The NYTimes on “Responding Before A Call Is Needed“:
Emergency medicine carries a deep aura of romance in America, with its first-responder traditions of adrenaline, acuity and bravery. But here in this rural mountain area of the West, and in a handful of other places around the nation, a new vision is gaining ground — that emergency workers should not wait around for crises to happen, but rather go out and prevent them….
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The original threads of community paramedicine trace back to places like Nova Scotia, which began experimenting with the idea around 2000 when a doctor who had served two remote islands off the Canadian coast retired; paramedics were recruited to fill the gap.
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Around the mid-2000s, San Francisco, and later San Diego and Washington, D.C., among others, began sending paramedics into homeless populations, aiming to reduce 911 calls.
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The new push, fueled by a cash-crunched public sector and looming changes to Medicaid under the federal health care overhaul, combines all those pieces, aiming for the first time to standardize training and create operating systems that can function from farm country to big-city downtowns. The federal Health Resources and Services Administration, which works on health care access issues, is expected next year to release the first-ever system for measuring the performance of community paramedics, which could further accelerate the trend…
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In Texas, the emergency medical system that serves a 15-city area centered in Fort Worth, called MedStar, found that 21 people, calling 911 as often as twice a week or more, were accounting for more than 1 percent of the total call volume. So starting in July 2009, paramedics went out to see if behaviors could be changed, through counseling or treatment.
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More than 1,000 calls a year — at average cost of $1,200, and mostly nonreimbursable since those heavier users tended to be uninsured — were cut from the system, according to MedStar…
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But for all of what might seem like straightforward logic — that preventive care is better than emergency care — a single knotty problem remains. Under federal rules, emergency medical providers get reimbursed only if they transport a person. What that means is that cutting down on 911 calls, even in the name of better care, can have a built-in conflict of interest for emergency responders themselves…
“Community paramedicine” seems like an excellent concept for our fractured, socially impoverished era — a way to bridge the gaps between individuals who can’t navigate the Galtian gulches unassisted, and the pricey specialization of our World’s Best Healthcare machine. It also, to my inexpert eye, seems not unlike the district nursing system our Commonwealth cousins first implemented more than a century ago, at a time when the sociopolitical arguments were pretty familiar, too.
Kola Noscopy
This concept makes way too much sense to ever be implemented on a wide scale basis in the U.S. If there is not money to be made off of suffering, then the medical/government establishment does not give a shit.
LTL-FTC
I wish there were an open thread because I need someone to explain to me the relationship between today’s market crash and yesterday’s letter to Bernanke.
Correlation or (partial) causation?
trollhattan
Ten years ago I thought non-emergency, walk-in medical centers would be the next big thing, but I don’t get the sense they took off, at least not in my area. Even folks with insurance and primary care physicians tend to have medical things occur evenings and weekends, and we need user-friendly solutions.
More, and more aggressive preventive medicine sounds like an excellent concept. Too bad we have to bleed job-creator billyunaires(tm) to have it.
cathyx
With more and more people uninsured, we need to practice preventative medicine more than ever. And the cheapest way to practice preventative medicine is to eat right and exercise. But the problem with that is that we need to be self motivated and most people are too lazy to do it. Eating right doesn’t taste as good, and exercise is hard.
Short Bus Bully
Of course this is a great idea and it will be shot down by the usual suspects for the same stupid reasons:
“Preventative care is YOUR responsibility. I’m not paying for it when you should go out and take care of it yourself!”
And we go round and round and round…
paramedicx
Raleigh has been a leader in this area, as well. Paramedics as the old frontier doc can work but reimbursement will have to be tackled by models developed by MIT…people just don’t open the mail when it’s a hospital bill.
PeakVT
@LTL-FTC: Strictly correlation. If there was any causality, it was the other way – though frankly there shouldn’t have been because what the OMC said yesterday was entirely unsurprising.
The Other Bob
@Short Bus Bully: If Obama suggests it, this type of care will become the next “death panels”. Maybe it will be roving death squads who dress like paramedics?
kdaug
@LTL-FTC: One down with the REM vid.
Litlebritdifrnt2
Of course in the UK as well as District Nurses you also have GPs who still make house calls. It is a neat system as it is set up right now (my elderly mother uses the system all the time these days). You first make a phone call to the “on call” nurse. You discuss your symptoms with her and she goes through a very careful check list with you and looks up your history on the computer (with my Mum its a history of heart problems), your medications and all that. She then makes an assessment a) go straight to the A&E (ER) b) she is sending the on call GP, or c) take an asprin and call her in the morning scenario.
I cannot see this system ever working in this country simply because it makes so much sense and has no way of making someone millions. If there is no profit in it over here no one is interested.
Villago Delenda Est
Once again, we see incentives built into the system to increase costs.
Once again, health care itself is secondary to the cost incentives surrounding it.
Davis X. Machina
@The Other Bob:Uh-huh. Barefoot doctors. China. Cuba. Vietnam (the Wrong One).
They’ll hate it. Which suggests it should be done.
Villago Delenda Est
@Kola Noscopy:
Unless there is profit in the suffering of others, the US medical system cannot be bothered.
jl
The key is to provide timely access to care for populations that are at risk for high utilization rates. Providing ‘timely access’ often means the provider has to be proactive and go to the patients, rather than waiting for the patient to come to them, and providing education and preventive services.
For example, New Zealand has a version for expectant mothers and young children: Plunket Nurses.
Kola Noscopy
@Villago Delenda Est:
Thank you for saying it a little more clearly. :)
jl
The key to providing this kind of proactive care is to find health care professionals with adequate training, but are cheaper than doctors, who can stretch the amount of preventive and routine health care from a given supply of doctors.
In Europe, several countries use many more nurses per capita than the US, and use them in this way. Switzerland is an example, and some others.
You need to compare the total supply of health professionals, not just MDs, otherwise you get a misleading picture of the amount of care delivered to a population.
The US lags badly in this regard, except for pharmacists. The US has lead in utilizing pharmacists to stretch MD services. But you can’t pharmacists for wide ranging primary person to person preventive and evaluation. And a lot of pharmacists went into pharmacy because they don’t like that kind of work.
I’ve heard the story from several pharmacists and pathologists about how they were going to be doctors who dealt with live patients on a daily basis, until they got vomited, pissed, or pooped on, or a patient went apeshit. Then they had an epiphany about where they belonged in health care.
And also too, the personal debt run up during training, and the demand for pharmacists in high profit sectors of health care means that pharmacists can often be as expensive as primary care docs, so you can’t save much money through substitution.
jl
This is a repost of a comment in moderation. Can you guess the bad word? Did I find all the bad words? Let’s see.
The key to providing this kind of proactive care is to find health care professionals with adequate training, but are cheaper than doctors, who can stretch the amount of preventive and routine health care from a given supply of doctors.
In Europe, several countries use many more nurses per capita than the US, and use them in this way. Switzerland is an example, and some others (Norway, is another, I think).
You need to compare the total supply of health professionals, not just MDs, otherwise you get a misleading picture of the amount of care delivered to a population.
The US lags badly in this regard, except for farmususts. The US has lead in utilizing farmususts to stretch MD services. But farmususts are enough for comprehensive primary person to person preventive care and evaluation. And a lot of farmususts went into farmusy because they don’t like that kind of work.
I’ve heard the story from several farmususts and pathologists about how they were going to be doctors who dealt with live patients on a daily basis, until they got vomited, pissed, or pooped on, or a patient went apeshit. Then they had an epiphany about where they belonged in health care.
And also too, the personal debt run up during training, and the demand for farmususts in high profit sectors of health care means that they can often be as expensive as primary care docs, so you can’t save much money through substitution.
Roger Moore
If God wanted poor people to be healthy, he would have given them enough money to afford to go to the doctor.[/wingnut]
Martin
@Roger Moore: Given that the wingnut philosophy seems to have fully integrated ‘the invisible hand of the free market’ and ‘the invisible hand of God’ into one super-invisible hand, I think you’re dead on there.
Martin
@jl: You spelled pharmaçist wrong.
Short Bus Bully
@Roger Moore:
This, exactly.
Martin
@Villago Delenda Est: I’m always amazed at how common it is to see policy disassociated from outcomes. It’s everywhere – and there’s no sense that if desire a certain set of outcomes that perhaps you should create a set of policies that encourage those outcomes while discouraging the undesirable outcomes. You can mention this to policy makers and they’ll look at you as if it’s a different language – there’s no notion that the two could possibly be connected.
Short Bus Bully
@Martin:
Exactly. Also, too.
“Super-Invisible Hand” is teh ossum. I am totally stealing your idea and not giving your credit. Lurve the smart folks that comment around here…
Omnes Omnibus
@Martin: The what now?
Ian
Making access free also helps. People shouldn’t need to think about whether they can afford to go to a doctor about that weird little pain they’re feeling. We should not disincentivize preventative care.
Nutella
@Villago Delenda Est:
And we get more sickness, more suffering, and higher costs. It’s the American way.
This paramedicine plan is like the one in the New Yorker article about reducing health care costs and I had the same reaction to both: This is OBVIOUS! If we provide actual health care then illnesses can be managed in the best way for the patient which is almost always the cheapest in the long run.
But we don’t do long run in this country. We prefer to pretend that stupid and shortsighted decisions lead to the best outcomes even though evidence shows the opposite.
Short Bus Bully
@Nutella:
The stupid and shortsighted part is faith based so evidence doesn’t enter the equation with these folks. It’s literally not even part of the discussion; hence the open hatred towards science, education, etc.
Roger Moore
@Short Bus Bully:
Yeah, unfortunately I think it’s starting to write “mene, mene, tekel, upharsin”, but not enough people know how to read it.
harlana
relevant to a comment i saw on a previous thread, right now, people from 26-34 can get insurance for around $200 a month. I know that’s not ideal, you’d still have to live with mom and dad but you’d have health insurance (if you can work and make enough per month to pay the premium or your parents pay it). but then i guess there’s Medicaid. pcip dot gov
Origuy
The problem with healthcare costs isn’t the RNs and the MDs, it’s the MBAs.
Roger Moore
@Origuy:
The MBAs may be making things worse, but the actual health care providers aren’t helping matters. Doctors in the US get paid better than doctors in other countries. Speciаlist doctors in the US get paid massively more than their equivalents in other countries. This clearly has an effect on the cost of medicine.
KS in MA
@Roger Moore: LOL
Phoenician in a time of Romans
I used one of these in NZ when I was discharged from hospital following a very serious infection. Instead of taking up a hospital bed, I had a trained nurse coming in to my house for half an hour to an hour, changing and checking dressings, and taking a blood sample. They also arranged a house cleaning service to cope with the mess.
The end result was that I was a LOT more comfortable at home, while still being checked, and at far less expense to the system as a whole.
But, you know, that’s SOOOOOOCIALLLLLISM, so the US can’t do that. If I had been American, I would now be bankrupt and probably be worse off health-wise due to an inability to afford effective care.
IrishGirl
This sounds like the old concept of making home visits by doctors…..how is it different except the paramedics aren’t doctors……?
Not to pooh pooh the idea, but….