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Influx of seniors challenge emergency room system – Thousand Oaks Acorn

The number of older people in emergency rooms is expected to increase significantly over the next 30 years, doubling in the case of those older than 65 and potentially tripling among those over 85.

Our healthcare system is in critically short supply of primary care physicians and geriatric specialists to treat seniors. As a result, many seniors end up in emergency rooms rather than being treated in the community.

The emergency room can be an overwhelming place for seniors, as they must enter an unfamiliar environment, field rapid-fire questions, then experience fear and anxiety about the diagnosis that awaits.

Are our emergency rooms prepared for this significant growth in senior patients? The answer might be no, unless we heed a call to arms in the following critical areas.

Mental health

Nationwide, more than half of the people with mental illness go untreated, according to Mental Health America. Many seniors with mental illness dont realize they have it because they are dealing with multiple medical issues.

Their challenges are rarely purely psychiatric, and consequently, its hard in the ER to receive prompt comprehensive care for their mental illness.

Two hospital studies conducted from 2007 to 2010 found that the number of patients age 65 and older coming to the ER with mental health issues such as dementia, Alzheimers and depression increased nearly 21 percent. A lack of awareness among the general population about the mental illnesses facing seniors leads to older patients often ending up in the ER when a crisis occurs.

Drug side effects

An increasing number of older people are arriving at the ER as a result of side effects or adverse reactions to the prescription drugs they are taking.

According to Centers for Disease Control and Prevention, 35 percent of ER visits due to adverse events from prescription medications in 2013-14 were by adults age 65 years and older, compared with 26 percent in 2005-06. Among that group, seniors made up 44 percent of those who required hospitalization as a result of the drugs adverse effects.

Blood thinners, antibiotics and diabetes agents were involved in almost half of the prescription-drug-related visits.

In our fragmented healthcare system, patients are often seen by multiple physicians, each having an incomplete view of the patients drug use. Clinicians often hesitate to discontinue medications because of lack of familiarity with the medication or patient.

Opiates

Just last week the California Health Report published an article stating that the rate of patients over 65 seeking care at hospital ERs for opioid-related issues in California was second only to Arizona among the 50 states.

Often, older Americans who struggle with opioid addiction have been prescribed the medication to deal with managing pain upon being discharged from the hospital following surgery.

According to the Journal of the American Medical Association, of those who received an opioid prescription, more than 42 percent still had the prescription in place 90 days after they left the hospital.

ER visits often focus on the physical injuries (pain and broken bones from a fall that really was due to the loss of fine motor skillsa result of long-term opioid use) and push the root cause into the background. Because of the stigma, seniors also struggle with admitting drug dependency.

Identifying the caregiver

Almost half of all seniors over the age of 70 live alone today. Who advocates for them and how are these advocates identified in the emergency room?

Seniors enter the ER either from home, an assisted-living facility or, in some cases, from the streets. Frequently they do not have a family caregiver or an individual who is operating as their designated healthcare proxy with them.

The ER can be an overwhelming place, and a second set of ears, eyes and voice can lead to a better set of outcomes. Family caregivers also play critical roles in transitions from hospital to home or other post-acute settings.

As a community, we have an opportunity to work together to educate seniors and caregivers on what to expect when they enter the hospital and to inform hospital staff about the many challenges todays seniors face.

Consider joining Senior Concerns as it hosts a seminar titled Things You Should Know Before Your Next Hospital Stay from 5:30 to 7 p.m. Tues., Sept. 19 at 401 Hodencamp Road, Thousand Oaks. Call (805) 497- 0189 to reserve your seat.

Andrea Gallagher, a certified senior advisor, is president of Senior Concerns, a nonprofit agency serving Ventura and western Los Angeles counties. For more information, visit http://www.seniorconcerns.org, and for comments or questions, email agallagher@seniorconcerns.org.

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Influx of seniors challenge emergency room system – Thousand Oaks Acorn

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Think you need to go to ER? If your insurer doesn’t agree, you could pay – WHAS 11.com

(Photo: Thinkstock / Getty Images, Custom)

(INDYSTAR.com) – Indiana Anthem policyholders may soon discover that what they consider a medical emergency does not necessarily align with what their insurer considers a medical emergency.

Under a new program, Anthem will require Indiana policyholders who seek emergency care for certain nonemergency ailments to foot the emergency room bill. The insurer would still pick up the tab if the patient opted to go to a retail health clinic, urgent care center or doctors office.

Concerns over the high costs of emergency room care, combined with overcrowded emergency rooms, led to the new policy, said company spokesman Tony Felts in an email.

The ultimate goal of this is to encourage more efficient utilization of health care resources, relieve pressure on ERs that are already stretched thin and strengthen the relationship between our members and their primary care doctors, who are in the best position to influence the health of their patients, Felts wrote.

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Emergency room care costs 12 to 18 times as much as a visit to a retail health clinic, eight to 12 times as much as a visit to a doctors office and six to seven times more than an urgent care visit.

While Anthem officials say they have not yet set the date for when the program will begin in Indiana, it is already in place in three other states.

Emergency room doctors and patient advocates decry the new policies, saying they put patients in the uncomfortable position of making critical decisions about their health, when time may be of the essence.

Patients will be too often forced to be their own doctors, said Scott Mulhauser, board member of the advocacy group Consumers for Quality Care. Consumers shouldnt be evaluating their care in these tense moments . You dont want to guess wrong because the consequence can change your life forever.

With the new policy, patients may delay getting care they need, afraid of incurring a hefty bill, said Dr. Chris Burke, a board member of the Indiana American College of Emergency Physicians.

Because many nonemergent conditions present with similar symptoms to emergency ones, identifying the true emergencies can be challenging for a lay person, he added.

The problem is that many diagnoses, their symptoms overlap, and without a thorough evaluation by a physician, you cant tell until that evaluation is complete, said Burke, an emergency room physician with Medical Associates who practices at Community Hospitals East and North. Its wrong to insist that patients should self-diagnose. Most are not able to do that. I think most who come to the emergency department believe that they have a problem.

A patient could misinterpret a bad headache, for instance, as a migraine, failing to recognize it as a stroke that requires emergency care. Or nausea or indigestion could be mistaken for a gastrointestinal condition rather than a heart attack.

If a patient with the same symptoms wrongly concludes a heart attack, the good news that the condition was not more serious could lead to the bad news of being saddled with the full bill for the emergency care.

This past week, the advocacy group sent Indiana Insurance Commissioner Stephen Robertson a letter asking that he reject the policy.

The insurance department conducted a review and decided not to act further, said Jenifer Groth, director of communication and outreach.

“IDOI completed its review and determined the program is not changing any prior coverage and does not constitute a procedural or benefit change,” she wrote in an email. “The program is to make policyholders aware of the process for payment of ER claims by sending information that outlines how coverage of claims will be handled.”

Anthem officials say that they decided to implement the policy after studies showed that about 75 percent of the 6.5 million emergency room visits made by those younger than 65 annually are for conditions that do not actually require immediate medical care.

Four emergency room doctors helped the insurer draw up a list of about 300 medical codes that would be considered nonemergencies, such as suture removal, athletes foot and the common cold, Felts said in an email.

A medical director will review any claim made for care delivered in an emergency room rather than a more appropriate setting. The symptoms that drove the patient to the emergency room also will be taken into account, he said.

Only about 10 percent of all 190,000 emergency room visits in Indiana annually would be reviewed, and likely only about 4 percent would be denied, Felts said.

But according to the companys own research of its policyholders, many patients dont necessarily know where to go for immediate care. About two-thirds go to the emergency room if they are sick and the doctors office is closed. One-quarter think the emergency room is the best place to go no matter their ailment or the time of day.

Half of those surveyed said they knew about retail health clinics and walk-in centers and opt for the emergency room and just under three-quarters of people who have made emergency room visits are familiar with urgent care centers.

While Anthem said that concerns about rising health costs and overcrowding contributed to the development of the new policy, Burke, who has been in practice for three decades, said that this policy will likely have little impact on either of those.

Emergency room care nationwide only accounts for about 2 percent of health costs, he said. While crowded emergency rooms do exist, its often because theres no room in the hospital to admit patients, rather than rampant overuse.

Anthem has already put the program into effect in Kentucky, Missouri and Georgia and could eventually extend it to additional markets. Each state market determines its own list of what will and wont be covered, Felts said. In Indiana about 300 out of 2,000 diagnoses considered to be nonemergencies are included in the new policy.

The policy will not apply to pediatric patients younger than 14, those referred to the emergency room by medical providers, visits made on Sundays or holidays when other clinics and offices are closed and for patients who live farther than 15 miles from an urgent care facility.

Ideally, the new policy will strengthen the relationship between patients and their primary care providers, Felts said in a statement.

[W]e are committed to promoting care delivery in the most appropriate clinical setting; for nonemergent care, generally this is the patients primary care provider, he said. Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patients health status and should be the first medical professional patients see with any non-emergency medical concerns.

But health care advocate Mulhauser said that the policy could actually lead to high health expenditures if people wind up delaying needed care and end up worse off than if they had seen a health professional in a timely fashion.

When time matters and in those crisis situations, you want to feel the comfort of knowing that youre getting best medical care possible and not worrying about whether or not your insurer will cover your visit in a split second, he said. Forcing patients to make their own medical decisions that create incentives for them not to get the care they need can create real problems.”

Call IndyStar reporter Shari Rudavsky at (317) 444-6354. Follow her on Twitter and on Facebook.

INDYSTAR.com

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Banner Churchill Community Hospital breaks ground on new Emergency Department – Nevada Appeal

Officials with Banner Churchill Community Hospital broke ground on Aug. 15 on a $10 million Emergency Department expansion.

The expansion will add an additional 6 patient rooms. At the same time, a renovation of the existing space will take place.

The Emergency Department will double in size giving patients more privacy, shorter wait times and room accommodations such as TVs, while nurses and providers will benefit from improved efficiencies and better operational flow.

The expansion is expected to be completed by late spring or early summer with the entire project completed by the end of 2018.

“Our ED treats 20,000 patients a year in Fallon and the surrounding community,” said Robert Carnahan, chief executive officer of Banner Churchill Community Hospital in announcing the ground breaking. “With this expansion, we will have additional patient rooms that are larger which will support improved patient movement and delivery of care.”

Of the 16 new exam rooms, 11 will be regular patient rooms, two will be trauma rooms and new to the ED will be two observation rooms and an isolation room. Also included is an exam room with an electrocardiogram (EKG) to serve patients suffering from a heart attack.

In addition to the patient rooms, the project will feature a new waiting room and triage areas, expanded storage and office space as well as a centralized work area for nurses and providers to better monitor patients and integrate care.

“The ED was part of the original hospital and space is tight right now,” said Paul Rowley, development and construction project manager with Banner Health. “The way the new template is laid out it’s going to flow a lot better and service to patients will improve.”

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Prejudice in the emergency room – Medical Xpress

Esther Choo, M.D. ’01, wrote a Twitter thread that has brought national attention to racism in medicine.

Every so oftena few times a yeara patient at Oregon Health and Science University (OHSU) hospital in Portland refuses treatment in the emergency department from Esther Choo, M.D. ’01, M.P.H. It’s not because they consider her 15 years’ medical practice too paltry, or her School of Medicine degree insufficientbut because she is not white.

“It’s one of those things that you’re never prepared for,” said Choo, whose parents emigrated from Korea in the 1960s. “Nobody, at any point, has said, ‘Oh, by the way: you’re a woman and you’re a physician of color; you probably will have experiences like this.'” So Choo began that conversation with a Twitter thread the Sunday after the white supremacist rally on August 12 in Charlottesville, Va., that ended in violence and with the death of Heather Heyer when a car allegedly driven by a neo-Nazi plowed into a crowd of counter-protesters. In a matter of days, the thread had been retweeted more than 25,000 times (including by Chelsea Clinton and the physician-writer Atul Gawande, M.D.) and garnered more than 2,000 comments. The attention led to Choo’s appearance on CNN, where she discussed the issue of racism when it comes to patient care. Those patients who refused her capable care, Choo said, either chose to be treated by a white intern over the experienced doctor or walked, untreated, out of the emergency room.

“Breathtaking, isn’t it?” Choo tweeted, “To be so wedded to your theory of white superiority, that you will bet your life on it, even in the face of clear evidence to the contrary?” That evidence could hardly be clearer: in addition to her 12 years of post-residency practice, Choo has her degree from the School of Medicine, her residency at Boston Medical Center, and work as an associate professor and attending physician at Brown University under her belt. She’s now an associate professor at OHSU, where, in addition to her clinical duties, she studies health disparities, substance abuse disorders, and gender bias. She also writes and serves on the advisory board for FeminEM, a resource for women working in emergency medicine.

Her family’s story is a classic immigrant tale. Her parents came to the United States so her father could study engineering at Michigan State University. After receiving his doctorate, he went to work as an aerospace engineer for NASA in Cleveland, while her mother owned a home cleaning service. They became citizens and raised three childrenEsther’s two brothers are a biology teacher and a management consultant. Before coming to the school of medicine, Choo graduated from Yale College with a degree in English language and literature.

“It took me a long time to get to where I am now, where I don’t internalize it at all,” Choo said of her efforts to deal with racism at work. “But when you’re a younger physician and you’re still developing your knowledge base, there are so many doubts that you have. So when you encounter someone who looks at you and finds something wrong that’s so personal to youthat cannot be separated from youit just creeps into any available areas of insecurity. And somehow you walk away feeling less confident as a physician, because this person is questioning your legitimacy to be there.”

Choo’s experience is not unique. Many of the thousands of replies to her thread related similar experiences, an outpouring that raises concerns. An article last year in the New England Journal of Medicine discussed how physicians might deal with racist patients, and in December OHSU released what Choo called a prescient statement advising patients that hate speech and bigotry will not be toleratedand that requests for a specific physician based solely on race will not be honored.

“How do we improve the multiculturalism and the diversity of our physician workforce?” Choo said. “It’s really hard if you’re presenting some subsets of the physician work force with a harder road to travel.”

Nancy R. Angoff, M.P.H. ’81 M.D. ’90, HS ’93, associate dean for student affairs, who recalled seeing the qualities of compassionate care and calm leadership in Choo as a medical student, noted that the issue is a pressing one. “More and more, we’re looking at that as a form of mistreatment that our medical students face, that our trainees face, that we as an institution need to take seriously,” she said. “We need to foster an environment in which we respect each other.”

“Hospitals are not selective institutionswe treat everybody who walks in the door,” Choo said. “We are really thrown togetherpretty intimatelywith our patients, so we’re going to encounter a wide variety of opinions, and some of them will be extreme intolerance. It’s one thing to view it from across the country or on TV, and it’s another thing to have it in your workplace and up in your face.”

Some refuse to believe that Choo’s experience is genuine. To the doubters, Choo is gracious: “It’s a hard reality to acceptit shows the darker side of human nature,” she said. Injecting a positive note into that darker reality, Choo revealed in her Twitter thread what gives her hope: “A few get uncomfortable and apologize in the same breath they refuse to let me treat them,” she wrote. “You see, it’s a hell of a hard thing to maintain that level of hate face to face.”

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The Good, The Bad; The Ugly- Emergency Room Visits with a Migraine-Part 2 – Migraine.com (blog)

In Part 1 of this 2-part article I looked at the Ugly Side of ER Visits for a Migraineur. Part 2 will look at The Good, and constructive ways we can get more Good visits!

Sadly, the Good and Great ER visits for the Migraineur are often few and far between. However, a visit to the ER in June, is actually what prompted me to write this article. So, lets talk about a GOOD and even GREAT visit to the ER for someone with a migraine. I will use my June experience as an example. I was wheeled in, sunglasses on, by my husband with a 5-day level 10 migraine. Everything at home has failed. The triage nurse checked me in and noticed quickly I had slurred speech, terrible pain, and was pretty miserable. Even with a crowded ER, I was pushed to the head of the line and within moments whisked back to an observation room. Not a make-shift room with a pull around drape with others within 2 feet of you, but an actual self-contained room! Within minutes I had an IV in, a nurse checking my vitals, and a PA talking to us. They have electronic records at the hospital where I go so they are able to see that I am have Status Migrainous and have been treated for it for years. They even bring in pads for the bed in case I should have a seizure. They begin with fluids, anti-nausea medication, morphine, and Benadryl. This sometimes works, but in the case of this cycle it does nothing. They immediately call for a neurology consult. The attending doctor was extremely attentive and asked all the right questions. The neurologist came in and had actually taken the time to review my medical records! After some discussion, and what had worked and what had not worked, he asked if we had heard of the recent studies involving Ketamine and Migraines. My husband and I were in fact, familiar with them. He asked if I would be prepared to try a Ketamine injection to the IV to see how it took. Of course, the attending would have to approve because either he or the PA would have to be present. This time Ketamine was not a drip but injected into IV line.

WHAT?!? A doctor that was thinking outside the box? A compassionate doctor? We immediately said yes! It was not long before the PA returned with the syringe of Ketamine. I do not recommend this without research and done in well knowledgeable environment. It is not a wonderful experience but the immediate relief was enough to have them allow me to be discharged and my husband poured me into the car and once home into bed.

As I woke up the next morning I slowly opened my eyes expecting more migraine pain. What I got was greater relief that I have in several years! IT was a GREAT ER visit.

So, with all of these examples What can we do to prevent the UGLY and experience more Good visits to the ER as a Migraineur? Because the reality is that until hospitals begin to establish Migraine or infusion clinics, visits to the ER are going to happen for us!

What works for one person with a migraine may not work for another, yet ERs often use a standard procedure for treating all migraines. EVERYONE is different! You know your body and migraines better than anyone else! It is ok to question things and not give up and just live with the pain.

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The Good, The Bad; The Ugly- Emergency Room Visits with a Migraine-Part 2 – Migraine.com (blog)

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Traits of people who go to the emergency room because of alcohol – Addiction Now

The majority of people who frequently attend emergency rooms due to alcohol-related reasons are unemployed, isolated and not only mentally but also physically ill, a new U.K. study shows.

The authors of the study published Drugs: Education, Prevention & Policy explained that assessing the common characteristics of the population in need of recurrent emergency medical assistance can be valuable for several reasons, including addressing discrimination and improving treatment. Information about the characteristics of people who frequently visit emergency rooms for alcohol-related reasons is fairly limited and mostly derived from measurable surveys or demographic data.

The motivation behind [the study] was because there is a big problem with alcohol frequent attenders costing a huge amount of money to public sector services in the U.K., said author Tom Parkman, a postdoctoral research fellow in the Addictions department at Kings College in London.

They collected reports from six large hospitals in London that constantly have busy emergency departments. Physicians specialized in alcohol-related disorders and nurses from these hospitals provided the researchers with information about past-year emergency room visits before a sample (of 18 men and 12 women) was selected.

Partially-structured interviews that lasted between one to two hours were conducted with the 30 participants and covered topics such as sociodemographic details; present and past alcohol and other drug use; and addiction treatment history or desired support.

According to the researchers, each subject was sober enough to consent to be interviewed for the study, but some did drink before or during their interviews.

After the interviews were transcribed and analyzed, the researchers found that the majority of the subjects had a similar, long history of alcohol use.

The frequency of hospital visits varied drastically among the participants between 10 and 84 visits a year per participant and their patterns of substance use were also different, but almost all of them met the criteria for alcohol use disorder.

We found that there are push factors contributing to them attending for example, the dislike of community services, deteriorating health and excessive drinking, Parkman said. And pull factors from the hospitals [such as] being warm, always open [are] perceived as better quality compared to community services.

For some subjects, their alcohol addiction had reached life-threatening levels. One participant reported drinking bleach several times and another reported being terminally ill after having a severe liver disease among other problems.

Almost one-third of the subjects had been diagnosed with a mental illness and almost all others said they believed they had an undiagnosed psychiatric condition. Nearly all of them reported that they struggled with a chronic physical illness, including arthritis, epilepsy, Guillain-Barr syndrome and obstructive pulmonary disease. The majority admitted that these conditions were (continue reading)

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Traits of people who go to the emergency room because of alcohol

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The majority of people who frequently attend emergency rooms due to alcohol-related reasons are unemployed, isolated and not only mentally but also physically ill, a new U.K. study shows.

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Livia Areas-Holmblad

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Munson Healthcare Cadillac Hospital to Renovate Emergency Room – 9&10 News

The emergency room at Munson Healthcare Cadillac Hospital is getting a major makeover.

The hospital tells us they see almost 100 patients every single day in the ER, and that number is on the rise.

Right now, the ER has 15 rooms with beds.

And since the demand for ER care is rising, they also have two beds in the hallway where the patients have little to no privacy.

We’re up to 27,000 patients per year now, and in order to meet those needs we need a little bit more space, explains Jeremy Carlson, Manager of Emergency Services.

So now they’re doing just that.

Workers are drilling and sawing to create more space for the increasing number of patients Munson is seeing.

Ten years ago we were seeing probably 10,000 fewer patients a year so the design worked really well, Carlson says.

But it’s now time for a renovation.

So they’re re-locating the hallway beds into rooms to give patients more privacy, and theyre adding three extra rooms.

They’re not stopping there, though.

Better patient service means starting at the foundation, so the main staff workspace is getting a makeover too.

I’m excited about the renovation because I think from what the plans look like make its going to make it a more open, smooth space to work in, says ER Technician, Joe Berryhill. Youll be able to see the doc[tors] because there wont be big walls in front of you. So it’s pretty exciting.

Doctor, nurses and technicians will now be able to work side by side.

I think it’s going to help with the communication, Berryhill says. I think it’s going to be a lot [smoother], and in turn that’s going to make us take care of our patients a lot quicker with less obstacles in our way.

This project has been in the works for about a year now, and should be completed by May of 2018.

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Drugs in rectum, emergency room lead to struggle – Post-Bulletin

A Rochester man faces multiple felonies after authorities say he hid drugs in his rectum, removed them, then threw them around a hospital emergency room.

The incident began about 10:20 p.m. Sunday when an officer on patrol spotted a vehicle in the 1100 block of Eighth Avenue Southeast. The officer believed Michael Antwaun Common, 36, was behind the wheel, and knew Common was driving without a license, the report says.

A traffic stop was initiated, said Lt. Mike Sadauskis, which confirmed Common’s identity. He’d been stopped seven times since May 4 and cited for driving without a license, Sadauskis said, “seemed to be in a hurry,” and complained of a stomach ache.

The officer also knew Common’s criminal history included a conviction for drugs, Sadauskis said, and took Common into custody for continued criminal activity.

Common continued to complain of stomach pain, the report says, so the officer requested an ambulance. Common was taken to Mayo Clinic Hospital-Saint Marys Campus for an evaluation; the officer followed to stand by.

As he waited outside the exam room, the officer heard a struggle. He stepped into the room and saw the nurses struggling to prevent Common from putting something in his mouth, the report says.

It appeared to be a plastic bag with drugs in it, Sadauskis said, and the nurses confirmed they’d seen Common retrieve it from his rectum moments earlier.

As the officer and Common struggled for control of the bag, it ripped, “sending powder into the air,” the report says. The officer was able to “taste” it, and knew he’d ingested it, Sadauskis said. The two continued to struggle for possession of the bag as its contents continued to spread through the room.

The officer was able to deploy his stun gun, prompting Common to release his hold on the bag and allowed the officer to regain control.

According to the report, the bag contained 47.1 grams of methamphetamine, 23.6 grams of loose crack cocaine and 4 additional grams of crack cocaine in seven individual packages.

The officer was evaluated by medical staff and cleared, Sadauskis said, and Common was taken into custody.

He could be charged with multiple counts of felony drug crimes.

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Firefighters may make limited emergency room trips – Pamplin Media Group

City Council to consider ordinance breaking with traditional arrangement with private ambulance companies on Wednesday

In a small but potentially important move, Portland Fire & Rescue is asking the City Council for permission to bill Medicaid if it transports people to hospital emergency rooms.

Although PF&R crews respond to 63,000 medical calls each year, patients have historically been transported to emergency rooms by private ambulance companies. The arrangement has been questioned by some because PF&R crews and private ambulances respond to almost every medical call at about the same time.

City officials have discussed authorizing PF&R to do the transporting for several years. Interest has grown since the passage of the Affordable Care Act, which authortized Medicaid to pay for such trips when the patients do not have private insurance.

An ordinance to be be discussed by the council on Wednesday would authorized PF&R to transport patients to emergency rooms “in unique and unusual circumstances.” They are described as “high transport demand resulting from a major incident, excessive ambulance response delays caused by extreme weather, or a delayed ambulance response for a critical patient.”

According to the ordinance, transport fees in Multnomah County are set by the Multnomah County Contract Compliance and Rate Regulation Committee. Current charges are $1,008 plus $23.17 per mile. An impact statement accompanying the ordinance estimates PF&R could collect approximately $10,000 a year in additional revenue if the ordinance passes.

No additional PF&R employees would need to be hired, the impact statement says.

You can read the proposed ordinance and impact statement at http://www.portlandoregon.gov/auditor/article/651754.

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