The California Nurses Association is stepping up opposition to two bills that nurses say create a two-tier system of health care and pose a significant threat to the safety of patients in need of emergency medical care. One of the bills essentially allows paramedics to serve in primary care roles in place of licensed healthcare professionals.

Under SB 944 (supported by the insurance industry) and AB 1795 (sponsored by the hospital industry), paramedics responding to 911 or other ambulance calls would be authorized to perform medical clearance exams that are currently performed in emergency departments. Instead, based solely on the evaluation of the paramedics, who are trained in pre-hospital emergency care, patients would be diverted away from hospital emergency departments to alternate destinations with limited medical services, putting patients at risk. 

Why Nurses Oppose SB 944 and AB 1795 – a Two Tier Standard of Care

“These bills are modeled on the unfinished Health Workforce Pilot Projects which—for the most part—enrolled indigent, homeless, and elderly patients from medically underserved communities.  They’re creating a two-tier standard of care based on income,” said CNA Co-President Malinda Markowitz, RN.

“In fact, 99% of the patients diverted from one of the for–profit, investor-owned hospitals were Medi-Cal and uninsured patients.  None of the patients with private insurance were diverted from the ER.  The result has been that these projects have freed up psychiatric beds in the hospital for privately insured patients while rerouting Medi-Cal and uninsured patients away from a hospital emergency department.  It is disgraceful to treat our most vulnerable patients to a lower standard of care,” Markowitz continued.

The Profit Motive Behind SB 944 and AB 1795 – At the Expense of Patients

There are clear profit motives at work behind these bills as well, says CNA. Some of the alternate destination sites will directly benefit for-profit companies, including AMR, a private ambulance company. AMR has five of the pilot projects, which would be extended under the legislation, and passage of the bill would lead to additional funding for it, to AMR’s benefit. A former AMR CEO is the project manager for the pilot projects.

On the insurer’s side, Anthem Blue Cross recently indicated it would reimburse ambulance companies even when they don’t take the patient to the hospital, setting up an incentive to divert patients away from the hospital.

Insurers have a direct financial incentive to push patients to alternate destinations where the amount the insurers have to reimburse the providers are significantly lower than they would be in an ER, which provides more comprehensive care. The ER also has immediate access to a hospital operating room and intensive care unit.

The outward appearance of a patient picked up after a 911 call doesn’t always tell the full story. Patients calling for an ambulance may have multiple underlying medical conditions, and emergency department screening is the safest and most humane way to assure the appropriate level of care.

“All patients are unique, with their own medical history and conditions.  A comprehensive assessment makes a difference.  It saves lives,” said CNA Executive Director Bonnie Castillo, RN.

“Paramedics, while valuable first responders, simply do not have the expertise of a registered nurse, based on years of scientific education and clinical experience, to independently assess 911 patients for diversion from the ER,” said Castillo.

Misdiagnosis Leads to Delays in Potentially Life Saving Care

“Under the pilot projects, there have been instances where the paramedic made a decision out in the field to divert a patient away from the Emergency Room to an alternate destination site, and the patient was then denied admission to that alternate destination and sent to the ER,” Markowitz said.  “This misdiagnosis results in a delay in care that wastes valuable time for patients in emergency situations.”

Their assertions are supported by a study published in a January 2017 Lifeline Magazine article in which assessments by paramedics of patients transported to Arrowhead Regional Medical Center in Colton, CA between April and December 2015 from the Rialto Fire Department were compared to assessments of the same patients by licensed ED physicians.

The study concluded there was a significant difference between the paramedic and physician assessments: the paramedics under diagnosed the severity of a patient’s condition.

One of the bills, SB 944, would also allow paramedics to add primary care functions—like providing post-discharge follow-up care when a patient with a serious health condition is released from the hospital—to their main responsibilities of fighting fires and stabilizing and transporting patients with emergencies in pre-hospital and inter-hospital transport.

“How can paramedics handle both their existing responsibilities along with these new additional functions?” Markowitz asked.

“One of the pilot projects had to shut down enrollment and the paramedics had to go back to their regular responsibilities because they could not provide both the pilot project services as well as meet their required 911 response times.  This bill gives false hope to our communities that private ambulance companies and fire departments can provide both continuity of care and high quality health services in addition to their traditional EMS roles.”

“And, alarmingly, there was actually an increase in the rate of hospital re-admissions for the largest group of patients enrolled in the post-discharge/congestive heart failure pilot project,” Castillo noted.  “In fact, the rate of hospital re-admissions was actually higher for these patients during the pilot project than prior to the initiation of the pilot.”