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What if EMS quality had the same kind of effect on insurance rates that fire department quality has on fire insurance rates?
That is the question Ambulance Driver asks in This Weekend’s Homework Assignment.
I can hear the excuses beginning –
It isn’t that simple.
Why do we have so many defenders of medicrity, who only appear to be looking for extremely simple solutions and ignoring everything else?
Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H. L. Mencken.
Keeping things the way they are is an abysmal failure, but we are terrified of change.
Change requires thought and we seem to work harder at discouraging thought than at anything else.
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Fire insurance rates are not perfect.
Do we really want to avoid progress just because progress is imperfect?
The most imperfect choice is to continue to fail the same way.
Why do we remain silent when the defenders of mediocrity make such foolish statements.
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But this will lead to evidence-based medicine.
Evidence-based medicine is better than anecdote-based medicine and witchcraft-based medicine and tradition-based medicine and mediocrity-based medicine and . . . .
Fortunately, there is evidence to support evidence-based treatments and the defenders of anecdotalism may be dying off. If the anecdotalists are treated with their own medicine, they will die off at an accelerated rate.
Was Max Planck right, when he stated – A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.
Only in the cases of the most unreasonable traditionalists.
This raises the question, How common are these fanatics?
I think that most people are smart enough to pay attention to evidence.
Most of us will stop killing our patients when we are presented with enough evidence that we are harming our patients.
The problem is that some of us require a lot of evidence before we admit that their witchcraft is harmful.
We use furosemide (Lasix) much less than we used to.
We use bleeding to remove bad humors much less than we used to.
We use antiarrhythmics (lidocaine, amiodarone, procainamide, et cetera) for chest pain much less than we used to.
We use rotating tourniquets for CHF (Congestive Heart Failure) much less than we used to.
Most of the doctors who once advocated these treatments are probably still alive.
Most of the nurses who once advocated these treatments are probably still alive.
Most of the paramedics who once advocated these treatments are probably still alive.
These treatments did not work, but we used them anyway. We still use a lot of treatments that do not work, but we do not appear to have enough incentive to do what is best for our patients.
A monetary incentive might increase the elimination of dangerous, anecdote-based, tradition-based, witchcraft-based, and mediocrity-based treatments.
How many systems still apply high-flow oxygen for every patient who has an IV (IntraVenous) line placed?
We laugh at that nonsense, now, but I suspect that there are still systems giving high-flow oxygen to every patient treated according to paramedic protocols.
Are we any better if we only automatically give high-flow oxygen to chest pain patients, or trauma patients, or some others regardless of their oxygen saturation and their lack of breathing difficulty?
Barely.
We are still not basing our treatment on assessment or evidence.
We take better care of the protocol than we do of our patients.
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Our patients in Mediocrityville are dramatically different from your patients elsewhere.
That geographic boundary (where you cross from a place where one protocol is used, to a place where another protocol is used) makes no difference to the patient, but we act as if it is important.
That geographic boundary is only a boundary between levels of mediocrity.
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Ambulance Driver writes –
Now imagine, if you will, a similar mechanism for EMS systems. If your system boasts stellar cardiac arrest survival rates, or great response times, or pioneered a new sepsis alert protocol that lowered mortality in your area for sepsis patients, or just purchased CPAP devices that dramatically reduced the number of CHF patients getting costly ventilator care in your local ICU’s, why shouldn’t there be some break in health insurance premiums for the citizens you serve? For that matter, why not pay for performance? Should systems that perform exceeedingly well get better reimbursement than low-performing systems?
Still, there are criticisms.
Skip Kirkwood comments –
So here’s a messy question. When a fire department saves a building from destruction, it saves money because the insurance claim is smaller. When EMS saves a person from death, it costs the health insurance company MORE money – because they have to pay for the medical care, not for the improved health that comes out of it. It’s really cheaper for them if the patient dies.
Maybe we should be talking to the LIFE insurance companies!!!
Should we assume that Skip is correct that better EMS treatment will increase the cost of care?
CONCLUSION:
Robust evidence now supports the use of CPAP and NPPV in ACPE. Both techniques decrease NETI and mortality compared to SMT and none shows increased AMI risk. CPAP should be considered a first line intervention as NPPV did not show a better efficacy, even in patients with more severe conditions, and CPAP is cheaper and easier to implement in clinical practice.Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema–a systematic review and meta-analysis.
Winck JC, Azevedo LF, Costa-Pereira A, Antonelli M, Wyatt JC.
Crit Care. 2006;10(2):R69. Review.
PMID: 16646987 [PubMed – indexed for MEDLINE]
CPAP (Continuous Positive Airway Pressure ventilation).
NPPV (Non-invasive Positive Pressure Ventilation).
ACPE (Acute Cardiogenic Pulmonary Edema).
NETI (Need for EndoTracheal Intubation).
SMT (Standard Medical Therapy).
AMI (Acute Myocardial Infarction).
We need to do what is best for our patients and make examples of the people who provide excuses for not improving patient care. While Skip is probably being somewhat tongue-in-cheek, he is again ignoring evidence.
Should we assume that we are providing high quality care?
Should we find out the quality of the care we are providing?
Our patients deserve actual high quality care, not whatever we get from those of us too scared to find out what works.
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Skip is absolutely right about having to pay more for people who live than people who die. Your examples involving Epinephrine in cardiac arrest point that out very clearly.
The programs that should lead to health insurance discounts are not life-saving interventions; the programs that lead to health insurance discounts are the ones that reduce emergency transports and reduce hospital admissions. The cost improvement due to CPAP is a happy bonus of the improved care; not all improvements in procedures/medications/interventions are cheaper than their predecessors.
The only way to have a lasting reduction in health care costs is to treat the problems BEFORE they become emergencies. Treating a UTI or bronchitis is a hell of a lot cheaper than treating sepsis or septic shock. Keeping track of a CHF patient and helping them monitor their BP and diet is a hell of a lot cheaper than transporting them every couple of weeks for ACPE, even with CPAP rather than intubation.
Many people have said it: The target of an emergency system is fast, high quality, and cheap; but in practical terms, you can only have two of those three. Due to the fact that human lives are at stake, Emergency Medical Care needs to be fast and high-quality; the only way to make it cheap is to reduce the need. That means more community outreach, not more flashing lights and expensive gear.
mpatk,
So we ignore everyone alive and only focus on the costs of resuscitation?
If we look at quality, those resuscitating with epinephrine will produce far more cost than those resuscitated without epinephrine.
Focusing on quality would eliminate a lot of the expensive epi zombie costs.
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If I had stated that all improvements in procedures/medications/interventions are cheaper than their predecessors, you would have a valid point.
I never made any such statement.
However, it is interesting that you are willing to ignore any improvements and only reward those programs that keep the patient from ever entering the hospital.
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Any time I see someone telling people that there is ONLY one way to do things, I know that there is a whopper coming.
Eerything is simple.
ONLY one solution.
Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H. L. Mencken.
It is almost as if I am psychic and can see these objections coming.
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CPAP is too expensive.
We should stop buying CPAP.
12 leads are too expensive.
We should stop buying 12 leads.
We should only invest in things that keep patients out of the hospital, because ignoring the sudden onset of illness is good patient care and good patient care only leads to more expensive care.
We should only invest in things that keep patients out of the hospital, because ignoring the sudden onset of injury is good patient care and good patient care only leads to more expensive care.
Really?
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Rogue,
So you derive from my single example that all I am concerned with is cardiac arrest?
Where did I say to ignore improvements? I admit I did resort to some hyperbole when using the words “only way”. Would it help if I rephrased it to say that “The most effective method to reduce health care costs…”?
Because of the nature of emergencies, I find that area of medicine very unsuitable for cost-cutting measures. Emergencies need to be dealt with high quality and fast (in that order); reducing cost should always be secondary to those concerns.
No, I didn’t say to “ignore the sudden onset of injury”. I pointed out that emergencies are more expensive than routine management. Are you disputing that statement?
I never said that emergencies won’t happen. I said that we are better off spending our money on reducing the incident of avoidable and preventable emergencies; rather than in continuing to metaphorically “put our finger in the dike” and only deal with situations when they do become emergent. Are you contending that all the emergencies we respond to are unavoidable and unpreventable? I’ll even leave out the BS calls and stick with true medical emergencies; are you asserting that the best way to deal with them is to allow a person’s health/condition to deteriorate until a chronic condition becomes an emergency?
Nice twisting of what I actually said. Yes, claiming that “good EMS patient care leads to more expenses” was meant tongue-in-cheek; but it also leads to an important point. Good patient care doesn’t always mean emergency care. IMHO, the best patient care prevents emergencies; agree or disagree? Since we have finite resources, we need to focus (no, not only) on where the best patient care can be provided.
Fire departments have been doing the community outreach work for years: both inspections and educational programs. Why does EMS insist on waiting until the situation deteriorates into an emergency?
I dare say that, while it is not an excuse, some of the reason EMS isn’t doing far-reaching community outreach is because in theory hospitals and doctors offices should already be doing that sort of thing. The EMS agencies that are introducing community paramedics are leading the way towards a much better integrated healthcare system, utilizing our often unique interactions with patients as a jumping off point for more complete patient care, and I look forward to seeing where that goes.
mpatk,
You had written –
I pointed out that both of you are wrong.
You had also written –
My criticism of inappropriate use of epinephrine leading to worse outcomes and higher costs should NOT be generalized to all other medical care.
What Kelly wrote is about improving the quality of care.
You are criticizing improving the quality of care. You are using poor quality care as your example of high quality care.
We need to stop listening to people who defend low standards, then use those low standards to justify opposing high standards.
Your anti-evidence argument is not valid.
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It would help if you would not just assume that you have the one and only answer.
How is defending low quality working for you?
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Thank you for pointing out the silliness of the earlier comments you and Skip made.
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That was not what you wrote. I disputed what you wrote, which was entirely different from what you are writing now.
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How does low quality EMS keep patients out of the hospital?
You were criticizing a suggestion to improve the quality of care.
You, and Skip, essentially claimed that improving the quality of care is expensive. I don’t know how serious Skip was about his claim, but you have decided to defend your position.
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Why did you interpret improving quality as opposing prevention?
Where do you see anything of the sort?
Why do you claim that improving EMS means opposing prevention?
Please explain where you get this from.
Are you suggesting that we send low quality EMS to tell chest pain patients that they probably just have indigestion and that they do not need to go to the hospital?
Low quality is not going to save money.
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Fire prevention and medical emergency prevention are very different.
Fire prevention is simple by comparison. Mostly it is to improve building standards and fire fighting standards.
In what way would improving EMS standards NOT be a part of medical emergency prevention?
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Rogue,
Perhaps we read two different articles. IMHO, Kelly did not argue for improving quality of care; though from his past writings, it’s pretty clear that his advocating for improved quality of care is to be assumed.
Kelly’s article was about setting up an incentive system to promote improvements in not only patient care. I can’t speak for Skip; but what I was pointing out was that improving emergency patient care will not have that great an effect on the cost of healthcare. No effect on healthcare costs = no reason for health insurance companies to be interested.
Constantly running people to the hospital for emergency exacerbation of chronic conditions, with excellent EMS that keeps them alive and able to go home, is a dream for LIFE insurance companies (longer life = more premiums), but a nightmare for HEALTH insurance companies (more treatments at greater expense). Health insurance companies have a vested interest in people not calling 911. They will be (or should be) more interested in supporting a program that prevents emergencies; good or bad EMS care won’t make nearly the monetary difference to them that community programs will.
Which brings us to the next congitive disconnect…
(1) Did you miss the remark about FINITE RESOURCES? Ideal is to improve care and community involvement; but at a time where fire departments and private EMS are laying off workers, the money to do both isn’t there. Which leads to the 2nd point…
(2) Kelly was asking about health insurance incentives, not what is “the best thing for EMS to do”. From the health insurance perspective, what Skip said is right, just incomplete. It is cheaper for them if the patient dies…as opposed to living and just going right back to the ED a week later. (italics section added by mpatk).
Weren’t you the one complaining about defenders of mediocrity looking for the simplest solution? 🙂
I suppose it depends what you mean by “EMS standards”. The examples cited by Kelly (resuscitation rates, sepsis alert protocol, CPAP) only apply during the emergency; they don’t prevent the emergency. Take for example a sepsis alert protocol: so we slightly reduce their stay at the hospital … and they get back to their home/SNF a little faster … where their caregivers again wait until they’re septic before calling 911 … to start the whole cycle again. Three hospital admits of 5 days each vs. five hospital admits of 3 days each (yes, I’m exaggerating but not much).
I don’t know where you somehow magically read my mind to claim that I support lower standards. Never once did I say that we should leave the standards at their current low level. I was pointing out that this health care incentive idea is neither a valid reason, or a workable method, for improving Emergency Care standards.
The valid reason for improving EMS standards is that it saves lives, not to save a few bucks; and if saving a few bucks is the only way to convince people to improve standards, we’re SOL because we won’t save enough money to convince anyone.
mpatk,
Read it again.
This is a way of encouraging us to provide excellent EMS.
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Yes.
He appears to be promoting improvements in patient outcomes.
This brings us right back to the beginning.
Why do you oppose this?
Why are you opposed to improving patient outcomes?
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Has it been tried?
How would you know if you automatically oppose it and it has not been tried?
This appears to be the argument that you and Skip have provided –
I know that EMS only prolongs illness, so EMS will not provide any healthcare savings.
Provide some evidence. I don’t expect any evidence from Skip, because he doesn’t do that.
You’ll never get that flying machine off the ground!
Fortunately, the pioneers of aviation did not heed similar criticism.
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Again, where is your evidence?
If you are going to convince me, provide something more than your unshakable certainty.
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Malthus based his prediction of mass extinction with increasing global population on finite resources, too. We have enough food to feed everyone on the planet and the population keeps expanding.
The resources are only finite if we use our biases to artificially limit what we can do with them.
What is finite depends on your willingness to accept artificial limitations.
Assuming your Malthusian approach, how much do you want to strip from EMS to fund home visits from doctors, or PAs, or NPs, or nurses? They are trained in this, while EMS is generally not.
But that assumes that I buy in to your whole argument about no possible savings and a Sophie’s Choice between EMS and community EMS.
I do not accept your false dichotomy.
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You can’t speak for Skip, but you can speak for Kelly?
I think that you misinterpret what Kelly wrote. You can always go comment on Kelly’s blog and tell him what he meant.
What Skip meant depends on how firmly his tongue was buried in his cheek. I don’t see him as being “right.”
How many patients go right back to the ED a week later?
What percentage?
Are we considering the “hypochondriacs”? They aren’t likely to die from their illness, regardless of the quality of treatment.
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Is this all about finding irrelevant humor and then trying to defend that?
Comparatively simple and simple are not the same thing.
Simplistic is claiming that there is one simple solution, as you appear to have been suggesting.
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Who cares?
You keep complaining that I am criticizing your position for being overly simplistic, but then you keep oversimplifying EMS according to whether it is preventative.
I did not write about prevention.
I wrote about quality.
You seem to be obsessed with making this about choosing one or the other.
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No.
You are referring to a lack of quality of care in a nursing home, where they could start IV antibiotics and often avoid sending the patient to the hospital. Waiting until the patient is septic to address the condition is the root of the problem. You should be criticizing those doctors who neglect to be aggressive in treating infections that lead to sepsis. Go prevent some sepsis. Update me on the positive response of the doctors, their joy at having EMS tell them how to do their job, and how they now want you to be given more money to use your thousand hour diploma to tell them how to provide patient care. After all, they are just waiting for you to spread the good word of prevention.
Of course, if they listen to you, and improve the quality of care of their patients, they are only going to live longer and cost more money, rather than dying during an admission for sepsis.
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You appear to oppose improvements in quality because you pretend that you know what the result will be.
I have no such crystal ball, so I would want to try it out, rather than dogmatically oppose this idea.
The only way to remain ignorant is to oppose it.
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You provide a lot of certainty without any evidence.
I am thrilled that you are so idealistically opposing Kelly’s suggestion./
Why are our standards so low in EMS?
You and Skip provide excellent examples of the kind of opposition that crushes new ideas.
Laugh it off. Change the subject. Don’t look too closely at any possible value. Nothing to see here, just move along without thinking.
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You’re half right and half wrong. My blog post was about improving care and outcomes, and what might serve as an incentive to make that happen – incentives to citizens in the form of lower insurance premiums that make them more likely to support funding their EMS system, incentives to insurers in the form of lowered costs, and incentives to EMS systems in the form of pay-for-performance and increased support from the community.
While better care may not pay immediate dividends from insurers until we find some way to bolster preventative care, your argument in favor of preventative care has been used in exactly the opposite way by many healthcare pundits – preventative care actually *increases* costs by keeping people alive and in the system consuming resources for longer periods of time.
I don’t much buy that argument either. If we practiced effective preventative care, we might avoid some of the costlier forms of healthcare such as specialist and ED care. The problem is that we simply don’t HAVE nearly enough primary care physicians to accomplish that task, and that shortage is only going to get worse.
Can EMS fill the gap? Possibly, with greater education… and some *incentive* to seek it.
Skip’s argument was a good one, but only for cardiac arrest resuscitations, and it’s basically the same argument against the inordinately high amount if money we spend on end of life care.
Ambulance Driver,
We base too much of what we do on the tiny fraction of patients who are cardiac arrest patients. Yes, they can have some very dramatic responses to treatment, but they are not typical.
There is no reason to believe that basing everything else we do on cardiac arrests is good for other critically ill patients.
The people who treat chest pain, or difficulty breathing, or agitated delirium the same way they treat cardiac arrest, are probably not the people we should look to for leadership.
Discouraging consideration of innovative thoughts is not the way we can expect to improve.
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Rogue,
I’m out of this discussion. I was writing a reply, and realized I was just trying to “win the argument” rather than promote further discussion on the topic.
I do wonder why you insist on labeling me as opposing patient outcomes. I wasn’t trying to say that EMS education and standards should not improve; just that I think there would be more benefit by going into the community and diverting people to clinics and PMDs before they need an ED. Yes, SNFs are always going to be a problem; but what about the people at home? How many calls have we run on seriously sick patients where we’ve heard some variant of, “Yeah, I haven’t been feeling well, but I figured I’d get over it”? THOSE are the patients where the most cost savings, and the most improvement in quality of life, could be achieved. Monitoring of chronically ill patients, showing them that they’re on a downward spiral before they’re gasping for breath or too altered to know what’s happening, that is what I’m advocating for.
As for the funding, and the evidence, and so on: go on and give it a shot. No, I don’t know whether it would work or not; in the absence of evidence, I was giving what I thought the best opportunity to make the idea work. I apologize if it seemed I was denigrating improvements in emergency medicine and EMS standards; such was not my intent. My intent was to advocate for increasing our role in prevention; not to claim mock or insult other people.
mpatk,
There is nothing about this idea that takes anything away from what you want to do.
Only you have created this conflict.
We need to stop dismissing ideas that we have not explored because of some imagined threat to our pet projects.
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