Can’t we do more to limit EMS abuse?
Brian M. Light M.S.
National Emergency Resource Group
Let me first start off with a story. One 35-year-old male with multiple illnesses calling 911. This man’s disease he is being treated for is not the issue he called for, but his drinking is. The first call is at 10 am; a male has been drinking sitting on the front step. He is transported to the emergency room without incident. The patient is able to walk to the ambulance and climb in. The rest of the story starts at 5 pm with the same shift, paramedics, and fire crew. The patient was released via Uber to the house, and this time called because of intoxication and hiccups. This story is not the only occurrence of EMS abuse we see every day. Just one week earlier, a patient was discharged and slept in the ER lobby. When he was told to leave, he walked outside and called 911. There is abuse of the system at many levels. People are looking to have a warm place to sleep or unable to control addiction. We also overlook many of the instant gratification calls. These are the people without a real emergency, like calling 911 for Flu-like symptoms. How do we find ways to address these issues and change the actual call dynamics?
More systems are seeing increases in call volume. The increase in call volume is difficult, because this does not always equate to an increase in revenue. Many calls may be non-transports or even not paid. Emergency service has always had difficulty getting paid. On average, many systems only see a 30 percent collection rate. Many times. even when the patient is insured, they may have high deductibles. If McDonald’s was able to just collect on 30 percent of a hamburger, then we may see the same with cost. Cost goes up to meet the cost of runs. Let’s put out an example of collection rates. If McDonald’s charges $1.50 for a burger but only has 30 percent collect, they raise the price to offset the cost to the hamburger. What was $1.50 is now $5.00. These numbers are at a 30 percent collection and needing revenue of $1500 on the sale of 1000 burgers.
Recent research is stating that more and more people are going to the hospital by rideshare overusing or calling an ambulance. What is unable to be determined, is what patients are using these services. This ride share may come down to higher acuity patients taking a less expensive option while more non-paying transports are being taken on by 911 providers. These patients may not be going to the right facility or delaying care when the ER needs to prep for cath lab or other resources. This is a very odd problem, as the patients who need 911 need to be brought back into the system and others redirected to other resources. Many give out information on homeless shelters and soup kitchens to keep these people out of the system. They tend to know how the system works maybe better than many of us working in the order.
The other side is our instant magic fix. Many of us in emergency services are still waiting for this significant advance, but many patients believe it is out there. Systems across the country bring patients in by ambulance in a different fashion depending on the network. Busy systems may move patients to the waiting room depending on the availability of beds. Many in EMS have heard the, “I don’t have to wait if I take an ambulance”. Should ER triage work the same no matter how the patient may arrive? When developing the triage system, we have skipped the process that is supposed to support the sickest first. Should an ambulance take the last bed with ill patients in the lobby? Integrating a better process to send more patients to be triaged in the facility and find their place in line may help with two issues. First, the triage process will work as it is supposed to, and second, we alleviate the concept of ambulance equals bed. So many people have decided to call 911 thinking they will circumvent those that went in on their own. This mentality of those who feel they deserve preferential treatment are the true abusers of the system. We have many that use the system because of no other means, but what about those that could drive themselves or get an appointment with their PCP.
Chronically sick, or what is deemed frequent flyers, may not be the problem. While we do see many of this patient on numerous occasions, they are usually the ones chronically ill with no means of otherwise getting assistance. At risk populations may brunt the negative connotation with system abuse when the problem may not be them. Sick, elderly call many times however with little in the way of support services, they need a safety net. Increase in long-term care costs leaves many that maybe should be in some care situation. However, the price kept them home and isolated to fend for themselves. While it is an extra burden, the attempt to curb this may be fatal.
Many times, EMS is also left to defend itself. With abuse of the system on the rise, there is little some departments can do. Now more than ever, the need to create laws and hold those accountable may be needed. The thought of a ticket for calling 911 may be required across the country. Some jurisdictions have put these measures in place. One example is walking out of the ER because of long wait time to call 911. It is not overly familiar, however it has happened enough in some areas to warrant attention.
Many systems still use 24-hour shift schedules for emergency services. These crews may run throughout more and more of the shift. The safety concerns begin to rise, and the call volume also increases. Everyone that works these shifts understands the demands, however that doesn’t negate the fact that the volume is going up over relatively minor calls. Advanced providers tend to use little of their skill set as higher acuity call become less and less frequent.
With issues in EMS, “because we have always done it this way” is a typical answer. For our preservation, this needs to be an issue addressed sooner rather than later. The model we have always used may be what is hurting us the most. Being an industry of adaption and overcoming change is difficult if not impossible. Not every system is the same, but many have similar problems and can find answers to many common issues together. The industry can take a very active and educational role in fixing the systems they work in.