EMS Artifact

Everything old is new again, is a phrase that I’ve heard for years and years. It’s also the title of a song I’ve never heard of. It was in the film “All That Jazz” which I never saw. Where it originally came from, I have no idea.

That phrase was the first thing that came into my mind when I saw this article on EMS 1.

Time to let FDNY EMS stand on its own

The idea of a third service is not radical. Across the country, many cities recognize EMS as a distinct and vital public safety entity alongside police and fire. New York, ironically the city that never sleeps, remains asleep on this issue — keeping EMS under the shadow of the Fire Department. But the challenges EMS faces today aren’t just a result of budgetary neglect or political inertia — they’re rooted in a structural problem. You cannot fix a broken system while keeping EMS trapped in someone else’s house.

For a long time my former agency and the union that represents EMTs and Paramedics there had a very close relationship with the EMS system in New York City. We attended their events, they attended our events. That started back before the agency was assimilated by the fire department in New York City.

Lieutenant Anthony Almojera doesn’t seem to know that once upon a time EMS in New York City was indeed a third service system. It was a subsidiary of the New York City Health & Hospitals Corporation. That agency ran the ambulance service and the city owned hospitals.

In 1996, by order of them Mayor Rudy Giuliani NYC*EMS was “merged” with FNDY to create a combined agency. Most of the people who worked for the former third service are retired, and sadly many that I knew have died over the years.

Ironically, FDNY didn’t want to perform EMS, they just wanted to control is. At the time there a lot of comparisons to EMS being assimilated just like the Borg on Star Trek assimilated planets and societies. The merger was not smooth as the people who were now in charge didn’t understand anything about running an EMS system. They decided that running it like a fire department would be ideal. It wasn’t. They tried putting paramedics in squad like vehicles and staffing ambulances with just EMTs. That didn’t work. Eventually they went back to something like the EMS model that had been used before. That worked fairly well and is used to this day.

Of course EMS providers were treated like second class employees. On good days, that is. There was path of sorts to become a fire fighter. It was considered a “promotion” to be selected to go to the fire academy.

FDNY EMS is staffed primarily by EMTs and paramedics — workers who are highly trained, deeply experienced and often the first healthcare providers a person will ever encounter. Yet they are the lowest paid and most overworked of the city’s emergency responders. An FDNY firefighter and an EMS paramedic  may show up to the same scene, risk the same dangers and respond to the same calls. But one makes nearly double the salary of the other and receives far more comprehensive benefits. Why? Because one wears bunker gear and the other wears an EMS patch. This is not the fault of the firefighters themselves. The fault lies solely on the management of New York City and FDNY.

In this regard, nothing has changed. I will also say that EMS being a third service is not a magic solution to a nationwide problem.

Where I worked EMS calls far outstripped fire calls. In order to fix that, fire units were added to medical calls. This was a trick to accomplish two things. One was to make response times look better as the clock stopped when the first anything arrived on scene. The second was to keep from having to lay off firefighters as smoke detectors, better building codes, and sprinkler systems cut the number of deaths from fire year after year.

That wasn’t just in New York or where I worked, it was nation wide. In the late 1980s into the end of the 1990s there was a wave of takeovers of third service EMS agencies by fire departments eager to keep run numbers up and prevent layoffs.

I wish Lieutenant Almojera luck in his quest, but I fear that like Don Quixote his is The Impossible Dream.

Here is an article with a brief history of NYC*EMS. It’s from JEMS in 2022, so take it with a bit of salt even though the state that the content is that of the contributors not JEMS itself.

A Short History of New York City’s Emergency Ambulance Services

“Upcoding” is the term used in EMS for instances where an individual provider or his employer falsely documents the patient condition in order to increase the amount of money paid for ambulance transport.

A couple of examples of this are obtaining a 12 Lead EKG when one is not necessary. Another is using an ambulance to transport a patient that could be transported in a Chair Car.

Sometimes an IV will be placed where again none is required. Sometimes that is a paramedic who is really not clear on the concept of when a patient needs an IV. Other times they are following company policy, usually unwritten, but enforced none the less. This is known as “a line and a ride.”

This goes on every day in ambulance services across the United States. Typically this is done by private for profit ambulance services, however sometimes municipal services will do it as well.

A lot of people I know were incensed about the amount of fraud and abuse within United States Agency for International Development (USAID), but I’ve long maintained that Medicare and Medicaid fraud are far more prevalent and expensive than USAID.

Both Medicare and Medicaid are funded by the United States government. Medicaid is administered by the individual states, while Medicare is administered and paid for by the federal government.

The states name their versions of Medicaid as they wish. In California it’s “Medical,” in Massachusetts it’s “MassHealth.” Texas just calls it “Medicaid.” And so on.

The states primarily enforce fraud in Medicaid while the federal government enforces fraud for Medicare. Of course the federal government can investigate Medicaid fraud if a state isn’t vigilant enough.

There are both civil and criminal prosecutions for this type of fraud, but civil seems to be more common. At least at the state level.

This is a rather long prologue for this article,

AG Campbell Secures $6 Million Settlement With Weymouth-Based Ambulance Companies For MassHealth False Claims

BOSTON — Attorney General Andrea Joy Campbell today announced that her office has reached a $6 million settlement with two Weymouth-based ambulance companies, Brewster Ambulance Service, Inc. (Brewster) and EasCare, LLC (EasCare), and their current owners, Mark Brewster and George Brewster, Jr. The settlement resolves allegations that the companies and owners submitted false claims to MassHealth for more expensive services than were provided, violated MassHealth medical necessity requirements, and failed to disclose relevant information when submitting the companies’ applications to serve as MassHealth providers.

Note that EasCare is a subsidiary of Brewster ambulance.

“When companies violate our laws and defraud the MassHealth program, crucial taxpayer resources are misdirected from paying for health care for those who need it most,” said AG Campbell.

This is true. It means that people are in effect stealing taxpayer money and committing fraud.

Per its investigation, the AGO alleged that Brewster and EasCare fraudulently “upcoded” their claims to MassHealth by billing for more expensive levels of services than they actually provided or required, including billing for emergency services when only non-emergency services were provided or required.

Meets the exact definition of “upcoding”.

Additionally, the AGO alleged that the companies fraudulently billed MassHealth for medically unnecessary services and/or for nonemergency services without maintaining relevant medical necessity documentation, as required by MassHealth.

There is a required form, informally known as a “MedNec” that the crews must get signed by a medical provider.

A little bit more about this settlement.

Mass. ambulance companies to pay $6M to the state for overcharging MassHealth, AG says

Brewster Ambulance CEO Mark Brewster said in a statement to MassLive that the company was “pleased” to have settled the lawsuit.

“To be clear, the trips at issue were completed and this settlement reflects concerns about paperwork,” the statement reads. “We stand ready to work with state leaders and regulators to help clarify and strengthen documentation requirements so that this type of litigation doesn’t continue to impact our industry and our health care system.”

Yes, I’ll bet he’s pleased that they got away this cheap and no criminal charges were filed. He should just remember that the government doesn’t consider this to be “about paperwork,” they consider it fraud.

From the Attorney General’s press release,

The AGO asserted that this conduct constituted violations of various state laws, including the Massachusetts False Claims Act. These allegations were first uncovered through a whistleblower lawsuit filed in the District of Massachusetts.

A long time ago I was at dinner while attending an EMS conference. One of the other people was a FBI Agent who specialized in health care fraud investigations, including EMS services. The issue of Medicare and Medicaid fraud came up and he told me that “Disgruntled ex employees are an excellent source of information.”

In this case it’s likely that the whistleblower filed a Qi Tam law suit under which if successful the whistleblower gets some percentage of the judgement. The suit was filed in federal court in Boston, which may mean that the US Attorney for Eastern Massachusetts might want to have a chat with the management of Brewster and Eascare.

Such are the wages of upcoding.

This is an interesting article. It’s also incomplete, but I’ll get to that part later.

A $500 fee and a 60% drop: How one department tackled its lift assist crisis

In 2014, the Decatur (Illinois) Fire Department responded to 430 calls for lift assist services. By 2023, the number had risen to more than 1,000.

This is not unique to Decatur, IL. In fact, it’s not unique anywhere. Among the clients for which my company provides auditing services “Falls” are the most common (14-23%) call type. They also have a very high patient refusal rate.

This fee applies to what the author calls “skilled nursing facilities or nursing homes” that call an EMS system to help move patients that have fallen or are otherwise immobile. The author doesn’t explain what difference, if any there is between the two and I’ve always seen the two terms used interchangeably.

“We had facilities that were – I hate to use the word abuse, but they were utilizing our resources rather than the people that are paid to do that,” DFD Chief Neil Elder said. “They were taking liability off themselves and putting it on our taxpayers and our resources.”

Ideally nursing homes whatever term you use should have staff that are capable of moving a patient off the floor and back into bed or a chair of some type. I don’t know about the author, but I’d guess that Chief Elder (ironic name) has seen the kind of people that are employed at nursing homes. I know I have and some are very good at this, but some I wouldn’t trust to lift a full trash bag.

Be that as it may, it is still a resource draining problem for EMS agencies. Most fire departments provide some level of EMS service, even if they don’t have an ambulance.

Not mentioned here is that many states don’t acknowledge a thing known as a “Lift Assist.” This is a medical response since the majority of “lift assists” are the result of a patient falling some distance. For people sixty-five and older that fall distance is usually from standing height. As a result, if EMS providers are called to a scene for a “lift assist” they are required by protocol to perform and evaluation. The second that they make contact the “person” becomes a “patient” and if they refuse transport a patient refusal must be completed and documented.

There are exceptions to that in some areas, but it’s the general requirement in the US.

Every time an ambulance or fire truck rolls out the door there is a cost incurred. The cost varies from place to place, but there is a cost. In general that cost can not be recouped because insurance companies only pay if there is a transport. Again, there are exceptions, but generally a patient refusal is not reimbursable.

When I say “insurance companies” I include Medicare which is the largest medical insurer in the country. Medicaid is also a larger insurer. Between the two they dwarf the private insurance providers. Both only pay if there is a transport.

Most nursing home patients have one or both so EMS services can’t bill for lift assists.

The fee was also waived for nursing home residents who required any medical attention during the call, and residential calls for lift assists were also exempt from the fee.

This makes sense and since residents are often voters is politically wise as well.

Over the next 12 months, the DFD generated $13,500 from nursing homes that chose to pay the new $500 fee.

This is an interesting statement. From which I infer that there is no enforcement mechanism as the fee may be of dubious legality. Maybe not. Speaking costs and fees, there is no word if the nursing homes pass that fee along to the patients. Which might also be legally dubious.

In addition to the calls to private residences, which in some instances are multiple times a week, there is no mention of calls to Assisted Living Facilities (ALF) which may not be licensed as medical facilities and thus have legitimate concerns about liability. I’ve had relatives who lived in ALFs and even though they had a nurse on staff neither the nurse or any other workers were allowed to lift patients who had fallen.

Is this the answer to this time and resource consuming issue in EMS? Maybe, maybe not. Harking back to my call review experiences, most “lift assist” calls are to either ALFs or private residences. I have no statistical data as we don’t track that in our database. It might be interesting, I’ll have to see if it’s something my boss would want to add.

While a fee may result in fewer calls to medical facilities, I don’t see that solving the problem in private residence and ALF locations.

Some of those in private residences belong in ALFs and some of those in ALFs belong in nursing homes. People are stubborn and also nursing homes are very expensive.

This article, Ill. city council makes $500 lift assist fee permanent

includes this quote,

Under the ordinance, a lift assist is defined as physically moving a person’s position to a different position who does not require emergency medical treatment or transportation.

Of course the problem here is that you won’t know if the patient does not require treatment or transportation unless someone does an evaluation. The temptation for nursing home staff will be to call 9-1-1 and allege that the person who fell is injured. Not that anyone who works at a nursing home would ever exaggerate the severity of the call.

Anyway, it’s a unique approach and it will be interesting to see how it works out.

As I’ve probably mentioned a few times, in my post active EMS career I read a lot of Patient Care Reports. I’ve been doing this since shortly before I retired, so it’s close to thirteen years.

As a result of the thousands of PCRs I’ve read I’ve observed some trends. Most medics and EMTs try to do their job well. They don’t take inappropriate shortcuts, perform treatments and procedures competently, and mostly get the diagnosis of their patient correct.

Yes, there are still lazy paramedics out there. The ones I call “line and ride” paramedics who will start an IV and ride in with the patient, but not do anything else. Sometimes they shouldn’t have started the IV and sometimes they should have done a lot more than just start an IV.

I worked with a medic like that. Anything even vaguely, might be, cardiac he’d give them aspirin, IV, NTG and a ride to the hospital. He logic was that while he was on this call, dispatch couldn’t send him on another call.

He also referred to patients as “sausages” for reasons I never understood and never cared to understand. His reward for being such a lazy medic was that he was promoted to management.

Another kind of medic is the “Throw the drug box at the patient” medic. I worked with a few and I could never tell if they were super smart or just throwing medication at the patient in the hope that something worked.

Along with the clinically astute paramedic who exams the patient, looks at the medical history, medication and allergy lists and decides what the diagnosis is. He also directs the work of the rest of the crew and monitors the entire call. In some systems that have two medics per ambulance with good BLS providers, he may not actually touch the patient at all during the call. A couple I knew rarely put on gloves when they were the “tech” or “primary.”

Sadly the second two types of medics seem to be disappearing. Mostly that’s because they are retiring or moving on to other career fields. I suspect that volunteer services have similar or maybe worse retention problems. I have no direct experience with any volunteer services, so that’s just a guess.

I started to see what I call a “generational  change” in EMS providers sometime in the 20 teen years. As more people became paramedics the quality of EMS education and training seemed to decline.

There were, and I think still are a few programs run by the training divisions of ambulance services. From talking to medics that went through those programs it seems that academically they were “taught to the test.” Which meant that they could pass the certification exams. but didn’t have the theoretical underpinnings to understand why they were performing the skills and giving the treatments for patients.

An example is that if the patient’s heart rate was fast or slow, they’d start an IV and give a large bolus of fluid. Unless the underlying cause was hypotension, it was unlikely to change the patient condition for the better. They failed to understand that IV fluid is and should be treated as a medication. As with all medications there are indications, contraindications, and the potential for adverse effects.

When I had occasion to sit down and review a case like this I’d try to explain the anatomy and physiology of what had occurred on the call. This is knowledge that they should have been given during paramedic school and maybe had been so taught. Sadly, the looks on their faces told me that they either forgot or never comprehended that information.

All of this was happening in services of all types private or public. Some public services were somewhat better because they had training programs for new paramedics. Some were not better and would take a new paramedic and throw them to the wolves. Most of the private services I dealt with had a one or two day orientation intended to show the new medic where equipment and medications were kept in the ambulance. There was little to no oversight of new medics.

I will note at this point that this was personally good for me because it meant more work hours spent doing re education. It was decidedly not good for their patients because if I was meeting with a medic to review a call there was at least the possibility of some harm to the patient.

Many of the medics were receptive and appreciated the knowledge I passed along to them and based on our evaluation process they started doing better patient care. That’s why I do this work and use my very good EMS education and experience to help medics be better.

Then came COVID. EMS systems were overwhelmed by the call demand plus the isolation requirements that were adopted. This included being confined to their stations between calls and not being able to even watch TV, eat, or even just talk about calls together.

COVID drove a lot of the experienced medics and EMTs out of the field. Those who could retire did so in large numbers. Others just quit and it was almost impossible hire new providers. Providers that test positive, even if they were asymptomatic were sent home for two weeks. A manager I knew told me that if ten percent of his systems providers were out per day it would be impossible to maintain proper staffing levels.

EMS regulatory agencies started to approve “expediencies” that ended up being practices that had been abandoned years before as EMS grew up. Providers in some states were allowed to decide that a patient didn’t need to go to the hospital. This wasn’t so much to help with EMS overload, but was an effort to relieve the same kind of issues that hospitals were having. Staff were overworked for the same reasons as EMS.

Another was a temporary waiver to allow systems to work with one EMT or paramedic on the ambulance and a none certified vehicle operator who had little to no medical training.

Hospitals were tacitly allowed to hold the ambulance and patient outside the building for hours until a bed was available in the ED. More stress on providers and systems for the benefit of hospitals.

COVID is now in the rear view mirror, but the damage still lingers. If spend any time on Facebook you will see that all types of EMS systems are looking for paramedics and EMTs, especially paramedics. An EMT course can be anywhere from a minimum of 120 hours to 190 hours. The 190 hour courses have more information and usually cost more. A 120 hour course can be crammed into about three weeks of full time instruction. Someone can take that course, pass the exam and be hired within a bit more than a month.

An Advanced EMT course is somewhere between 30 to 350 hours of additional training. AEMTs can do some of the things that a paramedic can, but not most of them.

A paramedic program is six months to two years depending on where it is taken. It’s also much more expensive. The two year programs are usually paired with an Associates Degree.

Which is why the demand for paramedics is much higher than for either of the other levels.

That temporary waiver for ambulance staffing? In many areas it’s now become permanent. EMT and Ambulance Driver or worse Paramedic and Ambulance Driver.

How bad is the staffing crisis? I know several other retired paramedics who have been offered jobs by ambulance services. I’m talking about people in their mid 60s or even older.

As if.

At this point there is no way to know when or even if EMS will recover. Based on what I’m seeing, I am not very optimistic. EMS is a hard way to earn a living no matter where one works. There are far easier ways to earn more money and many people are taking those jobs instead.

I hope I’m wrong and that EMS will rebound because patients deserve the best care possible in or out of a hospital.