With the implementation of the Patient Protection and Affordable Care Act (PPACA), significant adjustments are coming in the way health care is delivered and paid for. Now is time to address the nation’s EMS approach in light of this changing environment. I’ll share why I think hospital-based EMS makes sense, but I know there will be other opinions. I look forward to reading them!
Current EMS Delivery
There are largely three options for EMS:
- Private systems. Units may work from stations or be roving to address their service area’s emergency and non-emergency needs. Private ambulance companies often provide inter-facility, non-emergency, as well as 911 calls.
- Fire department-based. These EMS transport systems typically use medic units only for 911 calls that respond from firehouses located strategically throughout the community. Of the 38,000 fire departments in this country, the majority now provide some type of EMS first-response services even if they do not actually transport patients.
- Hospital-based. These units may come from the hospital, stations or be roving as determined by call volume and need.
The Changing Field of Healthcare Delivery and Reimbursement
What will force EMS delivery to change the most? Managed care will move from a voluntary effort by organizations to control health care costs to one where these organizations actually become “gatekeepers.” In this new role, organizations will prevent people from making unnecessary 9-1-1 calls and incurring unnecessary costs. The PPACA is legally required. Although nobody truly knows how these changes will affect healthcare, there’s one thing we can be sure of: People will still become acutely ill or injured and our 9-1-1-based EMS systems will still be needed to address such emergencies.
How EMS deals with chronically ill patients who call 9-1-1 will need to change. Typically, these patients have waited too long to address their medical problem. Often they lack health insurance and use the emergency department (ED) as an entry into the healthcare system. For Medicare patients, these needs should be met through accountable care organizations (ACOs), which are just starting to form. With the continued aging of our population, the medicare demographic will grow, making it a larger percentage of EMS work. Expect all EMS systems to be impacted.
The main function of an ACO is to monitor and control reimbursements for healthcare providers. ACOs also monitor the quality of the care being provided. The PPACA allowed for the establishment of a Medicare Shared Savings Program (MSSP), which allows for ACOs to contract with Medicare. Under this type of scenario, the ACO needs to be totally responsible for the quality, cost, care, and management of at least 5,000 Medicare recipients. While EMS is only mentioned in a few places in the PPACA, it is clear the intent of the PPACA also includes pre-hospital delivered services.
An ACO can deny or reduce payment if the provider isn’t meeting quality standards. For example, reimbursement can be denied when a patient is readmitted to a hospital within three days for the same problem. Therefore it is in that hospital’s best interest to make certain the patient doesn’t get readmitted. In the past, hospitals may have viewed EMS merely as a means of delivering patients within their capture area, but under the PPACA, they will undoubtedly be more interested in the impact EMS will have on their patient’s overall course of care and recovery.
How does this impact EMS? To avoid readmitted patients and other quality of care issues, hospitals may choose to become the area’s primary EMS provider in order to control all aspects of the patient’s entry into and through the healthcare system. New EMS-related services provided by hospitals may include home visits within the first three days, or if complications arise, transporting the patient to a level of care other than a hospital ED. Hospitals could contract with existing EMS providers for services, but they may want greater control over operations and services delivered.
Potential Advantages of Hospital-based EMS
My own experience with managing a hospital-based service included the ability to obtain additional in-house cross training and educational opportunities, follow up to patient interventions and outcomes, and inclusion in a system that oversaw patients from the 9-1-1 call through discharge. Inter-facility transfer staffing was simple to arrange if an RN or other care provider was needed. Also, hospital staff gained a better appreciation of the skill set pre-hospital staff processed when were were called to assist with in-house emergencies.
With the changes brought on by the PPACA, a real advantage of hospital-based EMS is incorporation into a one-stop shop. When partnering with an ACO for reimbursement, the enhanced documentation of patient outcomes based upon a systematic approach will yield improved quality and efficiency. By having EMS services associated with a hospital billing operation, EMS can benefit from a dedicated staff with specialized training in meeting PPACA and ACO requirements. This could also benefit the public by recovering more of the EMS operations costs as well as provide better data to support the need for EMS services.
Conclusion
There are strong opinions about where EMS services are headed, and we can argue if PPACA will result in a progression for EMS. However, I think we can agree that change is coming. While I was surprised at how few responses I got on how the aging population could impact EMS, I am confident this topic will generate interesting discussion. Your thoughts?
Not sure who this writer is, so it is difficult to construct a complete response. In my 23 years as a career chief EMS officer, I have managed two hospital-operated (“based” is also a poor term) services – one operating 30 units per day and serving 1600 square miles, another operating 6 units per day serving a city of 240 square miles.
First, the author shows a limited knowledge of EMS systems by listing only about half of the viable options. There are plenty of places where non-private, non-fire, non-hospital EMS exists; in fact some of the premiere systems in the country.
Second – there is a significant difference between EMS and “ambulance service” that is not addressed. EMS is much more than just ambulances, please!
There is no doubt that hospitals COULD run decent EMS organizations, if they chose to do so. Unfortunately, hospitals have demonstrated time and time again that they WON’T invest what is necessary to do so. They run bare-bones, dead-end operations that are as much un-wanted step-children as they are anywhere else.
The number of hospitals operating ambulance services in the US has declined steadily, since the 1980s (when public hospitals began to move away from their government bases to being so-called “non-profits”). The move away accellerated in 2002, when the National Medicare Fee Schedule put hospitals on the same economic basis as all other ambulance services. Since then, they ran for the hills.
As for the training advantages and stuff – purely theoretical, particularly at a larger hospital. No matter the employer, EMS folks still stand in line behind residents interns, medical students, nurses, nursing students, etc.
Last, at least in my experience, hospital billing staff were horrible at billing for ambulance services. Hospital billing operations are geared toward Medicare part A, which is much different from part B, where EMS provides. One outsourcing experience yielded a >40% increase in cash revenue.
Be careful what you ask for, and study before you start advocating for a particular model if you’re not completely familiar with its performance characteristics.
Your article has one major inaccuracy. There are several more major models of EMS that you completely ignored with different revenue streams. These models of EMS not only make up some of the largest EMS agencies in the nation, but also some of the most flexible, diverse, robust, and yes…most successful
The two that are worth discussing the most are “Public Utility” model and the “third Service” Model.
The Public Utility Model is a blend of goverment and private for profit based EMS. Going way beyond a simple contract for service, the administrative model more closely resembles your gas company or electric company. These are highly regulated, highly compliant agencies with multipel revenue streams (tax base as well as goverment subsidies, memberships , and pay for performance) and are very Robust. Perhaps the most important thing about this model is that this model already resembles an ACO in many ways, and will likely have the easiest transition. SUNSTAR EMS is one of the largest, and does well over 100,000 calls a year for service.
The other model worth mentioning is the “Third Service” Model. A stricly govermental operation at the city or county level, it too has multiple revenue streams with typically 30-50% coming from tax base and the remainder from fee for service as well as other lesser sources. Some of the most progressive EMS agencies in the nation are third service, such as Wake County EMS, Austin Travis County EMS, Boston EMS, Ada County Paramedics, and the world renown King County Medic One (KCM1) . While it is easy to compare this model to the fire serivice (wich is also govermental and (much more tax based) , these agencies sole purpose is to provide EMS, and have much more flexibility to provide those services than their Fire Service or multi-role counterparts. The first community paramamedic programs started in third service agencies, and continue to lead the way. The strengths of this model include organiational focus on EMS provision and compliance, adaptablility, as well as the ability to go after multiple revenue streams as well. Perhaps the greatest strenght of thse agencies, even more than hospital ones, is the ability to embrace new trends in health care, where hospital agencies are often hampered by hospital politics and hospital bottom lines.
Regardless of the model, most of the high performing EMS agencies (and there are standouts in all models) are already well suppoerted by the medicial community and hospital agencies on a par not seen in lessor agencies, even hospital based ones (who often get caught up on the wrong end of the the pecking order in hospital organizations and inter-hospital politics). While your article brings up some very good points on changes in health care, it is overly simplistic and somewhat biased.
Respectully submitted….
Wonderful comments gentlemen. The blog was designed to generate discussion by the great minds such as yourselves as I fear we (EMS collectively) may not be the holder of our destiny if we don’t engage in conversation and ensure our voice is heard by those who must implement the PPACA. Judging by some of the gaps and oops that have surfaced, I would not be surprised to see EMS nationwide be an unintended casualty.
I much prefer a proactive approach and hopefully good discussion and dialog here will lead to constructive solutions that will keep high quality services intact, enhance others and leads to enhanced patient care options and advancement of the profession and industry as a whole.
No new ground covered here. As Skip and Croaker point out, the author ignores several other models of EMS delivery.
I’d have to say that the PUM type of service is a dying dead end. Many of them have failed over the past few years and been tuned in to traditional private services (MedStar) or fire based (Kansas MAST) services. The problem with PUM is that it relies on cost shifting much of the responsibility for response times back on to the city (usually the FD) while allowing the ambulance provider to skim the profit. After a point even city officials figure that scam out.
Hospital based services, both transporting and non transporting are, again as Skip points out, a dying breed. Even in NYC, which probably had the highest number and percentage of hospital operated systems, several hospitals have either shut down their services or subbed them out to private companies.
Finally, there is absolutely no reason to believe that EMTs and paramedics can serve as any sort of community based providers. First, because we’re not trained to do that. Second, because in many cases we’d end up running in to the nursing practices laws of various states. Nursing has a much more powerful lobbying function than does EMS, so we’d lose that battle.
For Croaker, some third service systems don’t rely heavily on tax payer subsidies or don’t have them at all. Hennepin County EMS gets $0.0 from the taxpayers. Boston EMS gets a small portion of it’s money from the city, but mostly pays for itself. The better third service systems evolved from hospital operated systems and maintain close ties to the medical community. That’s something that private and fire based services generally don’t do.
There was a time when hospital operated services might have been the way to run EMS, but that time passed when hospitals started to divest themselves of their ambulance services. It’s too late to turn back the clock.
I’m interested that comments seems focused on wanting a discussion about the various types of EMS service delivery as opposed to impact to EMS brought on by PPACA. I have to wonder if that means people are assuming it will have no impact on their favorite or current employer model and doing nothing is an option.
The question is will PPACA cause posturing by individual providers to cut the best deal, or will providers of all types stand together for a solution meeting the collective good of patient care nationwide.
I’m not sure exactly how providers could stand together on any sort of national basis.
The PPACA proposes setting up Accountable Care Organizations (ACOs), which are local organizations. If there are deals to be cut, they will be cut between the ACOs and ambulance organizations – so there is no central control or influence.
Does that allow early negotiated agreements to be used as “precedence” for later ones, regardless if they are like variables in cost of service delivery for example?
I suppose it could. The problem now is that nobody knows what these things are like and how they are going to evolve.
The national “community paramedicine” movement is probably a good example of collaboration in anticipation of future developments.