One of the things driving health care cost increases in the US is the way people use emergency rooms for routine medical care. Between 40 and 88 percent of all emergency room visits are for diseases and conditions that don’t require hospitalization – for colds and sore throats and simple sprains, headaches and back pain.
The cost difference is outrageous. A same-day visit to a primary care clinician runs between $100 and $170. The average cost for an emergency room visit is between $2400 and $2800. That difference accounts for billions of dollars of health care cost, which you and I pay for when we buy health insurance AND through the 1.45 percent deducted from every payroll check, every month. (That cost difference, multiplied by the 150 million ED visits every year in the US, is enough to buy primary care for all Americans, just sayin.)
Many things drive people to use the emergency room when they have a simple, non-emergent problem. Some people are just scared and don’t know what counts as an emergency. More and more people don’t have a primary care clinician or practice to call. Some people are just in a hurry – though the waits in emergency departments are often so long that going there is much slower than seeing a primary care clinician. And many people work during the day and can’t get time off to go to their regular primary care practice, so use the emergency department because it is their only option at night.
One way to reduce unnecessary ER utilization is a process called community paramedicine, also known as mobile integrated care. Community paramedical programs differ – but generally use one of two approaches. In the first approach, when EMS goes on scene after they have been called and find a patient with a minor medical problem, their paramedics treat those people in the field, using protocols provided by their physician medical directors or a partnering medical practice. In the second approach, when EMS is called and finds a patient with a minor medical problem, they transport the patient to a community health center with an urgent care area or another urgent care facility with whom they have a relationship. Some community paramedicine programs also do routine follow-up for homebound patients with chronic diseases like diabetes or congestive heart failure, or work with homebound people to prevent falls.
Community paramedicine has been around about 15 years and has been hugely successful in places as diverse as Washington DC and rural North Dakota. It is working today in over forty states the US, and in Canada, Australia and the UK. It reduces non- emergent ER utilization by over 30 percent where it is used.
So we have it everywhere in Rhode Island, right?
Wrong. Nope. Sorry. We don’t use community paramedicine very much in Rhode Island at all. A few pioneering places – West Warwick, South Kingstown, Charlestown, Providence and Pawtucket, at least intermittently, and a few others have dipped their toes in, but everyone struggles to make this work.
How can that be? What are the roadblocks?
The roadblocks are many and come from different directions. First, insurance companies, Medicaid and Medicare don’t pay EMS to transport to anywhere but an Emergency Department of a hospital, and don’t pay for treatment in the field by paramedics, so if EMS in any town tries to get community paramedicine started, they have to fund it themselves, from local taxes. That’s even though the substantial savings when they occur, accrue to Medicare, Medicaid and insurance companies, not local government, which is crazy right off the top. Then, to do community paramedicine right, we need many more paramedics, and many more paramedics for EMS and many more doctors, PAs, and nurse practitioners to staff the urgent care areas of community health centers – and we have a shortage of those health professionals already. Community Health Centers would need more funding to staff their urgent care areas, and they have little enough funding already. Community Health Centers already have more work than they can handle. And some union members in EMS don’t want community paramedicine to happen, because they fear it would reduce transports to emergency departments, and cost their members jobs, even though it would save the state big dollars.
It would take a strong hand and an outstretched arm to corral all the players, direct them, and find the funding and staff needed to make community paramedicine work in Rhode Island. Put another way, it would take leadership, which is sorely lacking in a state with many politicians, but few leaders.
Lacking leadership in Rhode Island, you and I pay the price. That’s crazy.
You can find Michael Fine’s commentaries and short stories on
https://michaelfinemd.substack.com/and on http://www.michaelfinemd.com
