October 10, 2019 | View as webpage

A recently introduced bill, HR.4527/S.2552, aims to provide a Medicare option to first responders facing a gap between retirement and Medicare eligibility. In this briefing, Skip Kirkwood explores potential revisions to the “Expanding Health Care Options for Early Retirees Act” in the lens of his recent retirement.

Also, Emergency Medicine Physicians Ryan Marino and Jeremiah Escajeda examine the lack of substantive data behind anecdotal claims that naloxone administration can cause aggression in patients who receive it.

Finally, join us in a webinar, “Taking the nation's pulse: The 2019 Fitch/EMS1 Trend Report” on Oct. 22, at 11 a.m. EST, as Fitch & Associates Partner Roxanne Shanks, MBA, and I share our take on the results of the 2019 EMS Trend Report survey and learn how you can participate in the 2020 EMS Trend Report data collection.

Do you know someone who would benefit from a subscription to Paramedic Chief and the Paramedic Chief Leadership Briefing? Forward this briefing and encourage them to subscribe.

Greg Friese, MS, NRP
Editor-in-Chief, EMS1

Will HR.4527/S.2552 expand or limit retired EMS insurance options?
By Skip Kirkwood

HR.4527/S.2552 – a bill to amend title XVIII of the Social Security Act to provide an option for first responders age 50 to 64 who are separated from service due to retirement or disability to buy into Medicare, has been introduced, and dubbed the “Expanding Health Care Options for Early Retirees Act.”

Sounds good, yes? But what do we know? In many states, public safety response personnel – often defined as police officers and firefighters, but sometimes including EMS personnel – enjoy the opportunity to retire before they reach the magic 65th (Medicare eligibility) year.

This is a good thing, because law enforcement, fire suppression and emergency medical services are games best played when young. Yes, we all know people in all three disciplines who remain on active duty until their later years, but physiology is physiology, and at some point, the body is reluctant or unable to perform the feats of strength, speed and endurance that the emergency response professions sometimes require.

Health insurance options for retired EMS providers

In years past, many governmental employers simply provided health insurance “for life” for their retirees. Some required minimum lengths of service – first 10 years, then 20 years, later 30 years – before the guarantee would kick in. The cost of these benefits was just kicked down the road, with future governmental bodies left to figure out how to pay for it.

In the late 1990s, the Government Accounting Standards Board changed its rules, and required governments to account for these “future costs” and to report them in annual financial reports. This exposed some huge un-funded liabilities, and caused many local governments to close down these benefits, or at least make changes to them. My employer at the time switched from health insurance for life to a defined-contribution post-employment health plan that would provide an employee a pot of money from which to buy his or her own health coverage. It took a lot of determined collective bargaining to keep these health insurance for life plans in union contracts going forward.

But there are plenty of public safety employees who don’t have such a safety net. Hospitals and non-profits, and other agencies without strong collective bargaining agreements, assume that staff will work until they are Social Security and Medicare eligible, which is a stretch for paramedics, EMTs and other clinical workers (as well as police officers and firefighters employed in non-traditional agencies, like universities, private corporations and non-profits).

Whether retirement is a discretionary decision or the result of disability (the kind that doesn’t get compensated for by worker’s compensation or other special fund), the gap between retirement and Medicare eligibility can be an expensive one.

I recently retired one year shy of my 65th – Medicare eligibility – birthday. In my case, maintaining my formerly county-funded health, dental and vision insurance for my family of four cost just over $2,200 per month. That is a chunk of change no matter how much you’ve saved. Fortunately, I only had to cover that for a year – but if I’d pulled the pin at 50, that would have been a huge expense.

3 Questions about the proposed HR.4527/S.2552

So – is the proposed HR.4527/S.2552 a good idea? It might be – or, it might need some revisions. There are a lot of questions to be asked and answered, including:

  1. Does the proposal provide coverage for only the first responder, or for spouses, children and other dependents too?
    • As proposed, it looks like just the individual
  2. Does buy in mean at full cost, or does it mean just pay the monthly premium? Currently, Medicare Part B (which covers outpatient care, doctor visits, etc.) costs (individually) $135-$270 per month, depending on income. Beneficiaries must also pay for Part D coverage, which pays some prescription drug costs. But if it means full cost, that could be nearly or as expensive as commercial insurance.
    • As proposed, it looks like it means the same as everybody else
  3. Does the proposal apply just to public employees, or to “first responders” who work for non-profits, hospitals and private-sector employers? How about volunteers in all three disciplines?
    • As proposed, it looks like it only covers public employees: an employee described in clause (i) of section 72(t)(10)(B) of the Internal Revenue Code of 1986 who provides firefighting services or emergency medical services

It is also conceivable that somehow this bill could motivate employers to eliminate current (perhaps better) benefits in favor of the Medicare option.

You can find the text of this bill and sign up for updates whenever anything changes with this bill here.

Additional resources:
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    When myths are more dangerous than reality

    By Ryan Marino, MD, and Jeremiah Escajeda, MD

    Recently, a passenger on a Delta flight died from an apparent overdose, sparking widespread media attention, with coverage attributing the death to a lack of naloxone on board.

    The coverage of this incident prompted dramatic and polarized responses across social media. One common theme of concern expressed that naloxone administration can cause aggression in patients who receive it and administration of naloxone risks assault to either bystanders or healthcare providers. While anecdotes were shared to justify this theory, there is a paucity of substantive data to corroborate this urban legend.

    Anecdotes are not the same as facts

    It is unclear where this rumor started. The only available evidence to support the phenomenon seems to come from two case reports from 1992 – notably, not even in substance users. Even more notably, naloxone-induced assaults have not been reproduced over the subsequent decades. All of the credible evidence that we have, suggesting administering naloxone will result in provider assault, are two case reports from the 1990s. 

    Treating patients with altered levels of consciousness, whether related to substances like drugs, low oxygen, low blood glucose or any other cause, can be challenging. Treating these patients, as with treating most patients, often involves working in close proximity, which can be a risk for assault, and assault of healthcare workers is a serious issue that cannot be blamed on these patients.

    The problem with attributing aggression and assault to patients who use drugs is that this is not supported by any evidence after decades of treating overdoses. It also adds to the stigma that these patients experience, which, in turn, can worsen the care they receive. In the case of naloxone for opioid overdoses, the alternative can be deadly. Additionally, there has been recent data demonstrating that assault of EMS professionals is on the rise, however, there has been no discovered causation as a result of increased naloxone administration in the prehospital setting. 

    Unfairly tarnishing a very safe, very old, very good and very safe drug

    Naloxone has been approved to reverse opioid overdose since 1971. An often-overlooked component of its longstanding use is that it is used to reverse over-sedation in hospital settings all the time, and has been for decades. If naloxone reversal were associated with increased incidence of aggression or assault, this would be well known and examples would be more common than just second-hand hearsay. In fact, a recent review of naloxone to treat heroin poisoned patients found a less than 3% rate of behavioral disturbance, not assault.

    In case there is any concern that hospital administration of naloxone is different than out-of-hospital administration, Tim Gauthier, MScN, NP, who has personally responded to hundreds of overdoses in his eight-plus years as the clinical coordinator of Vancouver’s Insite supervised drug injection site, says, “It is exceptionally rare for anyone to be combative when coming out of an OD, especially if we pay attention and attend to cues that we are scaring or triggering folks during emergence. Give space, genuine reassurance, and be gentle.”

    When titrated to restoration of breathing, rather than given punitively, naloxone is overwhelmingly unlikely to cause any adverse reactions at all.

    Every life is worth saving

    Despite increased awareness, significant biases still exist in medicine and directly impact patient care and continue to adversely affect patients who use drugs, even after years of highly-publicized coverage of epidemic overdose deaths. A recent analysis of overdose patients in emergency departments at multiple hospitals showed significant biases affecting whether take-home naloxone was provided to patients after opioid overdoses.

    One particular bias in delivering naloxone is a preference for more invasive respiratory support maneuvers. While bag-valve-mask ventilation is a mainstay of basic life support and is crucial to provide during resuscitation of an overdose, it should not preclude the administration of naloxone. BVM ventilation is susceptible to many areas for errors, and in the setting of an overdose, this can mean anoxia and irreversible brain injury.

    Furthermore, depending on the lay public – the vast majority of whom are not trained in advanced resuscitation techniques – to provide BVM ventilation is not a reasonable expectation and not an appropriate response to (easily preventable) widespread civilian deaths.

    The responsibility of EMS and all healthcare providers is to deliver the best care possible to our patients, and in the setting of respiratory failure from an overdose, restoring the patient’s ventilation via the antidote naloxone is the definitive management, whereas BVM ventilation is not. Also, naloxone distribution, when deployed to the community, has been shown to be safe, life-saving and cost effective.

    The mission of EMS is to provide the best quality, evidence-based care to all patients in all settings. We cannot let theoretical concerns about unfounded myths influence practice; human lives depend on it. After almost half a century, naloxone remains the definitive EMS therapy to treat respiratory failure in opioid overdose.

    About the authors

    Ryan Marino (@RyanMarino) is an emergency medicine physician and medical toxicologist at University Hospitals Cleveland Medical Center and an assistant professor of Emergency Medicine at Case Western Reserve University School of Medicine. He specializes in treating patients with substance use disorders and believes in treating all people better.

    Jeremiah Escajeda (@jerescajeda) is an emergency medicine physician and EMS medical director at the University of Pittsburgh’s School of Medicine/UPMC’s Department of Emergency Medicine. He pays special mind to substance use disorders, and how we can better treat substance use disorder patients prehospital. He is also a contributor to the PEC (Prehospital Emergency Care) podcast.

    Additional resources:
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    1. Register today. EMS1 Editor-in-Chief Greg Friese, MS, NRP, and Fitch & Associates Partner Roxanne Shank discuss the trends found in the EMS Trend Report – both worrisome and encouraging – in a free webinar.
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