Changes are coming

Reality. The reality is that the Patient Protection and Affordable Care Act, also known as Obama Care, is here to stay. There is not any real chance of the Act being repealed, regardless of what the Republicans are saying on the campaign trail.

Even though many people are focused on the individual mandate, that is actually one of the least important changes in the Act. One portion that is going to change health care as we know it, is the provision that states if a person is treated at a hospital for the same illness more than once in a 30 day period, the provider doesn't get paid. This one provision is going to change health care as we know it.

You see, there are a lot of patients out there who are not compliant with the requirements of their disease. There is the patient with high blood pressure who won't take his medication, the COPD patient who won't stop smoking, the drug abuser who won't stop taking heroin. Any paramedic will tell you that this is going to really impact EMS like no other provision. We have frequent flyers who are sometimes transported 4 or 5 times a day. Reimbursement for EMS services and for ER visits already hovers at 40% as a nationwide average, and this threatens to make that number even worse.

This means that the delivery of acute care will be more costly than ever. Hospitals are already looking at ways to control these costs. In a lecture at the Florida EMS conference this past weekend, Dr Ray Fowler was the keynote speaker. As a member of the Eagles society, an organization of medical directors of the country's largest cities, he jokes that you cannot be a part of the eagle society unless the city whose services you direct is visible from space. During the speech, Dr Fowler stated that there is already an effort underway to redefine the role that prehospital providers play.

To minimize costs, there is going to be a need for paramedics to triage patients in the field, taking the truly sick patients to the ER, and taking minor complaints to walk in clinics, and to CHF management centers. Other times, paramedics will deliver care in the field and not transport the patient at all. Also gone will be the days when ambulances sit on the corner waiting for a call. Instead, between emergency calls, ambulance crews will conduct in home follow up visits on patients who have been recently discharged from the hospital, to ensure that they are compliant with medications.In short, there will be a larger push for preventative and maintenance care, and a shift away from emergency care.

The specific skills suggested for the APP above and beyond those encompassed by lower levels of care are:
 -Rapid sequence intubation (RSI)
- Surgical cricothyrotomy
- Central venous access
- Blood product administration
- Local anesthesia
- Anterior packing for epistaxis
- Dislocation reduction
- Trephination of nails
- Wound closure (sutures)
- Urinary catheterization
- Alternate disposition of patients (treat and street, or take them to places other than the ED)

In other words, APPs would gain some skill sets and training, while "regular" paramedics would lose others.

To those of you who have been in EMS any amount of time know that this is nothing new. Many of these proposed changes have been rumored for years, but have never come to fruition, mostly due to resistance from the nursing and physician communities. The difference is that now there is a real financial incentive for it to happen. If and when it does, the demand for paramedics will skyrocket.

Already in Texas, Minnesota, Colorado and  are beginning programs called "Community Paramedic" or "Advanced Practice Paramedic.(pdf alert)" The thought here is to provide a level of care that is sufficient for many routine and preventative care scenarios that enables $15 to $20 an hour paramedics to do jobs that are currently handled by expensive physicians, nurse practitioners, and physician assistants- all of whom make $50 to $200 an hour.

I know that the agency that I worked for planned for this when the last fire station was built. There is an area of the building that is set up and designed to be a walk in clinic that will be staffed by paramedics. The prediction during the design phase of the structure was that this clinic would be a reality within the next ten years. Firefighter paramedics will staff the clinic 24 hours a day while not actually on emergency calls. 

Whether or not this will degrade care is still to be seen. The answer to that depends on how the program is done. There are a lot of lazy, incompetent medics out there, and if the selection, training, and hiring of these newly needed medics is not done well, it will be a disaster. On the other hand, done correctly, it would control costs and enable more advanced providers to spend more time on patients who are actually sick.

From the view of paramedics, this will greatly increase work loads of an already  hectic and busy EMS personnel, even as it eases the workload of hospitals. Medics will demand and receive more pay, and if not, there will be a mass exodus of good medics into other fields.

Interesting times.