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Health-Care Reform Spurs Paradigm Shift

March marks one year since the Patient Protection and Affordable Care Act was signed into law. We’ve already seen significant steps taken toward insuring an additional 32 million Americans targeted by the bill.

This past year brought added access through adult dependent coverage up to age 26, establishment of a federal insurance program for pre-existing conditions, consumer protections prohibiting lifetime dollar limits on coverage and elimination of children’s coverage denial due to pre-existing conditions.

These are all incremental steps included in the law to extend health-care coverage. And although the law isn’t perfect, more people already have access to insurance than before, and many more will have access by the time the last mandate goes into effect. In fact, in 2014, it becomes law that each and every American citizen must have health-care coverage or they’ll have to pay a penalty.

Trickle Down Effect
This additional coverage will mean increased demand for services because people feel like they have additional access. It’s a fact that emergency departments (EDs) across the country are already seeing an increased number of patient visits. According to an analysis by Mitchell Katz, MD, this increase isn’t due to the additional privately insured patients as one would expect.1 Rather, it’s a result of more adult Medicaid visits.

In 2014, the health-care reform law is scheduled to significantly add to Medicaid rolls. This one provision will expand health insurance coverage to millions of Americans, but it won’t automatically create more doctors. As such, a lack of primary care physicians coupled with the fact that most existing physicians don’t accept Medicaid, will ultimately result in even more crowded EDs and, consequently, more calls for EMS.

As we’re all aware, whatever affects the ED will also affect EMS.

There will quickly be increasing short-term stress on the EMS workforce, equipment and even communication. Additionally, hospitals will be looking to EMS for solutions to help curb hospital re-admissions, to route patients to the best source of care and to focus on prevention and provide even more complex treatments in the field.

Paradigm Shift
EMS is currently at the forefront of a paradigm shift in the way prehospital care is delivered, but the concept isn’t new. The Red River Project (see “Return of the Rural Paramedic,” May 2010 JEMS) has often been cited as an example of how a community transitioned paramedics to mid-level providers. The community overcame training, public relations and billing hurdles to become an EMS health-care provider service, not just an emergency field care and transport service.

This new focus will retool prehospital care to concentrate more on prevention and avoiding the emergency in the first place, rather than just emergency intervention. Opportunities may be as simple as home inspections or as complex as processing a blood chemistry panel or diagnosing congestive heart failure.

Think of how much good an EMT or medic could do by removing unused prescription medications from a home, identifying risks of tripping or falling for the elderly, providing child safety suggestions for parents or assisting with the creation of a disaster plan or kit.

How much sense would it make for a medic to be able to perform a portable X-ray onsite to help diagnose a sprain versus a break, circumventing the ED and referring the patient directly to an orthopedist?

It’s been proven that it’s often less expensive to prevent the need for hospitalization than to treat a patient in the ED. It’s widely known that the ED is the most expensive place to provide health care.

If reform is really about providing access to quality care with the least expense, then focusing on prevention, routing patients appropriately and expanding prehospital care is a logical place to start. And honestly, there’s no reason why EMS couldn’t be reimbursed more like home health services.

Expanding Roles
EMS was largely left out of the original legislation. But EMS is crucial to helping America’s health-care system succeed under reform through expanded job descriptions.

The role of the traditional medic is going to change, and there will be doubt, resistance and challenges. But the opportunity exists for EMTs and paramedics to begin providing prevention, education and primary care, in addition to emergency care.

When firefighters started becoming medics, they were widely perceived as medics who also fought fires—not just firefighters. Paramedics will have to overcome similar perception hurdles as their roles change and they move to advanced-practice paramedics or even emergency medical inspectors.

Regardless, learning a new skill to help prevent a bad outcome is always a terrific opportunity to advance the field of prehospital care and ultimately improve the patient experience. JEMS

1. Katz M. Future of the safety net under health reform. JAMA. 2010;304:679–680.

This article originally appeared in January 2011 JEMS as “Paradigm Shift: Reduce ED overcrowding by expanding EMS’ scope of practice.”


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