Report: FIRE doing EMS should come to an end.

[Tigger]

To me the root issue came about when someone realized that EMS could possibly make a municipality revenue. Suddenly fire departments could justify their budgets because now they bring in revenue. Except for the part where they do not. Reimbursements are at an all time low as are collections in most places. Running a 911 EMS system is not going to be profitable almost anywhere outside of wealthy suburbs.

And that's fine.

We should not expect emergency services to be profitable, that is not their intent. The unhappy fire-EMS marriage will end when this collectively realized by those that fund us. To do this we need to be cost effective and provide more services than we do now so we are worth that funding.

 

[SandpitMedic]

I agree with most of what you said, except this:

We should not expect emergency services to be profitable, that is not their intent.

This is free market capitalism. The same reason hospital corporations make billions, and healthcare corporations make billions, and insurance companies make billions, and AKflightmedic makes billions (just kidding), and every other service that morally shouldn't be for profit (unrelated example: prisons) is the reason why EMS has turned into a for-profit industry. There is money to be made, and someone is going to make it.

I see nothing wrong with charging for a service - unless we as a society say that in a true emergency we will foot the bill for each other via taxes (like the FD/PD) then why shouldn't EMS bill. (I'm not talking about Medicaid- that is a broken and antiquated system as well which has its place, but needs an overhaul). I think making EMS a tax subsidized industry would help it; that is one of the fire based EMS ideas that works. However, if it isn't a true emergency, which is about 75% give-or-take (and that's being generous) of all calls, the person receiving the service should foot the bill 100%. Whether that's private pay or covered by insurance is irrelevant, but it should be at a personal cost to the "customer." Just like if I pay for a taxi or for my phone bill. Everything else in our society works that way. Why should ambulance rides be any different?

Edit to add: I do not agree with charging insane amounts for "record profits" and all that jazz - it should be at a price that is reasonable and covers the costs of services. Not a price gouging system like we currently have.

So whether or not fire goes back to providing fire/rescue/BLS only, and a third party or agency provides for all ALS and BLS transports, well... Someone has to pay for it, regardless. And the current "paying for it" system is not sustainable.

 

[Tigger]

I agree with most of what you said, except this:


This is free market capitalism. The same reason hospital corporations make billions, and healthcare corporations make billions, and insurance companies make billions, and AKflightmedic makes billions (just kidding), and every other service that morally shouldn't be for profit (unrelated example: prisons) is the reason why EMS has turned into a for-profit industry. There is money to be made, and someone is going to make it.

I see nothing wrong with charging for a service - unless we as a society say that in a true emergency we will foot the bill for each other via taxes (like the FD/PD) then why shouldn't EMS bill. (I'm not talking about Medicaid- that is a broken and antiquated system as well which has its place, but needs an overhaul). I think making EMS a tax subsidized industry would help it; that is one of the fire based EMS ideas that works. However, if it isn't a true emergency, which is about 75% give-or-take (and that's being generous) of all calls, the person receiving the service should foot the bill 100%. Whether that's private pay or covered by insurance is irrelevant, but it should be at a personal cost to the "customer." Just like if I pay for a taxi or for my phone bill. Everything else in our society works that way. Why should ambulance rides be any different?

Edit to add: I do not agree with charging insane amounts for "record profits" and all that jazz - it should be at a price that is reasonable and covers the costs of services. Not a price gouging system like we currently have.

So whether or not fire goes back to providing fire/rescue/BLS only, and a third party or agency provides for all ALS and BLS transports, well... Someone has to pay for it, regardless. And the current "paying for it" system is not sustainable.

There are other means of funding besides billing the patient, as you have noted. The residents (and visitors if you do it right) should be funding the EMS system, but doing so through reimbursements is just not a realistic goal. We are hoping to pass a sales tax in my area, which I think is an awesome solution.

 

[SandpitMedic]

Yeah... Taxing could be a good way... Of course. We are certainly taxed out the wazoo as it is. It shouldn't be free for the abusers. Yes, a tax for covering actual emergencies. But not for the habitual 911 callers and riders.

 

[MonkeyArrow]

Yeah... Taxing could be a good way... Of course. We are certainly taxed out the wazoo as it is. It shouldn't be free for the abusers. Yes, a tax for covering actual emergencies. But not for the habitual 911 callers and riders.

The majority of people who erroneously call 911 do not have means of payment anyways. What are you going to do to a homeless guy? Sue him, collect what money. In my experience, people who have insurance and therefore you are likely to get reimbursement from are not your typical 911 abuser.

 

[Carlos Danger]

The SoCal model of every EMS response requiring a 5-man crew on a $600,000 ALS engine plus a separate transport ambulance is, on its face, ridiculously wasteful and inefficient. You can probably purchase, maintain, and staff at least two - perhaps three - ALS ambulances for every ALS engine. And you'd need fewer engines, too, if they were only responding to fires and MVC's instead of to every EMS call. It only makes sense when you finally see it for what it really is - a means of maintaining manpower and budgetary allotments, and nothing more. Public safety expenditures well above the national average are a big part of the reason why so many municipalities in CA are in such horrible financial shape. It is unsustainable.

I'm personally a fan of EMS being operated as either a county or city based third service. I think it just makes sense. But I also have to concede that there are lots of examples of FD's doing a really good job of running EMS, and some really good private services, too.

The bottom line is that the vast majority of EMS calls can be safely and effectively run by a single ambulance with a two-person crew, and anything more is simply wasteful.

 

[Tigger]

Yeah... Taxing could be a good way... Of course. We are certainly taxed out the wazoo as it is. It shouldn't be free for the abusers. Yes, a tax for covering actual emergencies. But not for the habitual 911 callers and riders.

Compared to the rest of the developed world that considers access to healthcare to be a right....we pay much less.

There are many reasons why the US is far behind the rest of the developed world when it comes to EMS. The lack of funding is no doubt one of them.

 

[SandpitMedic]

Compared to the rest of the developed world...

Have you ever been outside of the US? (Excluding Canada) Serious question, not to be a smart ***.
You can read all of these wonderful things about how every other socialist system is so great, and you can read how all of these socialist systems are crumbling and the providers/patients are worse off then we are. You can read whatever you want, and there's plenty of versions out there to fit your idea of how it is. However, until you have experience in other "developed" countries then it really doesn't matter. Theoretically, yeah that's very moral and ethical...everyone should be entitled to free healthcare. But the reality is that nothing is free - someone is paying for it. And the system ain't so great. :/ Go work in or intern in one of those systems and report back your personal experiences.
Am I saying the US has the best system? Absolutely not... I'm just saying neither do the "everyone gets free healthcare" nations either.

@MonkeyArrow, true... there is a homeless population to take into account. However, there are far more abusers in the gap between homeless and rich people who pay their bills (or at least try to pay their bills). Is every bill going to get paid? Of course not. But that doesn't mean the way we are doing it is right... because clearly it is not. I'm with Remi, as I stated. It's grossly inefficient financially and practically.

 

[Tigger]

Have you ever been outside of the US? (Excluding Canada) Serious question, not to be a smart ***.
You can read all of these wonderful things about how every other socialist system is so great, and you can read how all of these socialist systems are crumbling and the providers/patients are worse off then we are. You can read whatever you want, and there's plenty of versions out there to fit your idea of how it is. However, until you have experience in other "developed" countries then it really doesn't matter. Theoretically, yeah that's very moral and ethical...everyone should be entitled to free healthcare. But the reality is that nothing is free - someone is paying for it. And the system ain't so great. :/ Go work in or intern in one of those systems and report back your personal experiences.
Am I saying the US has the best system? Absolutely not... I'm just saying neither do the "everyone gets free healthcare" nations either.

Well let's get a few things straight first. I am not suggesting it's free. To have these systems requires more tax revenue, pure and simple. No one is entitled to free healthcare, but people should be able to access it. This county has a healthcare access problem, which is why the EDs are overcrowded and the ambulances often filled with system abusers. EMS and the ED are guaranteed access points, but they are far from cost effective. One way to fix this is to expand and change the way this country provides primary care, but that will likely increase taxes.

And to answer your questions, yes. I lived in New Zealand for six months in 2012. I accessed their healthcare system as a patient with preexisting conditions (lumbar fractures) without any issues and found the care I received to be on par with what I had been receiving in the states, and easier to get. I was working a sports medicine job prior to leaving so I think I have adequate means to compare the two. I didn't intern there (tough to do as a someone on a student visa), but I did do some rides with St. John in Auckland and spoke at length with a few EMS providers there. I also have elderly extended family who live there, so we spent a fair bit of time talking about how healthcare differs from the two countries. In 2013 I wrote my undergrad thesis on healthcare access challenges for Maori, noting that despite very pressing problems, New Zealand actually has effective measures in place to overhaul population healthcare practices, unlike this country. They spend money on developing primary and preventative care networks, and it shows with their outcomes.

I've travelled through a fair bit of Europe as well, but I am not going to say I've done much more than amateur research on their prehospital care.

 

[SandpitMedic]

Good assessment on our issue in the U.S. Sorry I misinterpreted your statement (access vs. free)

That's a broad brush though, and has little to do with who is providing EMS at the field level (FD vs other). Sorry for the thread derail, but yes you are correct that it is a general healthcare issue. I don't really want to dive into that in this thread.

Also, I'm glad you've got some worldly experience. That comes in handy. I've got some buddies that used to be with St. John... Sounds cool. I hadn't realized how strict their protocols were... Also for another thread

 

[DrParasite]

the issue with that line of thinking in, and always has been, there are typically more staffed and inservice fire engines than ambulances in any given area, despite the fact that said area has more medical calls than fire calls. So the closer unit (typically the fire truck) gets there first, stops the clock, initiates handholding, and might even initiate some patient care (CPR, defib, bleeding control, etc).

If any given area wanted to actually get Fire Depts to stop doing EMS runs, they would need to have as many in service ambulance as their are in service engines, and we all know that has been a pipe dream of mine for the past 15 years, and will probably never happen.

 

[Tigger]

That's a broad brush though, and has little to do with who is providing EMS at the field level (FD vs other). Sorry for the thread derail, but yes you are correct that it is a general healthcare issue. I don't really want to dive into that in this thread.

Meh, I see it as related. The IAFF has not exactly been supportive of allowing EMS to progress. They've protested increased educational standards and are now being obstinate about EMS being moved to Health and Human Services. Not to mention that the vast majority of FDs providing EMS did it to save FF jobs and there isn't exactly a rush by EMS/Fire agencies to start providing additional pre-hospital healthcare services, which is what EMS needs to become if it wants to remain relevant. There are exceptions of course.

 

[46Young]

No... the point is... stop putting paramedics on fire trucks all together. Stop forcing all the firemen to go to medic school.

Everyone now will be grandfathered in of course, they will never get away with getting rid of folks for being over qualified. No matter how hard they pushed, but implementing new rules. Then you'd save a ton by cutting the salary 5, 10, 20 percent (I dunno, I'm not an economist) on new hires, and in turn reduce the pensions, etc... You'd also save by not having to buy ALL of your apparatus ALS equipment, you could also spend less on purchasing 2-3-4 more ambulances versus a single pumper or ladder truck. All of these things are pretty much mentioned in the article.

Okay, for example: staffing one engine is the equivalent of staffing two ambulances (in terms of personnel). Even if you took away two engines, and added three ambulances, you're still saving hundreds of thousands of dollars just on payroll alone by now having six responders where you used to have eight, AND you can cover more area with the additional unit. It's math... less people = less payroll/bennies/pensions/etc. That's not even counting the money saved on all that other stuff that we've mentioned...

Are you following?

The SoCal model of every EMS response requiring a 5-man crew on a $600,000 ALS engine plus a separate transport ambulance is, on its face, ridiculously wasteful and inefficient. You can probably purchase, maintain, and staff at least two - perhaps three - ALS ambulances for every ALS engine. And you'd need fewer engines, too, if they were only responding to fires and MVC's instead of to every EMS call. It only makes sense when you finally see it for what it really is - a means of maintaining manpower and budgetary allotments, and nothing more. Public safety expenditures well above the national average are a big part of the reason why so many municipalities in CA are in such horrible financial shape. It is unsustainable.

I'm personally a fan of EMS being operated as either a county or city based third service. I think it just makes sense. But I also have to concede that there are lots of examples of FD's doing a really good job of running EMS, and some really good private services, too.

The bottom line is that the vast majority of EMS calls can be safely and effectively run by a single ambulance with a two-person crew, and anything more is simply wasteful.

It is very true that you can get a lot better EMS coverage with a few ambulances than one engine with 4-5 people. However, it is not a matter of meeting EMS demand by adding more engines instead of ambulances. It is instead a mater of using already existing fire apparatus to augment the EMS response, or more typically make up for a lack of deployment on the EMS side. Fire apparatus are staffed and deployed the way they are because there needs to be a timely response to suppression incidents. Regardless of suppression call volume, there still needs to be adequate coverage of a district, especially with type 5 construction, and heavy fire load (synthetics, plastics and such that are found in abundance in modern homes). Along with that, it is not a matter of how many calls are EMS, and how many calls are suppression. Most departments have 70% to 80% calls dispatched as EMS. What most people fail to realize is that a fair number of suppression calls require more than one fire apparatus (box alarms, inside gas leak, pin job, fire alarm, Hazmat, CO alarm, things like that). EMS typically gets an ambulance with two people on it at a minimum. A more fair way to compare suppression vs. EMS call volume would be to count the total number of ambulances that received a call over a year vs. the total number of suppression units that received a call over a year (excluding medical aid of course). That would tell a very different picture than the old "80% of calls are EMS, so take away engines and put more ambulances on the street."

Don't get me wrong, I feel that most places don't put out enough ambulances to handle call surges, much less give the average unit some downtime (#SSM/PUMsucks). The truth is, most employers are going to put out just enough ambulances to handle normal call volume. This goes for fire departments as well as privates, hospitals, and third service municipal alike. They all do it. Given this to be true in many places, it makes sense to have fire do first response to help out, since they are typically more idle than EMS, because they are staffed/deployed to cover an area irrespective of call volume or lack thereof. Look at the NIST studies to see why fire suppression requires a timely response, along with safe staffing levels if you don't believe me.

Having suppression first response may not necessarily affect pt. outcomes, but the manpower does help out the txp crew immensely. How many broken down EMT's and medics do you know that are in pain every day, or had to leave the field? You now have several extra hands to carry equipment and assist in pt. care. I can say from experience that when I was in NYC, 20 min. on-scene for BLS and 30 mins. for ALS was typical for us. In my current system, I can get off scene in 10-15 min. for BLS, and 15-20 for ALS, or 10-15 for ALS if I take the engine medic with me and do most of the stuff in trainsit. There is a time savings to be had with suppression first response. Preferably, it would be BLS suppression with dual medic txp. Otherwise, one txp medic nd one suppression medic, so that you have two medics to care for a critical pt.

As far as revenue, if EMS was not profitable. how would a private company be able to go into contract with the local govt? They would lose money, or the govt would have to pay them enough to make it profitable. Better to leave it to the municipality, rather than have the private operate with managing costs as the highest priority.

 

[Tigger]

Though I do not think that fire departments really have much business providing EMS, I agree with your point about suppression. Removing fire apparatus staffing or funding and replacing that with ambulances is not the solution. Staffing requirements for fire suppression have not changed much and probably need to remain. But if that's the argument that's going to be used, they should not also be providing EMS response to all medical calls like is done in so many places. I cannot count how many times I've had the engine crew take off in the middle of an EMS run because they have a fire call, which looks awful. But, that is in fact what they are there for.

Here in Colorado Springs AMR provides a medic/basic ambulance and the engine companies (and most trucks [sigh]) all have a medic as well, with the goal of having two medics on scene for every call in case of a critical patient. Now maybe this is a local problem, but the concept sucks. You have a paramedic who rarely spends more than five minutes with most patients and often drags his or her feet before providing treatment until the ambulance medic arrives in charge of the responding ambulance, who is shockingly halfway decent at medicine. You can imagine how this plays out.

If you want to be a paramedic (or any EMS provider), you need to be able to run a call from start to finish, and the current system does not allow for that. If the FD were not our overlords, it would be different. We do not need an engine company for most calls, and it would be nice to have extra hands that didn't repeatedly question the transporting paramedic's actions because they have no idea what they are doing.

 

[46Young]

We have 4 on the engine, and four on the majority of our ladder trucks, with the left bucket being a medic. If the suppression piece needs to go on another call, the suppression medic can stay on-scene for txp. The engine or truck will clear from an EMS run with a non-acute pt. to run another ALS in the first due if the txp crew doesn't need them, same for fire calls.

Not that difficult to work things out with the txp crew

 

[46Young]

FWIW, regarding the disdain of fire crews towards having to do EMS txp, from what I've seen and heard, the issue isn't so much of hating to pt. care per se. The bad attitude towards txp is more because of the nature of many of the calls, how they're typically non-acute, typically situations where an ambulance was not needed. This viewpoint is not exclusive to fire. These types of calls routinely burn out career EMT's and medics as well. The EMS people are pretty much stuck with having to run these nothing calls all of the time, whereas the fire people desire an escape from these time draining, unnecessary calls by getting off the ambulance onto a suppression piece.

When my department changed from a tiered ALS/BLS system with fire ALS first response to an all-ALS system (every txp unit EMT/Medic), I lost my love for txp. Just like many others, I have grown tired of responding and not getting to eat breakfast, lunch, or dinner at a normal time, from PT or a drill, or getting up three times a night to run toe pain, drunks, drug seekers, BS neck and back pain from an MVC, flu/stomach virus calls from 20-somethings, things like that. These txps take 45-90 minutes out of your day, and for nothing. You made zero difference in their outcome, and they could have easily driven themselves, got a cab, or had a friend drive them to urgent care.

Realize that I got my start in NYC 911, three as a basic, two as a medic, and another 7 in my current system as a medic. When I started out I envisioned myself as a career medic, but the all-ALS system has killed my enthusiasm for txp. Life is much better as an engine medic. Every firehouse in my system has an ALS engine and a medic unit, and four stations have an extra medic unit. We chase the medic on the majority of our calls (we have the same EMD system being used by dispatchers with no EMS experience). If the medic needs me to txp, it is because the pt. is in some sort of real distress, so I get to do pt. care, and the txp. medic gets stuck with cleanup (I do what I can until the engine shows up) and the report, and I get to go in-service. A 90 min. call is only a 30 min. call for me. In my particular situation, I see no benefit whatsoever to be the txp medic instead of the suppression medic. My txp days are laden with several mandatory reports for each txp, and I'm ultimately held responsible for everything that goes on with the calls. That means that I need to babysit personnel that I do not know, like OT and exchange people. Bags don't make it in, or if people botch up interventions, it falls back to me. I'm happy that I get to move back and forth from the txp unit on a regular basis. The OT vacancies in the station typically move to the ambulance, as the stations take care of their people by moving them fro the ambo to the suppression piece if the vacancy is there. This means that if you're on the bus, you can look forward to holdover/recall, or at the least being stuck an hour or two past shift change waiting for OT personnel to show up for relief.

That is why I, and the majority of fire based EMS people try to avoid working txp.

 

[avdrummerboy]

In other words, you're burnt out, all but the most critical of calls make you suicidal. You are proving an oft repeated point really, that a lot of people get into fire to do anything other than EMS. One of the main points of us incorrectly labeled 'anti-FD' folks is that fire SHOULD focus on fire/ rescue, the fun stuff that you get into the fire service to do, and EMS should handle the med aids and transports. Where I work, we cancel fire on basically everything short of a full arrest or a 1000 pounder, and guess what? It works great, there are no issues and the FD is kept in service for what they are there for, fires and rescues. This idea that the FD needs to respond to every single medical aid call is ridiculous and it's time that that point be realized and addressed.

 

[46Young]

Not entirely accurate - a common complaint from people that get into EMS for EMS, not just fire, is that EMS is 90% hand holding and 10% action. Single role EMS people tire of running minor calls, just like fire fire based providers prefer to avoid if possible.

In my case, I did 5 yrs in the NYC 911 system. As a basic, I got sick of bs calls. I became a medic. Medics don't get dispatched to BLS. Maybe half of my patients required ALS beyond an ECG and IV. It kepte interested in 911 txp. Now, I'm in an all-ALS system, so basically I'm BLS again with an occasional, very occasional good ALS call. There's no fulfillment in that.

Fire people escape from that by going into different job functions. Single role EMS get into dispatch, promote (rare), educate/promote into another area of healthcare, or just quit. 13 years in the field, with well over 13 yrs worth of txp time (based on a 40 hr workweek), I'm over doing non-acute BLS or VOMIT (vitals/O2/Monitor/IV/Txp) as the vast majority of calls. Give me my old ALS job types with no dispatched BLS, running out of a station that has beds, shower, gym, kitchen, a 24/72 schedule, with NY money, with FD retirement and benefits, I would be okay doing txp for the long term. That does not exist.

I've had enough of getting up 2-3 times a night for BLS, or eating meals 2-3 hrs. after the fact. That would be fine if they were good ALS, but the typical headache for five days, N&V after eating bad Taco Bell, I have neck and back pain after an MBA with nothing more than paint transfer, not so much.

 

[avdrummerboy]

The burnout of non tiered people and those of us who suffer in an all ALS system, where too many ALS personnel end up on insane calls like hangnails, all complicating the scene, comes from a outdated and preposterous system of protocols and abilities (not skills.) We need to be able to refuse to take the nonsense calls as well as be able to transport to alternative care centers- urgent care, mental health centers, etc.- not just hospital ED's.

And again, you yourself are living proof that an ALS fire apparatus is not needed on every single call, you only went out of the worst of the worst where the extra ALS helping hands would be needed. 99% of calls need nothing other than an ambulance (private or otherwise) and most off of that barely qualifies for BLS transport. The fire department should respond to just that, fire and rescue.

 

[adamNYC]

When I hit a car on my bicycle fire once showed up and gave me an icepack, then left when EMS arrived.