Would you like to be a Primary Care Paramedic?

[18G]

Vene...
You know, it is a great tactic in a debate to try and passively reduce the other persons position as an attempt to highlight and make your own position sound superior. You do a great job of using that tactic.

All I have heard you spew is your own jaded opinion on why Paramedic care is worthless and a waste of money. Where are your statistics and research to support your position? I have not provided any in this informal debate because I am shooting off replies while sitting on the couch with my laptop. If this were a "real" debate in a Community then I would have statistics to support everything I have said.

I have read the recent studies that show pre-hospital pain management is highly effective and needs to become more aggressive. And the studies that show pre-hospital Zofran use is highly beneficial at reducing patient suffering. And the studies that show early pre-hospital steriod use lowers hospital admission for asthma. And many more. I really don't have the time to search for them all and paste the links.

What I have promoted is not dogma or feel good speak. A degreed, Paramedic level EMS provider should be considered the new "basic" level provider with levels going up from there. EMT's should be what First Responders are now.

One last point I wanted to touch on is the comparison of nursing to Paramedicine. That is a really unfair comparison. Nursing evolution only had what... a 100 year or so jump on EMS? If EMS evolution had a 100 year jump start I'm sure we would be much further ahead. Considering EMS started in about 1968 and its now only 2011 I would say EMS has come much further in that short amount of time then what nursing did. But then again, nursing is a completely different field with a much different set of variables to overcome.

I'll give you some kind advice as well. If your gonna convince me and others that EMS and Paramedicine is a sham, then your going to have to provide some proof of that. Your gonna have to show me that my interventions are ineffective and my level of knowledge as a Paramedic makes no difference in comparison to a EMT-Basic. Prove to me that my two years of education is equal to 140hr EMT program. Prove to me my capabilities are no more then the EMT-Basics. Prove to me that my drugs and equipment make no difference in pain and suffering and life and death.

I had a larger reply typed and this stupid laptop closed the tab somehow.

 

[18G]

MedicRob... I would love to see EMS education programs like you describe! That is what I am kinda talking about. The current Paramedic today would be entry level into the EMS field and go up from there. I would love to have a bachelors option for Paramedicine and not one that is focused on EMS Management.

 

[thegreypilgrim]

Psychiatric is a good idea. Why can't we add things like Pulmonary Artery caths, Intracranial Pressure Monitoring, IV Pumps, and other ICU skills to the specialty part? That is the best part about a 4th year specialty, you have an entire year to train them in a specialty area.

1st and 2nd year = General Education
3rd year = Paramedic Curriculum for NREMT purposes and testing
4th year = Specialty Year and Internship in specialty area

Again, I don't see any reason why we couldn't. I'm interested to know what role the paramedic could play in the ICU as it's not something I've thought of: and I assume you mean the actual ICU since you have CCT/Aeromedical listed as separate specialties. What would that mean for nursing?

PS - did you get my last PM?

 

[jrm818]

Just to cast some perspective on the importance of demonstrating improved outcomes as a result of EMS.

I stumbled over this article yesterday, and low and behold its relevant today: http://www.boston.com/lifestyle/hea...ill_chasing_in_the_era_of_health_care_reform/

It's sort of an interesting report on the ridiculousness that is medical billing in the lovely US of A, but the most important part I think is this: It's a BCBS rep. speaking about why insurance companies are trying to reduce compensation for ambulance transport: "According to spokesman Jay McQuaide, the state’s Blue Cross customers spend about $80 million a year for services that do not “improve the quality or effectiveness of the care” – $60 million of that total goes toward ambulances."

Individual examples of a subset of patients that seem to obviously benefit from EMS, even if accepted, don’t gain much ground to combating attitudes like that. We need to be able to provide real evidence (patient-relevant outcome oriented data) that we improve the overall quality of care for our patients. Thus far the evidence is spotty (and, as Vene noted, some of the better evidence is OPALS, which is not flattering)

Even demonstrating survival to hospital is probably insufficient. If temporarily alive patients ungratefully die without regard the quality of their EMS care, it's all for naught. You don’t get brownie points for storing corpses in an ED or ICU.

It's clear that we don't need (and couldn't obtain anyways) evidence of a benefit for every possible intervention for every possible patient presentation. At some point it is of course time to admit that parachutes improve fall survival (http://www.ncbi.nlm.nih.gov/pubmed/14684649). However, EMS isn’t about parachutes versus no parachute (medical care or no medical care): it’s often about parachute now or later (in field or in the hospital).

It’s not just a matter of carrying out the research that will demonstrate once and for all that EMS/Paramedics provides better outcomes. It’s not at all certain that the research will show that. Before we can prove that paramedics are better, they need to actually be better. With the current state of protocol driven “medicine” (medicine by numbers, I think Vene has called it medicine by epidemiology) I have to wonder….

Edit: I can think of a rather short list of conditions with good evidence of improval with ALS level prehospital care. As noted pain control, perhaps early interventions for very severe CHF/COPD, primarily by staving off intubation, trauma and MI only by virtue of transport to a proper facility and early notification, and thats...about it. I'm sure there are several more, but really if we're hanging our hat on pain control and receiving hospital destination, we may have issues with cost justification.

 

[medicRob]

It's sort of an interesting report on the ridiculousness that is medical billing in the lovely US of A, but the most important part I think is this: It's a BCBS rep. speaking about why insurance companies are trying to reduce compensation for ambulance transport: "According to spokesman Jay McQuaide, the state’s Blue Cross customers spend about $80 million a year for services that do not “improve the quality or effectiveness of the care” – $60 million of that total goes toward ambulances."

Insurance will be one of, if not the biggest hurdle that paramedicine will face in its rise toward profession. This is why we need to look to new revenue streams such as "Urgent Care Billing" instead of just "Emergent", and we need to give paramedics the education to be seen NATIONALLY in the language of the law as "licensed providers" (This is different than just having a license). Once we do this, maybe we can start billing Paramedic skill hours instead of mileage. It is hard for a profession to step away from the ambulance when their only basis for billing at the moment is based upon mileage.

Whenever I perform a skill as an RN, there is a certain $ amount attached to that equipment and a certain time that is attached to that skill (It is the reasonable amount of time the insurance company feels I should be able to perform that skill in), those are called skill hours. As a licensed professional, when I perform a skill, revenue earned on the basis of those skill hours and various other factors (Time of stay, ancillary services rendered, etc). If we could bill Paramedics in hospitals as skill hours (which would require them to be recognized nationally by the letter of the law as 'licensed professionals' <-- This is where I bring in the idea of Bachelors programs, we can do this). New revenue streams will be generated, hospitals will think more of hiring paramedics at expanded salaries, etc.

The medical center that I work at has kind of blinded me to what is going on nationally. We are so far ahead of the curve that each patient in the ER not only has an RN, but also a Paramedic. The RN and the Paramedic work together with the MD and APRNs to care for this patient. The Paramedic not only just carries out skills like IV Starts and med pushes, but he/she also plays an active role in care planning. It is an amazing system.

Unfortunately, it seems that my hospital is one of those rare exceptions.

 

[18G]

I would love to see a breakdown of that $60 million the insurance rep speaks of. Routine, non-emergency transports are big business for ambulance companies and I would venture to say that much of the $60 million goes for these type of transports and not 911, ALS level services.

A routine ambulance transport from ED back to nursing home is quite a bill! Same way with doctors office transport that are most often BS certified medically necessary. So I would also venture to say the reps statement of, "...that do not “improve the quality or effectiveness of the care" refers to these non-emergency transports that mostly could go by other means.

I can think of a rather short list of conditions with good evidence of improval with ALS level prehospital care. As noted pain control, perhaps early interventions for very severe CHF/COPD, primarily by staving off intubation, trauma and MI only by virtue of transport to a proper facility and early notification, and thats...about it. I'm sure there are several more, but really if we're hanging our hat on pain control and receiving hospital destination, we may have issues with cost justification.

I can think of many more examples. EMS is dynamic and patients get themselves in a slew of unpredicted situations. What about the patient who is riding a tractor that overturns, patient is pinned with severe trauma and face down in the mud.. (real call btw). The Paramedic performed a digital intubation successfully. How do you account for this level of skill and these situations? Should this patient not have had this level of provider in his Community? BLS would have sufficed in this situatioin?

 

[18G]

A great article and interesting read I saw posted on JEMS Connect.... outlines how research is not a "tell all" and can be flawed and rigged to show the researchers desired outcome.

Lies, Damned Lies, and Medical Science

http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/#

It's not always about the research.

 

[Veneficus]

Unless you want to implement something like the Community Paramedicine program that Rob was talking about and work toward deflating local ED census.

Educated paramedics --> Treat and Release & Referral --> reduction in cumulative health expenditures and better career options for paramedics themselves.

Something like that could certainly benefit an urban area and could not be performed by Basics.

That would be ideal, but with most major cities using FD based EMS as the primary source of prehospital providers, they would first have to embrace health prevention as they did fire prevention and I really don't see that as being the culture anytime soon.

It doesn't make economic sense to have a seperate 911 service from it because at that point you could just use a home health nurse and that would totally defeat the purpose of having paramedics diversify to that role.

If yo create overlap, not only do you not reduce costs, but you put the nursing lobby in direct conflict with EMS. From a political standpoint, it is a losing position. The power that nursing has is quite solidified for a small group of disorganized EMS people to overcome. Especially with the current educational standards.

 

[usalsfyre]

What I have promoted is not dogma or feel good speak. A degreed, Paramedic level EMS provider should be considered the new "basic" level provider with levels going up from there. EMT's should be what First Responders are now.

I think the point Vene is trying to make is the majority of prehospital providers DON'T WANT this. They are too tied up in "hey look at this cool stuff I can do" to be bothered with the science behind it. Unless you dangle money in front of them, there's no drive to improve. I see this in about 90% of paramedics, but only 30 or 40% of other health care providers I speak with.

One last point I wanted to touch on is the comparison of nursing to Paramedicine. That is a really unfair comparison. Nursing evolution only had what... a 100 year or so jump on EMS? If EMS evolution had a 100 year jump start I'm sure we would be much further ahead. Considering EMS started in about 1968 and its now only 2011 I would say EMS has come much further in that short amount of time then what nursing did. But then again, nursing is a completely different field with a much different set of variables to overcome.

Other allied health fields (lab, radiography((sorta)), respiratory, pharmacy, PT and OT, and many other I'm forgetting) have managed to impose higher education as entry. Why? Because the members of their respective fields weren't short-sighted. Meanwhile, paramedics have eschewed education in favor of things like labor unions to raise wages.

I'll give you some kind advice as well. If your gonna convince me and others that EMS and Paramedicine is a sham, then your going to have to provide some proof of that. Your gonna have to show me that my interventions are ineffective and my level of knowledge as a Paramedic makes no difference in comparison to a EMT-Basic. Prove to me that my two years of education is equal to 140hr EMT program. Prove to me my capabilities are no more then the EMT-Basics. Prove to me that my drugs and equipment make no difference in pain and suffering and life and death.

I understand what your saying. The problem is, 18G, usalsfyre, medicRob, and many others on this forum aren't the norm in the US, we're the outliers. The norm is the guy who doesn't know an alpha receptor from an alpha cell in the pancreas, thinks giving narcotics to anyone is "feeding drug seekers", and thinks paramedics "do the same job as ER doctors with half the pay" (I kid you not, I was on an employee retention commitee and saw this in more than one survey) and above all, protocol is king because "we're not doctors!" As long as this is the predominate person in our profession (and right now it is, I've talked to a lot of folks) then we don't stand a chance at real change. The impetus won't come from above, they're happy making money and justifying manpower/budget. The force for change has to come from providers. Right now, I don't see that happening, before EMS crashes and burns completely.

 

[thegreypilgrim]

That would be ideal, but with most major cities using FD based EMS as the primary source of prehospital providers, they would first have to embrace health prevention as they did fire prevention and I really don't see that as being the culture anytime soon.

There lies the rub, of course, but I thought we were talking about an ideal

It doesn't make economic sense to have a seperate 911 service from it because at that point you could just use a home health nurse and that would totally defeat the purpose of having paramedics diversify to that role.

I'm not entirely sure about this. From what I understand you have to be referred to a home health service and it's all part of a pre-scheduled arrangement. Not available on the fly. Furthermore, home health nursing has been around for years and thus far does not seem to have substantially reduced otherwise unnecessary 911 activations. Paramedics could fill the void here.

If yo create overlap, not only do you not reduce costs, but you put the nursing lobby in direct conflict with EMS. From a political standpoint, it is a losing position. The power that nursing has is quite solidified for a small group of disorganized EMS people to overcome. Especially with the current educational standards.

Much bigger problem here. In any instance where the nursing lobby comes in conflict with EMS, EMS is going to lose. Hence the vicious circularity and compounded nature of barriers to the professionalization of EMS. Once you think you have one problem solved (or, at the very least, a strategy for solving it) you come up against another impenetrable barrier.

 

[medicRob]

If yo create overlap, not only do you not reduce costs, but you put the nursing lobby in direct conflict with EMS. From a political standpoint, it is a losing position. The power that nursing has is quite solidified for a small group of disorganized EMS people to overcome. Especially with the current educational standards.

..and what's bad for nursing is bad for business, and we know that none of you want that. bwahahahah

 

[Veneficus]

Vene...
You know, it is a great tactic in a debate to try and passively reduce the other persons position as an attempt to highlight and make your own position sound superior. You do a great job of using that tactic.

All I have heard you spew is your own jaded opinion on why Paramedic care is worthless and a waste of money. Where are your statistics and research to support your position? I have not provided any in this informal debate because I am shooting off replies while sitting on the couch with my laptop. If this were a "real" debate in a Community then I would have statistics to support everything I have said.

I have read the recent studies that show pre-hospital pain management is highly effective and needs to become more aggressive. And the studies that show pre-hospital Zofran use is highly beneficial at reducing patient suffering. And the studies that show early pre-hospital steriod use lowers hospital admission for asthma. And many more. I really don't have the time to search for them all and paste the links.

What I have promoted is not dogma or feel good speak. A degreed, Paramedic level EMS provider should be considered the new "basic" level provider with levels going up from there. EMT's should be what First Responders are now.

One last point I wanted to touch on is the comparison of nursing to Paramedicine. That is a really unfair comparison. Nursing evolution only had what... a 100 year or so jump on EMS? If EMS evolution had a 100 year jump start I'm sure we would be much further ahead. Considering EMS started in about 1968 and its now only 2011 I would say EMS has come much further in that short amount of time then what nursing did. But then again, nursing is a completely different field with a much different set of variables to overcome.

I'll give you some kind advice as well. If your gonna convince me and others that EMS and Paramedicine is a sham, then your going to have to provide some proof of that. Your gonna have to show me that my interventions are ineffective and my level of knowledge as a Paramedic makes no difference in comparison to a EMT-Basic. Prove to me that my two years of education is equal to 140hr EMT program. Prove to me my capabilities are no more then the EMT-Basics. Prove to me that my drugs and equipment make no difference in pain and suffering and life and death.

I had a larger reply typed and this stupid laptop closed the tab somehow.

In a pubmed search of:

EMS

EMS effectiveness

Emergency medical services

Emergency medical services effectiveness

paramedics

The only relevant study I found was:

Performance and skill retention of intubation by paramedics using seven different airway devices-A manikin study.
Ruetzler K, Roessler B, Potura L, Priemayr A, Robak O, Schuster E, Frass M.

Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Austria.

Aside from the OPALS study I can find nothing else.

 

[jrm818]

I would love to see a breakdown of that $60 million the insurance rep speaks of. Routine, non-emergency transports are big business for ambulance companies and I would venture to say that much of the $60 million goes for these type of transports and not 911, ALS level services.

A routine ambulance transport from ED back to nursing home is quite a bill! Same way with doctors office transport that are most often BS certified medically necessary. So I would also venture to say the reps statement of, "...that do not “improve the quality or effectiveness of the care" refers to these non-emergency transports that mostly could go by other means.

I suspect that you're right about the cost including a large amount of non-emergency transport. It doesn't seem like the insurance companies really distinguish the between emergency and routine ALS service, and really neither do ambulance services. Everywhere I've worked the billing (to my knowledge) is the same for an interfacilty as for emergency transport: the only price differences have been based on the number of "advanced" skills that were performed. It doesn’t seem like BCBS thinks they get very much for the procedures they pay for, be they in emergency or non-emergency situations.

I think part of the issue is that EMS tries to distinguish between "ALS" and "BLS" by the skills that each level of provider is entitled to perform. Thus "ALS care" is care in which at least one ALS skill is provided. There is no credit, for example, for an advanced evaluation that determines that no ALS procedure is required.

When physicians bill for service, their reimbursement level is tied not only to the interventions they perform, but to the complexity of the medical situation and the critical thinking required. Their billing system has its own problems, but I think its relevant to think about the idea behind the two billing mechanisms: EMS is all about what skill was performed, but there is relatively little attention given to medical decision making. I think that reflects pretty accurately the training attitude I've seen and the thought process of medics in the field, and that seems like a huge problem.

If we insist on valuing (literally, with money) EMS according to the procedures it is able to perform, we're missing the boat. Yes, some procedures that paramedics perform can be demonstrated to improve outcomes. It doesn't take a paramedic to follow a cookbook and perform a psychomotor skill, however. We can get procedures with relatively uneducated and poorly paid providers.

However, in most systems its unlikely that there will be more than a small subset of patients who benefit from receiving any specific intervention at t=0 rather than t=20 minutes, and that benefit diminishes with decreasing time differences. There is only so much good EMS can do by providing "early" treatment.

Instead we need to focus on creating a system where providers are equipped to make educated decisions about the best way to care for individual patients in a way that those decisions either reduce healthcare costs, improve efficiency, or improve patient outcomes.

I can think of many more examples. EMS is dynamic and patients get themselves in a slew of unpredicted situations. What about the patient who is riding a tractor that overturns, patient is pinned with severe trauma and face down in the mud.. (real call btw). The Paramedic performed a digital intubation successfully. How do you account for this level of skill and these situations? Should this patient not have had this level of provider in his Community? BLS would have sufficed in this situatioin?

Honestly, we can play with any number of examples, but the issue is the idea of picking a few select patients who benefit, versus addressing the overall needs of the population and designing a system to meet the needs of a lot of them, more than a select group of very ill patients.

I won't dispute that for this individual patient their respiratory status was possibly improved by the presence of a paramedic (although, a basic with a blind insertion device may have accomplished a similar feat without risking his digits...). That isn't the issue. The problem is that there isn't any compelling evidence that the "ALS" care improved this patients outcome. There is of course now a great study indicating that RSI can improve TBI outcomes down under, but that certianly does not prove that American "ALS" is capable of the same benefits given the differences in philosophy.

Conditions for which "ALS" is clearly demonstrated to improve relevant outcomes are few and far between. National EMS Advisory Council put out a position paper about the demonstrated benefits of EMS in December 09 (http://www.ems.gov/pdf/nemsac-dec2009.pdf). It's great that the group is advocating for EMS, but the list of situations in which ALS has demonstrated benefits was rather sparce. It was essentially my list: MI/Stroke/trauma due to transport decisions, respiratory failure due largely due to CPAP (A “basic skill” in PA), perhaps TBI due to overall management, and that’s about it.

It would be nice to add some conditions to the list, and we probably can, but that's a bit of missing the forest for the trees.

Crafting a huge paramedic based EMS system based on a list of the small subset of patients with extremely time sensitive complaints is not likely to yield large returns. Many of these patients will die nomatter what we do, there aren’t very many of them, and basics with protocols including a few advanced tools (and on-line medical direction Rampart style) are likely to provide just as good care as our current paramedics.

The goal really ought to be creating a system that can bring real long term solutions (rather than temporizing measures) to the sorts of problems that cause people to call 911. This may involve things like alternate clinical pathways, treat and release, etc., as well as more advanced thinking when dealing with very ill patients, rather than current protocolized treatments. That will require a level of knowledge and critical thinking that is currently beyond the design parameters of current paramedics, but it seems like a good way to achieve enough benefit with EMS to justify the expense. The current idea of charging a thousand bucks for a few “advanced” skills will not cut it.

 

[jrm818]

A great article and interesting read I saw posted on JEMS Connect.... outlines how research is not a "tell all" and can be flawed and rigged to show the researchers desired outcome.

Lies, Damned Lies, and Medical Science

http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/#

It's not always about the research.

Of course if we had some more EMS grown research, we could have some flaws in favor of EMS for once....

Did you take a peak at my parachute link? I don't think anyone here (if I dare speak for all those here smarter than I) is trying to claim that research is everything, but it is part of the equation of changing the impression of others. The other part of changing beliefs about the inadequacy of EMS is actually making it adequate (well, really, that's the first part).

 

[18G]

I don't need a research study to tell me that what I do makes a difference in a persons life. I know when I make someone breathe better, take their pain away, relieve their nausea, reverse an allergic reaction, etc, etc, etc.

If people need a research study to validate every single thing they do then they need to go to Burger King and work where its clear the hot grill cooks the meat and makes a delicious double cheeseburger.

I love the work I do and I see how it benefits peoples lives. I don't dismiss research as I love reading the data and I think its very much needed. But I don't get carried away with it and assume just because a study isn't found that a certain modality isn't valid or makes any difference. And a single study isn't totally persuasive either.

I've stated my position and have no more to comment at this time. I'm all for Paramedic care being entry level and hopefully one day it is.

 

[medicRob]

The problem is, 18G, usalsfyre, medicRob, and many others on this forum aren't the norm in the US, we're the outliers.

That's right... I'm an outlier. I am 2 standard deviations from the mean, I am 85% sure of that.. /statistics joke

 

[usalsfyre]

I don't need a research study to tell me that what I do makes a difference in a persons life. I know when I make someone breathe better, take their pain away, relieve their nausea, reverse an allergic reaction, etc, etc, etc.

If people need a research study to validate every single thing they do then they need to go to Burger King and work where its clear the hot grill cooks the meat and makes a delicious double cheeseburger.

I love the work I do and I see how it benefits peoples lives. I don't dismiss research as I love reading the data and I think its very much needed. But I don't get carried away with it and assume just because a study isn't found that a certain modality isn't valid or makes any difference. And a single study isn't totally persuasive either.

I've stated my position and have no more to comment at this time. I'm all for Paramedic care being entry level and hopefully one day it is.

It's not that YOU understand that value, it's selling your worth to others. You need research to do this. We fail miserably at this, and the majority of providers show no interest in changing it.

 

[medicRob]

How would paramedics function in an actual ICU environment though? I foresee the ANA expending all political capital they have to prevent something like that from happening. Not against the idea of course, but just want to see how you'd get around carving out a role for paramedics in the ICU that didn't step on nursing's toes.

In the same way they function in our ER currently, right alongside nurses. Are nurses gonna be pissed? You bet ya, but aren't we already pissed that you are pushing drugs and intubating with a 1 year education? We'll get over it.

RN / Paramedic Patient Care Team Model
http://www.mc.vanderbilt.edu/root/sbworddocs/er_services/patient_care_team_model.ppt

For more info:

http://www.mc.vanderbilt.edu/root/vumc.php?site=adulted&doc=828

 

[bigbaldguy]

I don't need a research study to tell me that what I do makes a difference in a persons life. I know when I make someone breathe better, take their pain away, relieve their nausea, reverse an allergic reaction, etc, etc, etc.

If people need a research study to validate every single thing they do then they need to go to Burger King and work where its clear the hot grill cooks the meat and makes a delicious double cheeseburger.

I love the work I do and I see how it benefits peoples lives. I don't dismiss research as I love reading the data and I think its very much needed. But I don't get carried away with it and assume just because a study isn't found that a certain modality isn't valid or makes any difference. And a single study isn't totally persuasive either.

I've stated my position and have no more to comment at this time. I'm all for Paramedic care being entry level and hopefully one day it is.

Well put. Numbers don't mean everything but they certainly shouldn't be ignored.

 

[medicRob]

Well put. Numbers don't mean everything but they certainly shouldn't be ignored.

Numbers may not mean everything, but numbers talk. There is a reason the evolution of medicine relies so heavily on research. Also, as far as research being 'rigged', etc. Anyone with a proper education in research evaluation can spot a so called 'rigged' study from a mile away. Just take a look at the "Prehospital Fluids increases mortality in trauma patients" post in the Advanced Medical forum. When evaluating research, you must learn to look for inconsistencies.. Does this mean all research is bad? Nope.

I am with Vene on this one. EMS in the US is going to have to crash and burn before it learns its lesson. The fact is, in medicine when you make a claim that something is effective, you are typically expected to have solid research backing you. Unfortunately, EMS suffers from 2 situations.

1. Lack of a proper research base for the profession.
2. It is just not that effective, not when you compare it to systems like New Zealand, Australia, and Canada.