What To Do with Frequent Flyers?
By Emmy ShearerPublished May 1, 2013Two summers ago, I volunteered with an EMS-fire agency in Berkeley, California as part of my EMT certification process. Fresh out of skills training, I was prepared for the worst. When the first siren went off the first day, scenes of CPR, uncontrollable bleeding, and respiratory failure flashed through my head.
As it turned out, the call was actually from a homeless man who wanted a free, bagged lunch from the ER.
Non-emergency 911 callers are not as uncommon as many would like to think. Called “frequent flyers” in the pre-hospital care world, some who dial 911 in non-emergencies on a regular basis are seeking attention, free meals, or even just a ride downtown on the taxpayer’s dollar; but many more do so because they lack insurance and access to primary care, so ER’s are their only possible source of medical attention.
Regardless of the reason, non-emergency ambulance rides negatively affect local care providers and citizens alike. Needless ambulance rides not only add to the workload and lower morale among EMS workers, they also divert ambulance resources away from other potentially life-endangered callers. What’s more, these patients contribute to emergency room overcrowding and increased “wall time,” or waiting time, for patients who need immediate medical attention.
These unnecessary rides also come with huge price tags. In the case of municipally-funded EMS agencies, ambulance rides not covered by private insurance, Medicaid, or Medicare get shifted to local taxpayers. In Chicago, this translates to $900 per basic life support ambulance ride, $1,050 per advanced life support ride, $25 for use of oxygen en route, and an additional $17 per mile traveled. In the case of private, for-profit agencies, these costs get shifted to paying customers by way of higher transport fees. And even when the rides are covered by public insurance, such as Medicaid, these costs eventually find their way back to residents through increased state taxes.
In efforts to reduce additional Medicaid spending, many states have tried enacting laws that allow them to refuse ER payments for people who should not be there. Under these rules, states would not pay for ambulance rides or ER bills for patients simply using the system for a free lunch or as a primary care clinic.
However, these laws miss the larger underlying problem. While their enactment may lower state taxes slightly by slowing Medicaid spending, these costs are likely to be shifted to counties. Ambulances and hospitals will have to make up for their losses somehow, and thus the burden will be shifted to local residents in the form of either higher local taxes, more expensive service fees, or reduced service availability (think longer ER waiting time, longer response time for ambulances, etc).
Moreover, these laws also unfairly target another group: people who are legitimately concerned about a health issue, but are unsure if they should go to the ER.
Consider a 64 year-old man with a family history of cardiac problems who wakes up in the middle of the night experiencing chest pain. Is it just heartburn from last night’s dinner? Or is it the first signs of an acute myocardial infarction? Certainly, a trip to the ER to double check is justified. But, under these new laws, he may have to worry about paying the cost of his visit if it turns out to be just heartburn. Such logic turns the whole point of the EMS system up side down.
Perhaps one alternative solution to the problem of false non-emergency 911 calls is to grant transport discretion to EMS providers. In this situation, EMS workers would be allowed to refuse hospital transport to callers they deem to have non-emergency injuries or illnesses. Such proposals are not new, but are controversial mainly for liability reasons. EMS providers, after all, are not trained in diagnosis. How can hospitals be sure they would turn away the right people?
Pennsylvania has found one way to limit the liability problem. Their state legislation grants transport discretion to EMS providers, but only after a “MedControl” check: a call to an ER doctor relaying signs and symptoms. The doctor at the other end of the line makes the final transport call, saving unnecessary transportation without sacrificing all MD diagnostics.
While transport discretion with MedControl laws would be a good starting point, even this proposal fails to solve the most disturbing problem of all: limited access to primary care. At the end of the day, frequent flyers calling 911 because they don’t have primary care physicians are still left without viable alternatives.
Will PPACA’s expansion of Medicaid coverage to 16 million new citizens ease this problem? Maybe, if primary care doctors are willing to accept Medicaid payments for these new patients, and if states even accept federal funding for Medicaid expansion in the first place.
I guess we’ll have to wait and see. In the meantime, it may be in states’ best interests to try out Pennsylvania’s MedControl policies for themselves.