be happier, since they're being utilized more appropriately, and making more money. ED folks will be happier due to less crowding and more true emergency medicine.
9. In short: reimbursement, liability, and education all need to develop together. However, the overall model seems sound.
Thoughts?
