 This is Think Tech Hawaii, Community Matters here. Good morning. This is Craig Thomas, host of Much More About Medicine, and part of the Think Tech live stream series and assisted by sound engineer Rich Priebus, and joined today by Jim Howe, director of City and County EMS. Thank you, Jim. Hi, Craig. Good morning. Hi. When I was considering this show, I wanted to get Jim because of the headlines at the time, which were related to doubling of the projected health care insurance premiums over the next eight years, pretty sobering thought. More subsequent headlines only increased that thing, and the ones I have in mind are yesterday's announcement that Amazon, Berkshire Hathaway, and J.P. Morgan Chase are getting into the health care business. We shouldn't forget that a similar operation years ago is how Kaiser Plan exists today. The other headline, and we'll circle to this, is the whole, this is not a drill, saga, which to me is emblematic of the problem. We get excited about things. We implement stuff that is hardly likely to impact health, and we get carried away. And honestly, I think that's what happened with that. And I'll be interested in your thoughts about all those things. The reason that I invited Jim today is because we first got to know each other, I think, on the order of 20 years ago. We did some AEDs for ocean safety, and some jellyfish sting remedies, and things like that found out that most of them didn't work. And I grew to appreciate the approach that ocean safety has to keeping people from drowning. So Jim, welcome. Thank you. And yes, Craig, thank you. I'm relatively new to the position that I'm in right now with the Emergency Services Department. Our department handles both the ocean safety needs for the community here on Oahu and also the EMS Prehospital Emergency Medical Needs for all of our community and visitors. And I appreciate the opportunity to be here today. I think one of the things that I'm coming at this from is that I really have a very long background as sort of a first responder, and I'm at the very tip of the spear when it comes to the entry into the medical system from the field. And we kind of understand that we're sort of the special forces of medicine out there in the field. We're the green berets of the Navy SEALs, so to speak. And so to come into this world of medicine at that level gives me a very different perspective on really what works and maybe what isn't quite so effective. One of the things that I clearly recognize through my career is that when we have a completely reactive system, we are going to miss the target on a lot of the kinds of needs that our community has. We need to have a proactive system, one where we're out assessing and meeting the needs before they become major medical emergencies. And we, through that effort at Ocean Safety, have really changed the dynamic of the needs of our community here on Oahu, and then this is spread around the world, and it's been highly effective. So when I hear and learn about our medical system, I understand that it's a fee-for-service system. And we're really in that mode, we're just reacting. We're not looking at the underlying causes, and we're missing what I think, in my opinion, is a proactive approach both at the front end, at that special forces level, but also throughout the entire system. And in our conversation about this very big news about Amazon and Berkshire Hathaway and JP Morgan coming into the health care market, bringing in some disruptive factors, I'm really curious as to how they're going to approach it, and will it be a more proactive model versus just a fee-for-service model, and how that's going to impact the system? I'm curious too, and I think they've already said, we don't know what it's going to look like, but they're going to bring tremendous resource, and they have more than a million covered lives to work on their model with. And I'm honestly optimistic, because I agree with you. Right now, I think we're focusing on delivery of services, whether at the tip of the spear, or what I do in the emergency department, or inpatient, or specialty services, rather than what actually impacts health. And the problem is, it's a lot easier to record, I don't know, a CAT scan, or mammography, or any number of things, which may or may not be beneficial. And we get lots of them, because we pay for them. And the same, so that's one element. The fee-for-service part is one element. To me, there's another one. And that's actually where I would loop in the, this is not a drill issue, which is drama is attractive. And we like to think if there's a potential problem, there is a dramatic solution. The problem is, the dramatic solutions may not work at all, or they may be harmful. And I think this is true probably throughout society, but definitely throughout medicine. And specifically, I'm not sure I want to know if there's a missile coming, because there's really nothing to do about it. I'm either going to make it or I'm not, and it depends on where I was before. And there's definitely harm to interventions that aren't likely to help. Right. So I think on, I'm a lifeguard, I'm a beach guy. And one of the things that you talk about drama, well, doing a big rescue and grabbing the rescue tube, and the person's out in the water screaming, and all of those kinds of things, you know, that's very dramatic. Yes. It's also very, very dangerous. Yes. It's dangerous for the person that is in that circumstance, because their life is on the line. But it's also very dangerous for the person who's responding in that rescue scenario. There's just so many things that can go wrong in that. Essentially what we did, coming from that perspective of how to minimize the drama, we used to use a metric of rescues or drowning fatalities as a metric to measure how successful our program was. The challenge that we got into is that, well, there were lots of drownings and lots of rescues, we get more money. Sounds like the rest of health care. We were shooting at the wrong target. What we did is we made a fundamental decision that we wanted to move into a preventive system. And we wanted to say, we are going to look at every possible way that we can intervene, educate, cajole, people to make good decisions. And really we had to go into how do we affect behavior change? And how do we communicate effectively with really every kind of person that you can imagine from all over the world with all languages and all backgrounds? They all end up on our beaches here. Absolutely. So we have this sort of beautiful little opportunity to be a laboratory of the world in how to affect behavior change. And we work with some great people in the field of injury prevention and epidemiology. And we design some programs. And then we actually put them into action. So as we began to put it into action and to begin to focus on prevention versus these rescues and the deaths, lo and behold, we saw it worked. Isn't that wonderful? It worked. And of course, over time, you refined that. Yes. So lower drama, but harder to get funding. Yes, that's the great dichotomy. Lower drama, more success, harder to get funding. And my guess, this is probably a mixed event impact on your personnel. People love drama. But you really don't want them to solicit it. And this is a challenge throughout medicine. Less is often better. And in medicine and health at large, actually, let's stick with health. In health at large, behavior is the huge driver. And we all know this. And I personally, I like to eat a lot. And I don't exercise as much as I should. And we could talk about the distribution of the items in my diet, which could use some improvement. I know these things. How do I impact myself? How do we impact others? Because the whole goal, actually, is to stay out of the interventional side of the health care system. So the way I view this in my training is as an economist. So that was my college training. I didn't know that, but it's relevant to many things. It is relevant to many, many, many things. And it's been a really great foundation for me in my career because how we look at the interaction between behavior and cost, behavior and the allocation of resource, these are all things that we study very carefully in the field of economics. And we're looking for outcomes. So if we're seeing outcomes that are working, then we just want to keep doing it. Yes. If we see outcomes that are not working, we want to do something different. Absolutely. So inadvertently, gave me a segue to one of my favorite precepts. There was a guy named Herbert Stein, who was an economist. And his famous saying is, I wrote it down. I didn't know you were an economist. If something cannot go on forever, it will stop. Correct. And honestly, I think that's where we're at. Currently, all in, health care is about 18% of GDP. That's staggering. It's about twice equivalent countries. And we don't even cover everybody. Could have put in the headlines about the nibbling away at the ACA, but we may save that for a different day. And it's projected to double. Not going to happen. Something else will happen. So I would love something rational to happen. And it's kind of what you said. Let's focus on what improves health, where we're wasting resource, where we're causing harm, like dramatic too late rescues, for example. But many others, things like, well, maybe we should talk about specific challenges facing the EMS side of the prehospital services. I'm perfectly good with more ocean safety, but it segues into the rest. Yes, it does. But before we go to that, and I do want to highlight that, I'd like to kind of comment sort of nationally, 18% of GDP. Staggering. 18 cents on every dollar that we produce in our economy is going to health care. Why? Think what that could do. And if we had stunning health, you might say it's worth it. Because after all, we want to be healthy. But honestly, we're mid-pack at best. We're going to take a break now. This is Craig Thomas with, I guess, to Jim Howell from the director of EMS. And it's much more about medicine. Thank you. This is Think Tech Hawaii, raising public awareness. You can be the greatest. You can be the best. You can be the king, come play, and now your chest. You can be the world. You can be the war. You could talk to God. The host of Voice of the Veteran, seen here live every Thursday afternoon at 1 PM on Think Tech Hawaii. As a fellow veteran and veteran's advocate with over 23 years' experience serving veterans, active duty, and family members, I hope to educate everyone on benefits and accessibility services by inviting professionals in the field to appear on the show. In addition, I hope to plan on inviting guest veterans to talk about their concerns and possibly offer solutions. As we navigate and work together through issues, we can all benefit. Please join me every Thursday at 1 PM for the Voice of the Veteran. Aloha. Welcome back. This is Craig Thomas, much more about medicine with guest Jim Howe from Emergency Medical Services. He's the director. And before the break, we were talking about how $0.18 of every dollar in the US is spent on providing health services and how this was not particularly matched with good health or really much else. It's really a shame. It's a tremendous loss of opportunity. Well, locally, of course, there's opportunity, too. And that's actually why we're talking today. So I think to kind of take this big picture and bring it into a context where we can look at it within our own community, where are we being impacted at the front end of the medical entry system, which is our EMS, Emergency Medical Services Service? This is the pre-hospital entry into the medical system. And that system is being hugely impacted right now by three populations in our community. The first is our senior population. We see this entry impact for those that are 65 plus. And we see that as people age in place at home, that their medical needs have to be met. And they're met by a variety of methods. But as they get a bit older, they begin to use the EMS system at a rate approximately four times that of any other population group. 30% of our population is 65 plus. And that group is going to continue, that baby boom cohort is going to continue through, and they're living longer. Yes. And so if we continue with a completely reactive model, we're just going to see more and more transport calls from a home, from a nursing home, to the ER for this population group. And it's not like the problem solved when they get to the ER. We call these low acuity complex patients. They have definite medical issues, often multiple. But they also need support, assistance, other things, which honestly we in the ED can't provide. We might be able to connect them up to them, but it's really hard to know what to do. So struggle for you, then a struggle for us. And honestly, I don't think either of us serves them well. Interestingly, I like going on long bike trips, and I bike down the east coast of Australia. They spend about half as much on health care as we do. But you know what they spend a lot of money on? Senior citizen communities. Correct. They have housing. They have support infrastructure. Looks really nice. And it's got to be the right idea. So it's clearly obvious that our cost of full-time senior care is extremely expensive. And for most of our families, most of our families in this community, it's not affordable. And there's very limited options in terms of insurance. The insurance options have declined because of the very high cost structure of these programs. So we need to really look at it's not working. It's not working? So what are we going to do? Exactly so. And that's, go ahead. We could talk, well, I was just going to say, we could talk about some of the various hurdles about getting insurance, which involve, among other things, depleting other assets, which is a real problem. I guess I'll just output it out there. I personally think that a society with as much resources as ours should provide systems to promote health to all its citizens and do what it takes. So if it's housing or aging in place care, which is far better than aging somewhere else care and cheaper, we should be doing that. And to the extent we're leaving out sections of the segments of the population, and I know you deal with those segments, we're hurting everyone. Correct. So that goes perfectly to the next group that really impacts our pre-hospital medical delivery system in the state of Hawaii. And that is the folks, these low acuity, high use. They tend to be people who are living on the street. There are homeless, both sheltered and unsheltered populations with chronic medical conditions, but also in many cases, they're using our EMS system for rides to the hospital. And it's such a misallocation of our resources. Here we have highly trained medical professionals in a fully equipped pre-hospital treatment facility on wheels who are going out onto the streets thousands and thousands of times based on calls coming in from 911, and they can't even find the person. Or they get there and the person really is saying, I don't really need help. And yet we're sending that resource out time and time and time again. Meanwhile, that resource is not available for another individual in the community that has an acute issue that requires a very timely response medically for a positive outcome. We're delaying that response to them. And that's happening quite frequently today. So A, that's terrible. And B, there's obviously some real issues of that, not the least of which is driving is dangerous, lights and sirens are more dangerous. And I appreciate they're not always employed, but still, besides the cost, besides the opportunity cost, go to the guy with the heart attack instead, those are issues also. Correct. Oh, go ahead. So the question is, this is the current state of affairs. What are we going to do different? My sense is we have to get away from the, just like you had to get away from the dramatic drownings, we have to get away from the ambulance run or ED census metrics. And we actually have to look at the impacts, the interventions that impact health. So these people, and there are multiple categories of people who are high-utilizers, they all have challenges. It's just that their challenge is not well-met by EMS or emergency departments, or for that matter, inpatient hospital services. And we're expending enormous resource. If we spent the same resource in different ways on a number of these segments of the population, we'd probably do much better. And the system needs disruption to change and fix that. So I think that what I want to go back to is my lifeguard experience, because I'm really bringing this system that we developed right here, right here in Oahu, that has now really spread worldwide and is highly effective. And a lot of it was changing the metrics that we used to measure. So today, instead of doing thousands and thousands of rescues and medical treatments, today we do millions of preventive actions. 2.5 million preventive actions taken by our lifeguard service last year. That's pretty astonishing, because, I don't know, what is it, 1.4 residents and 9 million tourists? So you're telling me that you are touching almost one in four people in the state every year. That's correct. That's impressive. And that's where the focus has gone. So in terms of our metrics, we now, as I mentioned, because we're holding the drowning rate steady, we're holding the major medical rate steady. And this is Oahu with increasing numbers of people. So we have actually termed this rescues that never happened. Literally, that's what we're doing when we prevent. And so the focus there and that focus of attention is safer for the individuals involved. It's safer for the providers, the lifeguards themselves. And it's highly cost effective. But nonetheless, it still takes a lifeguard out on the beach to do it. It can't be done with a sign. It can't be done with a website. You need this personal interaction. And I see that exact same system translating into our EMS world. How? In a couple of fashions. The first is we have to be able to continue to meet the demand when people call us. Absolutely. And right now, we're behind the curve on that, frankly, we are. We have to increase our service levels just to meet the demand. At the same time, I believe we should be investing in this more proactive system to see if we can't hold that demand line steady as we clearly know is going to increase with our aging population. But see if we can't hold that steady at our current level of financial input by investing in a proactive service. And there's a whole bunch of different models that have been used nationally, some with very, very, very good results. And it's a generalized term called community paramedicine. So the term itself has an interesting history. And actually, community paramedicine is used on Catalina Island, for instance. There's lifeguard paramedics on Catalina Island that do ocean rescue. They run a medical clinic. They run the hyperbaric chamber. They transport patients. They're lifeguard paramedics. That's cool. So you don't have a doctor staff there. You have a rescue medical treatment staff. That's one model. But the model that I think we would like to focus on, or should focus on here, is one where we're using our medical trained personnel and combining them with our social services personnel. We're spending a lot of money with folks out contacting our high user population on the streets. But they can never address the medical needs. They can offer them housing. They can offer them assistance. But we're missing that link of dealing with their medical issues early on so that we don't end up transporting them to the ER at tremendous cost, both direct and indirect. And that's where I think our first intervention measures should go. Makes sense to me. Although we have categories of, shall we call them, low acuity complex patients, the obviously different individuals need different resources. But if we could decrease the number of runs that don't result in medical benefit, which is substantial, and help people age in place or get the care they need away from high acuity facilities, obviously, that would be tremendous. I look forward to seeing how this goes. And we should have you come back. I'd love to come back and report the success of this program to you. And we really think collectively within the EMS community that this approach is going to provide benefit to our community. I do too. Thank you, Jim. This is Craig Thomas, much more about medicine with guest Jim Howe, director of the emergency medical services for the sitting count of Honolulu. Thank you. Thank you, Craig. Appreciate it. Thank you.