IAFF, IAFC Fire-based EMS

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Permalink Reply by Marshall on November 10, 2009 at 4:20pm

What about publicly traded EMS organizations? Why don't we start by getting rid of them as their priorities lie with shareholders, not patients.

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Permalink Reply by Skip Kirkwood on November 10, 2009 at 6:47pm

Mike, somebody famous, a long time ago, said that "Americans get exactly the quality of government that they deserve." If they are apathetic, elect crooks or people who are bought and paid for by special interests, it's because they don't care enough to participate in government. Some call them "sheeple."

It's the job of citizens to look out for THEMSELVES - that's what democracy is all about. The problem is that nobody (except now the IAFF-IAFC coalition) is spending any energy educating them.

Marshall, does that mean we should completely nationalize everything to do with health care? Every physician, nurse, and paramedic I know works for their own economic interest (or other personal gain).

????

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Permalink Reply by Ben Waller on November 11, 2009 at 2:28pm

Marshall,

Most non-fire EMS systems are not committed to evidence-based approaches, research, or even using really objective processes to operate. How is that different from your complaint about fire/EMS combination systems, other than the absence of firefighting capability?

If we're going to be objective, we can't bash fire/EMS combination systems while giving non-fire EMS systems a pass for doing - or not doing - exactly the same things.

A lot of what I hear should be incorporated into "the future of EMS" is already happening at a lot of fire/EMS combination systems.

1) Revenue streams that are not solely based on transport reimbursement.
2) Higher pay
3) Job security - no EMS contract whims
4) A real career ladder
5) Realistic span of control for field supervisors
6) Unified advocacy voice
7) Special Operations integration
8) Non-traditional service delivery options
9) NIMS/ICS integration
10) Defined prerequisites and objective-based testing for supervisor promotion
11) Higher education options for management
12) Injury prevention programs (Risk Watch, Car Seat Installation, Feet First/First Time, etc.)


Marshall said:

In my humblest of opinions, and maybe this is common knowledge, but this seems more like an identity crisis for EMS. I think the majority of EMS providers who do not belong to a FD want to establish EMS is a legitimate entity separate from Fire and Police. I for one would love to see EMS a separate entity and out of the FD. I find it really sad that FD's are looking at EMS as a means to justify their existence to tax payers and local government. This doesn't mean I believe FD do a horrible job at providing service - but are they willing to do and promote research? Improve quality through objective processes? Commitment to best practices and evidence based approaches?

I guess I just find this position statement to be an attack on me personally because I'm proud of what I do and the service I work for. I don't want to be associated with a FD - otherwise I would've been a FF. From my experiences and those that I have known who work for a EMS/FD only do it because of the compensation - not because they believe EMS delivered through a FD is the best means of delivery.

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Permalink Reply by Ben Waller on November 11, 2009 at 2:32pm

Doc,

The expenses will rise for every system when the educational requirements increase.
That means that the systems with the most paramedics - urban systems - will take the largest budget hits.

Those systems are not all fire/EMS combinations, and the non-fire ones will not be exempt from the budget hit.


dr-exmedic said:

Ben Waller said:

The prime issue for fire departments - and a lot of non-fire EMS systems - is the volunteer sector, particularly in the northeast and midwest where a lot of those programs are at least somewhat viable. When you raise the requirements to a degree, you're going to essentially eliminate volunteers, and in areas that have the perception that the only way they can have services is through volunteers, that's a huge problem.

That's a huge issue, and there is also a bunch of push-back from depts which have pushed the "paramedic on every street corner" model--every time the education gets longer, their budgets suffer.

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Permalink Reply by dr-exmedic on November 11, 2009 at 5:28pm

Ben Waller said:

The expenses will rise for every system when the educational requirements increase.
That means that the systems with the most paramedics - urban systems - will take the largest budget hits.

Those systems are not all fire/EMS combinations, and the non-fire ones will not be exempt from the budget hit.

Undoubtedly. But those with the most medics per capita will hurt the most. I agree that they are not exclusively fire-based (which is why I did not specify either way in that particular post--heck, if I called 911 from home I will not get an EMT on an ambulance--100% paramedics here at Pittsburgh's 3rd service).

For a given call volume, though, a system that uses ALS engines is going to have more paramedics than a system that uses only ambulances.

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Permalink Reply by dr-exmedic on November 11, 2009 at 5:41pm

Marshall said:

What about publicly traded EMS organizations? Why don't we start by getting rid of them as their priorities lie with shareholders, not patients.

Yes, but to please the shareholders, they have to get revenue, which often times means treating customers well--and the evil here is not the fact that it's a private company, it's that the customers (the municipal govts giving out the contracts) aren't demanding enough. Think about USPS vs. UPS--one is cheaper, but the other is a far better way to send a package if you're willing to spring for it.

A private company is perfectly capable of providing wonderful medical care, if only the customers demand it (important caveat: and are willing to pay for it).

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Permalink Reply by dr-exmedic on November 11, 2009 at 5:57pm

For those of you playing the home game, NAEMT has no particular plans to respond, as it "supports informed local decision-making to identify the best type of service delivery model for each community. We encourage EMS agencies and their advocates to respect and embrace the diversity of EMS systems in the U.S. and encourage local decision-makers to examine and weigh a variety of delivery options to ensure that they implement the EMS system that is best for their community. Further, we are not aware of any data-supported evidence that indicates that one delivery model is more effective or efficient than others." Their email response attached a response available here, titled "Validity of Diverse EMS Models."

I was actually impressed by how quickly they got back to me--next business day. :)

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Permalink Reply by Ben Waller on November 11, 2009 at 8:34pm

Doc,

"For a given call volume, though, a system that uses ALS engines is going to have more paramedics than a system that uses only ambulances.".

Not necessarily. A system like Phoenix FD's that uses EMTs on the ambulances and paramedics on the ALS engines won't necessarily have more paramedics than one that puts all the ALS on the ambulances.

Ditto for FDs that run paramedic light rescues with private BLS as the transport component. (LA County is an example)

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Permalink Reply by Ben Waller on November 11, 2009 at 8:55pm

Robert,

Even if shorter scene times are not clinically significant to an individual patient, they're significant to the system. Shorter scene times equal better unit availability. Better unit availability equals the need for fewer units in big systems and less need to move units around in any system that uses a deployment model that isn't completely static. All of that equals less expense to run the system - less fuel, less brake and tire wear, and in big systems, less personnel costs per tour.

Not every savings directly affects a given patient's outcome, but savings can and do cumulatively help the sytem reduce costs.

Robert Sullivan said:

Just because JEMS publishes a press release doesn't mean it adovcates for that delivery model. Its readers can look at this more objectively than people reading about it in the mainstream press. I do have a problem when JEMS publishes bad studies. See Priority Traffic from July '09: Timing EMS: Staffing & deployment patterns matter.

The study found that more firefighter/EMT first responders on scene lead to small incremental scene time differences. It implies that this is clinically significant, which has been debunked by real scientific studies. It also concludes that more firefighters are needed on EMS scenes to achieve these insignificant results. How objective do you think the control group was?

Google scholar David Cone and see what he's found about FD first response. And I wish JEMS would turn its BS filter up a notch.

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Permalink Reply by Skip Kirkwood on November 11, 2009 at 10:01pm

I think that analysis is tacking suppositions on to assumptions and possibilities and reaching some iron-clad conclusions.

Who knows? Without some really good controlled studies, that shorter scene time could be achieved by, oh, walking your chest pain patients to the truck without doing a 12 lead in the house. I can think of maybe 5% of calls where quick scene times might be useful, but who knows, striving for quick could be hurtful to the patients. We just don't know.

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Permalink Reply by Marshall on November 12, 2009 at 12:15am

Doc, Skip, Ben....

I must agree with you in principle that yes, in order to please shareholders you must make revenue/profits and that through excellent customer service you will increase your market share; but lets take a different look at it.

What if you aren't making profits? Does the CEO say "Be nicer, smile bigger, and stroke our customers to death?" Our customers aren't just patients, but any hospital, nursing home, assisted living center who require their patients transported for an eval or Dr. appointment, etc. Sure - customers could demand better care and service - but they won't. Only for the simple fact that they aren't educated enough (I blame this on EMS its self). How does a publicly traded organization respond when they came $.02 under their forecasted EPS in the fist quarter subsequently dropping stock prices 20%? Cut corners - maybe? Layoffs... possibly. Who knows... I don't work for one so I can only speculate. Am I for socialized medicine - absolutely.

Now... given the current financial situation we are in; I personally find it reasonable to assume not all corporations, organizations, industries do not practice or support fiscal responsibility or make the most ethical decisions (again - priorities lie with shareholders, not customers). I also believe just because "we're health care" doesn't mean we're immune to this. It's just easier because everyone needs health care - people can go without shopping for non-essential items.

Sure... everyone has some sort of financial interest and we all want to make more money. I know I do... but I don't want to make more money simply just by being a paramedic. I want to climb the chain, get an education (hopefully MBA), and make this industry better - while making a comfortable living salary, which I know requires hard work.

Now, I don't believe the Fire service is the best answer to EMS and its' problems - nor do I believe private for or non-profit is the answer either. I tend to agree with Mike with the concept of regionalized EMS; I just think it makes sense. If what Mr. Waller says is true - and I have no reason not to believe him, then hats off to the Fire industry. But let me pose this question - if some private contracting fire service came to your city and told the city council they would provide fire service, prevention, and protection at a fraction of their current cost (only because of sheer volume can they offer a discounted price) and higher the existing FF's (at a much lower pay rate); how would that make you feel?




dr-exmedic said:

Marshall said:

What about publicly traded EMS organizations? Why don't we start by getting rid of them as their priorities lie with shareholders, not patients.

Yes, but to please the shareholders, they have to get revenue, which often times means treating customers well--and the evil here is not the fact that it's a private company, it's that the customers (the municipal govts giving out the contracts) aren't demanding enough. Think about USPS vs. UPS--one is cheaper, but the other is a far better way to send a package if you're willing to spring for it.

A private company is perfectly capable of providing wonderful medical care, if only the customers demand it (important caveat: and are willing to pay for it).

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Permalink Reply by dr-exmedic on November 12, 2009 at 3:01pm

Marshall said:

Sure - customers could demand better care and service - but they won't. Only for the simple fact that they aren't educated enough (I blame this on EMS its self).

Totally agreed there. :)

Now... given the current financial situation we are in; I personally find it reasonable to assume not all corporations, organizations, industries do not practice or support fiscal responsibility or make the most ethical decisions (again - priorities lie with shareholders, not customers).

I would agree with you there, but only if we include govt in that list of organizations that don't always practice fiscal responsibility or make ethical decisions. Govt can be just as evil and rotten as corps, maybe more so--if XYZ Bank has unethical practices, I can leave and find a new bank in a couple of hours, but if I move into a corrupt city, there's a lot more investment involved to change situations. If ABC Widgets doesn't practice fiscal responsibility, it goes out of business; if Uncle Sam runs out of money, we print more until our dollars don't buy anything anymore. If I don't have enough money to pay my cell phone bill, Verizon can't put me in jail.

The whole PUM is based on the theory that a closely-watched monopoly corporation will do a decent job at a decent price--a notion that I find a bit laughable, because cable companies in many cities are regulated very similarly to public utilities. Talk about a bad service at a lousy price. :) (Just got competition in our local cable market, btw--and now we're getting the same cable package for less money.)

I tend to agree with Mike with the concept of regionalized EMS; I just think it makes sense.

Although I'm coming at that decision from a slightly different direction, if I had to design an EMS system, that's exactly how I would do it. Let the paramedics specialize in paramedicine and the FFs specialize in fire.

But let me pose this question - if some private contracting fire service came to your city and told the city council they would provide fire service, prevention, and protection at a fraction of their current cost (only because of sheer volume can they offer a discounted price) and higher the existing FF's (at a much lower pay rate); how would that make you feel?

I can't answer the feeling question, but I can point you to an analysis (a bit old, but nevertheless relevant) of how private FDs can work. They also use Denmark as an example; apparently much of the fire service there is a private corporation. Doesn't always sound like it's a bad deal, if the deal is constructed carefully:

Rural/Metro also conducts an extensive public education campaign that includes Fire Prevention Week activities, a Junior Fire Setter Program, and a “Learn Not to Burn” program in the public schools. The firm provides CPR courses to Scottsdale residents and area businesses alike, and has as its goal the training of 5,000 persons annually....The company's financial success is a reflection of its success in preventing and combatting fires. Indeed, with an annual per-capita fire loss of only $5.77, Rural/Metro has one of the lowest percapita fire loss rates in the nation—75 percent lower, in fact, than the national average ($23.45). And the cost to the taxpayers is 49 percent lower than the national average.

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