by Ramon A. Robertson
With an estimate of 240 million calls per year, 9-1-1 operators are shockingly busy — collectively, that’s a numbing 8 incoming calls per second in perpetuity across the nation. 2 While Emergency Medical Services (EMS) have expanded to meet the public demand, they have shriveled (by force) in their agency and potency to deliver patient-centered care to the community. Unfortunately, it is the money trail that leads us toward the single greatest accounting contributor of their diminished efficacy: their compensation is strictly linked to a fee-for-service model, that directly rewards transportation and often overlooks (or sidelines) infield medical care. 1 To be clear: EMS is only paid if they ultimately transport patients to the hospital; the lights-and-sirens response, the onsite acute medical care, and any other instructive/supporting measures, do not alone command reimbursement. 1 From a business perspective, this sets up an unhealthy nidus for the management of patients with sub-transportative needs, and encourages over-aggressive and/or needless advanced care maneuvers and/or routing. 1 Not only does this payment model uncannily usurp the medical role of EMS workers (by relegating them to mere transportation functions), but it also adds to the already intolerable weight of non-emergent cases currently cluttering hospital emergency departments.
While the recent passage of the Affordable Care Act has turned the nation’s attention toward more judicious usage of healthcare resources, it has given no explicit, federal direction for a renewed role of EMS and/or a reassessment of reimbursement policies. What it has delivered on, however, is a healthcare movement that has deliberately started to depart from the traditional fee-for-service model, and which is more concerned with patient-centered and -directed care, preventative services, and increased public health of the community. 1 The recent healthcare shift away from monetizing autonomous services and towards incentivizing holistic patient wellness, is the precise portal for innovation which supports not only an increased communal role of EMS, but also creates the potential space for modernizing initiatives that may generate alternative forms of income for the industry. 1 Additionally, if paramedical service roles were expanded within existing protocols, this could also cyclically tame the flux of transport-associated 9-1-1 calls: as more proactive, preventive services could potentially diminish the necessity for a number of advanced disease rescues.
Among the local organizations who have devoted missions to improve and more tightly integrate EMS into the healthcare continuum, the New York Mobile Integrated Healthcare Association (NYMIHA) has aggressively sought since it’s inception, to spawn innovative models in the advancement of pre-hospital care. Its goals are simple – “1) to make EMS more adaptive to changes in the healthcare system, 2) to align EMS with the continuum of healthcare providers and resources, and 3) to integrate EMS into the public health infrastructure.” The ultimate ambition of the NYMIHA is a revisualization of the EMS architecture – one where the public (and patrons) recognize and respect the full value of what EMS providers are already well-capable and amply-positioned to accomplish within the communities they serve. Any progress towards this end, however, can only move forward by having an open dialogue between payers, policymakers, and the invested EMS community, about how we can best align our intentions and motivations for a better healthcare system.
In light of the funding challenges, EMS community leaders have begun to brainstorm ways to command a realignment of EMS compensation — to one that is tailored toward patient disposition. In a larger context, EMS movers and shakers have also started to reconsider an expanding role and utility of EMS workers in the community.
The first idea is to reconfigure EMS beyond the traditional emergency response – via the creation of a response algorithm to different types of 9-1-1 calls. 1 When dispatch receives a call, based on a standardized protocol, the response could include an emergent lights and sirens response, a delayed response, a verbal reply (i.e. 24/7 nursing line, Poison Control), or a multi-patient vehicle (i.e. to transport a patient to a dialysis or substance abuse clinic). 1 By having a tiered response model, the goal is to limit the use of emergency resources to calls that fully require this advanced response. In a busy, urban metropolis, it helps to be able to allocate limited resources responsibly: a child who swallowed a tablespoon of toothpaste may necessitate less of an emergent response compared to the type I diabetic in active diabetic ketoacidosis.
The second objective is to more fairly align “patient-centered” care with EMS reimbursement. If we are establishing a more refined system that responds according to patient need (with reasonable healthcare accountability), the reimbursement system must be reworked, as to not penalize EMS for their decisions on healthcare delivery. 1 In other words, if the EMS response to a minor fender-bender turns out to be a relatively benign call (no advanced life support necessary), this does not render their use of time and modicum of resources availed, insignificant – it does not mean that they should not be paid at all. Yet still, this is the current set-up of the repayment system – no transportation, no payment. A growing interest in EMS, given the emergency room crowding that is all too well known, is the alternate transportation of patients based on disposition – some patients could be adequately (even more efficiently) served at other stations of care: PMD office, urgent care, dialysis clinic, or even a family member’s home. This plan would more directly place patients at sites of care that were strictly dependent on their needs, in hopes of having a more dedicated response to their primary health concerns. This makes sense in the formula of accountable care, but it will need to be respected as a meaningful form of transit and compensated as such to work.
The third aim is to expand the role of EMS providers – 1) to enable more billable services under the existing fee-for-service model, and 2) to refresh the public perception of EMS workers in the community. By allowing the role of EMS workers to be expanded by law, EMT’s and paramedics are given greater leverage to perform tasks that not only meet community needs, but also provide a way for them to utilize their expertise as a conduit for reimbursement (i.e. flu vaccinations). Giving EMS more expansive roles also emboldens their work and credibility as more than simple “ambulance drivers” and gives them a more respected and rewarding place in the pre-hospital continuum of care and amongst public perception, while meeting the fiscal necessities of the business.
What we are effectively proposing is a series of ways to circumvent the current problems that have persisted within the EMS community. We encourage a refashioning of the system that starts with the dispatch response – using a triage algorithm that most appropriately attends to the needs of patients – thereby activating an advanced care response only when genuinely necessary. Next, we are asking for an allowance of EMS services to provide and be compensated for transportation services that do not have the hospital as an end destination, but are still supportive of quality patient care at alternate care sites. Finally, we propose a few payment models that may better enable EMS to be amply compensated without making extensive changes to the existing operating system; we also request that the EMS role be widened to allow for more billable services that would also help to compensate for the current losses generated by the reigning reimbursement policies. These changes would collectively improve the efficiency and quality of EMS delivery and patient care and also expand and strengthen the role of EMS workers in communities.
Ramon is a 4th year medical student at Albert Einstein College of Medicine and an MPH candidate at Mount Sinai School of Medicine. His unwavering interest in emergency medicine since childhood, led him to train and serve as an EMT-I at Emory University, and most recently, to become an intern for the New York Mobile Integrated HealthCare Association – a statewide coalition whose aim is to be a leader in the maturing field of community paramedicine and other innovative EMS advancements. He remains confident that CHiPs, House, and Breaking Bad are television series whose brilliance are matchless. He looks forward to watching Usain Bolt run even faster in the Rio 2016 Olympics, as well as the Miami Heat clutch another championship in the foreseeable future.
1 Realigning Reimbursement Policy and Financial Incentives to Support Patient-Centered Out-of-Hospital Care http://www.naemt.org/Libraries/Community%20Paramedicine/February%202013%20JAMA%20-%20Patient-Centered%20Out-of-Hospital%20Care.sflb
2 “9-1-1 Statistics – National Emergency Number Association.” 9-1-1 Statistics – National Emergency Number Association. N.p., Apr. 2014. Web. 05 Apr. 2014.