I don't think I need to remind any of you, especially those that are EMT/Paramedic qualified and run a medic, what it's like to bring a patient to a major ER in any metropolitan area. Some of you have had to wait as long as 8 hours for a bed to clear so you could transfer control of your patient to the hospital. I'm not saying that's the norm now but it may well be sooner than later if things don't change.
Let me give you a scenario, it may or may not be what you experience in your jurisdiction. Say it's Friday night night and the boys and girls at the local manufacturing plants know that it's payday for them. You know it's going to be a busy night because for some reason and you still don't understand it, when the moon is full people seem to lose all sense of intelligence. Let's use the figures that Washington DC use for cost recovery for ALS because those were the first I came across. Advance Life Support - Level 2 will now cost the patient, the insurance company, Medicare, Medicaid (unless the patient is of indigent status and then the public picks up the tab of roughly $953 plus $6.60 per mile. That's for an apparatus that generally costs $200,000 to $250,000, brand new. If your department's purchase price is less, lucky you.
So, the company has paid all of the employees and they're really happy. As I mentioned before, it's a full moon and you've already had several runs to the few factories in the industrial section of your city. A few where quite serious but you and your partner as well as the other EMS crews are pleased that everyone got to the ER alive. The bill is going to be paid by the companies because they are considered industrial accidents. You and your partner can take sometime and have dinner at the firehouse with the rest of the Brothers. You're not lucky tonight because you didn't get a chance to even get one bite of dinner before the gong goes off for a medical call. It serious enough that a couple of Engines as well as three Medics are called out on this run, it's an MVA, Motor Vehicle Accident. There are five vehicles but only one of the vehicles, a small car has an entrapped occupant. The Brothers from the Rescue Company are doing what they do best, car busting.
You and the rest of your fire department follow EMS protocol to the tee. All "t"s are crossed and all "i"s are dotted. Your Medic picks up the most seriously injured motorist and transports to the metropolitan area's only Level 1 trauma hospital. As you pull up the the ER you find that there are 7 other Medics already there, some from your department but some from neighbouring departments as well. You have to sit there to wait for patients on the other Medics to be unload before you back your Medic up to the double width doors of the ER. Your partner in back is getting concerned that she might lose the patient if he doesn't get into the ER very soon. But, the hospitals policy is first come first unloaded. Then and only then will your patient go through triage.
Patience is the order of the day here. Finally, you're able to squeeze the big Bus into a spot that wasn't really big enough and there are currently five Medics parked in three parking spaces and no one has traded paint or bent any body panels. The Medic is put into park and the rear suspension kneels down so it's easier to unload the Stryker bound patient. You help your partner to wheel your charge into the ER only to find that while you though that there were only 7 other Medics at the ER tonight there are more like 12 or may be more. You remember that you missed dinner, again. Gotta move the Medic so another ambulance can have the spot. You find a spot, it's where the other five ambulances are parked that you didn't see at the ER. This doesn't look good at all. As you turn off the engine it starts raining. It's a block walk back to the ER and your rain gear is in your partners bag, which she has with her.
You get back to the ER to find that your in a holding pattern, much like being stacked up at La Guardia or Kennedy International. Remember, you can not just drop and run. the hospital must accept your patient and that won't happen until they have an open hospital bed. Not just room in the ER which there isn't but a free hospital bed.
Finally the charge nurse comes to your and tells you to put your patient in ER room 7. You still can't leave because she hasn't accepted him, yet. Your partner has taken the lead and had filled out most of the paperwork for cost recovery as well as NFIRS reporting. The nurse asked of you know what his insurance company is and of course your partner was more concerned about keeping him alive on the trip to the hospital and not who was going to pay the bill. She finds his wallet in his left hip pocket and is digging though it looking for that health insurance card. There isn't any. Care must still be given anyway because that is the law of the land. You look up at the clock on the wall and then it dawns on you that you've been at the ER for 4 hours and just now the hospital has reluctantly accepted your patient.
The patient as it happens is in indigent status, meaning that he doesn't have a means to repay the bill. The hospital will do all it can, including hiring a collection agency to squeeze the patient for any money because the hospital, even though it is a public hospital, the taxpayer's have refused budget increases for the operating expenses for the hospital. Now, since the patient is in an indigent status that also means that your fire department probably will not be able to do any cost recovery. The fire department is not a profit centre for the municipality but the mayor has warned the Chief of the Department that the constant cost over runs will not be tolerated any longer. So, going back to the cost figures for Washington DC Fire & EMS, your department is now going to have to swallow the flat $953 and the 15 miles ($ 99.00) plus the cost of all the medical supplies expended on your patient.
Now, if you think you have it bad, consider the hospital that not only has accepted patients from all the ambulances before yours and will continue well after you have left and then ambulatory patients that brought themselves in. The system is broken and the politicians are once again playing games. I would think that it would take a rocket scientist to figure the solution. For those citizens that are uninsured, simply extend Medicaid to them until they give back on their feet. If they don't in say six months, automatically transfer them to the Medicare rolls.