Step-dad is a firefighter; so many times they get to the scenes of accidents, and everything looks fine on the outside, patient feels completely fine so refuses ride to the hospital, but then 2-3 hours (sometimes even up to a day later) they end up far worse off and sometimes even dead from internal injuries that EMTs are not qualified to assess.
Person: No, free.
You: So how will the doctor get paid?
Person: By the government.
You: Where does the government get its money?
Person: Oh...
Even more, in most systems I know the amount paid for health insurance is fairly explicit. Where I live you actually get a bill from a non-state company (some things may be subsidized from other taxes, and if you can't afford it you also get a subsidy, though) so no, people don't think it's "really-really" free. It's "people with more money contribute more".
It works this way whether you're talking about a city-owned ambulance at the fire station or a privately-owned one idling in a parking lot somewhere. In either case, you (or your insurance, or your city, or your state...) are paying for a driver and at least one paramedic to sit around at the ready, not just for the quick trip.
If that were true - if the price was based on the cost - you would have small towns & rural areas where it would be so expensive, no one could use them, and cities where even though there were more ambulances, EMTs, etc, the cost would be spread so thin as to be barely noticeable
I don't believe the price is tied so directly to cost of service
Regarding rural areas and small towns: they often keep costs down by having crappy medical services in general, and slower response times specifically. It's not always that bad, though. If a town isn't sprawled out response times shouldn't suffer so much.
I have heard on more than one occasion that the reason emergency services (ambulances, ER, etc) are so expensive is to recover the cost of all the uninsured users.
People can be refused at a clinic if they have no insurance, so they go to ER for everything, where in many places they cannot be turned away. Hospitals therefore have to bill YOUR insurance to recover these costs
That's why your ambulance ride is so expensive.
> Hospitals therefore have to bill YOUR insurance to recover these costs
You know who takes an even bigger hit? Uninsured but solvent patients. Insurance companies have greater bargaining power.
None of that has anything to do with the ambulance business.
You're not only paying for the time you spend in the ambulance, but for the paramedics to be on standby, and for technicians to clean and prepare the ambulance for its next trip afterwards.
Both in the ~$200k neighborhood.
There was a public investigation in Paraguay when a public entity paid 200k for an ambulance, they should cost 100k at the most.
In Peru the cost of transforming a van into an ambulance is 14.000 dollars.
http://www.laestrella.com.pa/online/impreso/2011/10/05/dispa...
http://www.larepublica.pe/11-03-2007/hubo-sobrevaloracion-en...
We're in the processing of spec'ing two new ambulances. We're looking at 'mid-range' rigs, and most bids are coming in around $185k-$190k.
I've heard that a lot of medical expenses in the U.S. are due to the high amounts of litigation (I still can't believe the stories of healthcare costs in the United States).
The provider is Anjo Tech, according to the article.
By the way, if you want to be as anal about the definition of "free" as to include totally peripheral expenses (as if a pencil costs you $100 for signing a check with it), you might as well get to the bottom of it and say that everything is free on the basis that no matter or energy is ever expended.
It does cost you money. Europe plays a different game than the US but both are games. Thanks to Kennedy no one can be turned away from the ER for lack of insurance and bills are paid off later for cents on the dollar if you have no assets. If you have assets and no insurance too bad.
Which is funny, since they're only required to "stabilize" you once you're there. I know a guy who was attacked, suffered head injuries, and couldn't remember who he was. He was patched up and discharged in that condition since he didn't have his insurance card on him (and, I assume, since a shirtless and beaten-looking guy with long hair is just assumed to be homeless).
I am quite certain that behavior isn't typical of the hospitals in our area, but I bet it's totally legal. And a valuable cost-saving measure! An MBA somewhere is surely proud.
Hospitals make a lot of money from unpaid bills http://www.youtube.com/watch?feature=player_detailpage&v...
We have a (very good) public healthcare system here in Australia; but an ambulance will still cost you.
The costs of keeping ambulances ready, training, etc. could be socialized somehow. I benefit by having 5-10 minute EMS response times even if I never use it for 70 years, so paying for that out of taxes or some other universal subscription fee to users makes sense, rather than putting all the costs on those unlucky enough to need it.
In my case, I volunteer with a combination career/volunteer fire/rescue/EMS agency. Our 'operating costs' are payed by taxes, but if you use the service, you get a bill ranging from ~$100 for a routine BLS transport to ~$500 for a 'significant' ALS call (lots of drugs and advanced interventions). We don't itemize, but we do adjust billing based on what was done.
You could probably waive charging direct costs if you had some other way of deterring abuse, but they essentially always have to respond to 911 calls, so the only way I could think of doing so would be to arrest someone who misuses the service. A policy of informally losing the bill for legitimate calls might work, or doing the standard drug dealer "first one's free" strategy. But I don't think $100-500 for an ambulance would break most people, particularly with insurance; a charity could also cover the bills for some people.
The problem with 'a charity covering the bill' is that you then need people to donate out of goodwill. That doesn't often happen.
There's already fines and punishment for abusing emergency support systems (e.g.: calling 000/911/your country's equivalent). Even if you abuse that, and even if you mislead the call centre operator to dispatch an ambulance to your house, they're not going to ferry you to your desired location unless your vitals show reason to consider it a possible requirement.
Ambulance services are free here, insofar as you pay for a small tax on every rates bill (said rates cover ambulance and waste management services) edit: Apparently not since 2003 - it's now simply just covered by the State. There's no out-of-pocket expense. I can guarantee you that we don't have ambulances running people not requiring their services around 24/7.
And, if they're evaluating you on scene, even if they decide not to transport, they've already rolled the truck(s) to see you, which is probably much of the cost.
As rdl pointed out, the liability is just too high to refuse to take someone to the hospital.
However, it wouldn't surprise me if the liability issues were very different in the UK.
There's a separate argument about who should pay for what services, but "care should be delivered in the most cost-effective way to get the best patient outcomes" is independent of that.
Lots of 'fall down go booms' and 'they just aren't acting right' (yeah... it's called 'getting old')
There probably should be a cheaper way to treat them than sending SF Fire over and over to the same addresses. And that way would probably be both more comfortable for the patients and lead to better long-term outcomes. Maybe more extended inpatient care for them (in a low-cost-per-day facility)?
But I do understand what you are saying, I just do not think of it as spending money as my taxes most likely would not change regardless, they would just be used for something else.
The money to pay for that ambulance ride is coming from somewhere.
In any event, a trip to the ER is definitely warranted, even if it's not in an ambulance.
http://www.pbs.org/newshour/rundown/2013/03/struck-by-a-turt... http://www.hipaaspace.com/Medical_Billing/Coding/ICD-10/Diag...
There are also CPT codes that specify the procedures and diagnostic techniques that doctors and other healthcare providers do.
Insurance is then a mapping from ICD codes to allowed CPT codes. Good luck getting that information from your insurance company, however. Once I had a claim denied because someone transposed two digits in an ICD-9 code, and the treatment obviously didn't make sense. The insurance company couldn't tell me what the codes were - just that it was not an approved treatment for the reported condition. That took a lot of painful debugging to resolve.
Oh, and CPT codes are copyrighted by the AMA [1]. If you want to use them you have to pay licensing fees. Too bad it's not usually a case of "want to use" but instead "must use." I'm not sure if ICD codes are copyrighted.
[1] http://en.wikipedia.org/wiki/Current_Procedural_Terminology#...
There are _many_ people who call ambulances for things a taxi could handle just as well (often those people aren't worried about paying for it... medicaid will cover some small portion of the bill, and they'll ignore the rest), but a lightning strike isn't one of those things.
Probably the best use would be to have x-ray capability in the truck to verify placement of endotracheal tubes. Shooting an adequate chest film is something you can learn in 5-10 minutes (although, licensure requirements...).
(I've seen fairly portable CT, but in the sense of "shipping container with 1-2 day setup"; there are of course the CT and MR imaging trucks too.)
As far as '5-10' goes... rdl wasn't talking about interpreting films, he was talking about shooting them (and then transmitting them to a doc somewhere for interpretation).
There are some interpretations that could be taught in minutes . Most importantly, the one rdl mentioned, "Does that radio-opaque wire stay straight in the trachea, or does it deviate?".
Edit: I'm not sure the comparison to ED nurses is apt. Paramedics and nurses do very different jobs.
Patient positioning is something that we're pretty good at to begin with (if you think it's a pain to get them lined up to shoot the ET... try lining them up to drop it in the first place...)
But ETT and a few other things are the low hanging fruit. And with teleradiology you can even skip the "verify you got a decent image" step, particularly intra-hospital or for small images, because the rad can look at it immediately and tell you if you should reshoot.
I'd almost bet you could take a zero-training nurse or paramedic and give him a telerad-enabled x-ray or CT and get acceptable results working interactively with a radiologist and/or real rad tech remotely. Ultrasound might be trickier, but I saw midwives (who couldn't read or write, although they were really smart otherwise) trained in 3 days. I've never actually seen an MR used in person (since metal fragments tend to not go well with them; they just magically appeared on the PACS from elsewhere), but I imagine the basics of operating the machine aren't too much more difficult than a CT.
It has three primary uses: -FAST exams in trauma -IV access -Assessing for cardiac tamponade and guiding pericardiocentesis
Mobile CT are kind of interesting; I've only ever seen a mobile head CT, and that was designed to be wheeled into the OR to use in the middle of surgery, rather than sending the patient down the hall to the full body CT. But this was almost exclusively at hospitals designed around trauma care in a healthy 18-45 year old patient population.
In most of the hospitals I saw, it was never "mobile vs. portable", but "the Philips" or "the GE" vs. "the MinXRay", and even those were essentially left on wheeled carts most of the time.
Before that I was doing satellite/wireless/etc. networking, and some of my customers were various SOF who had fairly badass medics (regular army SF 18D is probably better than a civilian paramedic, at least for trauma, and the "other" guys had people beyond that, including some actual MDs who were also shooters). I did "combat lifesaver" class and then spent a lot of my spare time hanging out with the SF or SOF medics (because they tended to be more interesting than the shooters). I got some of the rad techs to teach me the basics of how to get decent images from CR/DR/CT/US, since I was trying to figure out which problems were caused by technique, which were caused by emitters or tables, which were caused by plates or scanners, and which were caused by our system. I kind of want to do an EMT course when I have time here, although I'm not sure where I'd volunteer to keep the skills current after that.
Before all of this I actually lived out in Baghdad for most of 2004/2005 with ~zero medical care or really any professional support (2 Americans, 100+ Iraqis), so it was mostly "learn anything you might possibly need well enough to do it yourself", and "don't get shot").
There were also civil affairs/outreach efforts, and some charity efforts (rotary club) to bring medical care to civilian population, which was weird, since Kabul had a private hospital with a 64-slice CT (when DOD had 16 and 32), and there was a private 2 Tesla MR in Jalalabad.
Mostly I was in "role 3" facilities, which were essentially as good a level 2 trauma center and a little bit of additional facility in the US. Also went to "role 2" (which were essentially 5-10 doctors, plus nurses and techs, with a couple of trauma bays, and X-Ray and US but not usually CT, and some of the FSTs (who augmented role 2 with much better surgical capabilities). In general the equipment and staff were top-notch, and the only problems were physical facilities. CTs tended to be in shipping containers, and the Army CSHes were big tent farms (which sucked), while USN and USAF tended to build fairly decent hardstand buildings (not as good as Stanford, but better than most of the rural counties).
On the issue of imaging without interpretation -- it's kind of funny. One of the big DoD pushes was to go back and have a radiologist read and issue an official report for every image shot of a US patient from the start of operations (2001/2002), in ... 2009 or 2010. There is the benefit that US people can't sue the government for malpractice, and Iraqis/Afghans aren't really in a position to sue, either (arguably the only ones with standing would be enemy combatants held in US custody).
AGFA was probably my least unfavorite, although IIRC they were really expensive. (In Kanadahar, the Canadian Forces who ran the medical role 3 until 2010 were using a pirated version of the software; they kept re-installing a trial license and hacking the date to work!) Really none of them were amazing, although I did really like the high-megapixel Barco monitors.
I've talked to some people doing an interesting cloud-hosted PACS (although they're in private beta, I see them listed in various places, so I think they're public -- radiology.io, now clariso.com.)
It was really funny when I was supporting an ActiveX-based system and every single one of the doctors had a Mac personally, and I used a Mac running VMware windows as my primary machine. I think the percentage of radiologists (or really, doctors in general) using Macs is >75%, but the hospital deployments are always Windows.
One good way for a new PACS or RIS to get started would be in training environments. Telerad is the other good way (sending CTs, and usually several studies, over a VSAT network with ~16/4M bandwidth for all of theater, was interesting -- especially since the goal was to always beat the patient to the facility to give surgical teams time to study the studies. Easy for the 8h ride to Landstuhl, hard for the <60 minute medevac helecopter from Jalalabad to Bagram.)
What surprised me is a lot of people wanted to at least be able to read reports (and usually look at images) on an iPad. Some rads even wanted to read on an iPhone screen (!!!) so they didn't have to get out of bed, although that was for things like sprained ankles and they'd read for real the next day. A Retina iPad is a pretty adequate device, though, honestly; it would be amazing to see what a Retina MacBook Pro 15 could do. (for everyone else, a radiology monitor is often $10-20k and approximately Retina resolution; there are some special FDA regulations about the screens for uniformity, but fundamentally they're 2-3x overpriced for what they are. A decent IPS LCD is perfectly adequate in many cases, particularly for CT/MR/US which are low resolution; mammography is the main area where really high quality screens matter (often black and white, 3-5MP). And the high quality screen really only matters for a radiologist; for every other doctor reviewing the images, a good quality normal monitor is perfectly adequate, as the rad writes a text report and marks up the images to identify anything important.)
I expect in 5-10 years ultrasound will be quite common, and x-ray may not be too far behind (mostly for respiratory related stuff... tube confirmation, confirming pleural effusions, etc...)
In the early (Johnny and Roy) days, it was _all_ telemedicine (send the strip and start LR...). We slowly got away from that for a variety of reasons, and are just now heading back to it.
While I'm not a huge fan of 'mother may I' medicine, I think it's crazy not to leverage the major advances in communications technology to bring a much broader range of specialties into the back of an ambulance.
Some area are having a lot of success with Paramedic Practitioners. The idea being that the can a) handle 'routine' medical calls without a trip to the ER, and can b) make proactive welfare checks on known frequent fliers (brittle diabetics, etc), reducing the load on the EMS system in general. Obviously they're also available as advanced level providers when needed, but this gives them something to do (and bill for) in their downtime.