Forces Beyond Your Control Are Destined to Impact Your Agency - Administration and Leadership - @

Forces Beyond Your Control Are Destined to Impact Your Agency


A.J. Heightman, MPA, EMT-P | From the January 2013 Issue | Monday, January 28, 2013

January is the time of year when people make resolutions, try to forget the problems (personal and financial) they encountered throughout the previous year and dive into the New Year with hope of success, or at least improvements. Unfortunately, January is also the start of a new budget year, and the “resolutions” made by agencies at the start of the year are often made too late to make an effect on the changes or improvements that are needed to have an effect during that year.

Think about it; couples plan their wedding for 12–18 months before the wedding date, and manufacturers plan and design new products secretly for years before they are manufactured and launched. But many response systems wait until a point when it’s too late to redesign their administrative and operational systems to meet budget goals or participate in new approaches to service delivery.

Moving from a non-transport first response system into a system of full-service fire first response and transport is an example of a project that a fire agency needs to plan well in advance of introduction of a proposal to a mayor and city council for it to be successful. Then, even if approved, it can take an agency a year to get the appropriate ambulances built. So design and bid specs also have to be preplanned and approved months before an order is made. Yet some agencies actually think they can make a major change, such as movefrom non-transport to full transport, in a few months.

In the next 12–18 months, you will see lots of action by agencies that have been thinking ahead by planning for changes in EMS reimbursement. These changes include the new world of healthcare reform with pay-for-performance; new delivery models and methodologies, such as the redirection or transport of patients to non-traditional (non-hospital) destinations; and use of community practice paramedics to reduce call load and keep patients from returning prematurely to hospitals in their service area.

Those agencies that are preplanning will reap the benefits and those that are not will begin to realize they’re spinning their fiscal wheels in the mud.

So let’s circle back to January. This first month of the year is when most agencies begin to implement their new budgets, business plans and projects in hopes of greater success, financial prosperity and territory fortification. Territory fortification is the ability to maintain contracts and service area in the face of political or economic changes and challenges.

Although private, non-profit and hospital-based agencies are familiar with the development of business plans, service contracts and territory fortification, many fire and third service EMS agencies are not.

What’s the reason some are more familiar and others are not? There’s been little need for municipal services to do so because they’ve offered what are termed “traditional services.” Traditional services include crews waiting in fixed stations for calls to come in, responding and going back to quarters to wait for the next run.

Agencies and workforces that fit in this category have also traditionally participated in standard budget development, had limited need for contracts or new business outside their normal operational parameters and had a reasonably certain hold on their service area (territory).

However, the economic downturn, municipal shortfalls in tax revenue and reduced or eliminated federal grants and financially supported programs during the past five years are changing all that. Municipalities are cutting back staff and services in hopes of stopping fiscal bleeding: cutting out EMS supervisors, training and quality assurance staff, holding off on implementing new projects and forcing their departments to “do without” rather than innovate and implement replacement programs and services.

The resultant cutbacks will have a snowball effect on the quality and quantity of service and, ultimately, affect the revenue a service has come to expect from third-party payers. In the future, if your system becomes less efficient and the quality of the patient care and follow-up diminishes, so too will the reimbursement your system receives for the “services” delivered.

Many agencies, particularly those operating in a traditional municipal environment, also aren’t paying close attention to the affect of the Patient Protection and Affordable Care Act (PPACA). They are ignoring the inevitable—that the waves of what some politely refer to as “Obama Care,” and the now famous “fiscal cliff,” could potentially overtake and suffocate them operationally and fiscally.

Although I’m not an economist and don’t claim to be an expert on the PPACA, my position and access to EMS systems and industry experts compel me to give you a few things to think about. The Patient Protection and Affordable Care Act will affect the way you operate in the future. And if you’re not thinking, planning and preparing for the future, you will be affected, perhaps negatively, in the future.

It’s important to note that there’s a difference between strategic planning and innovating. Innovation can occur throughout your normal operational and budget year. But strategic planning needs to be performed in advance of target projects and usually phased in over time.

Strategic planning also involves careful review by key stakeholders and managers and, to be truly successful, cannot be just the ideas of the director. Top-down planning, often referred to as “management in a bubble,” is dangerous because it often reflects just the ideas of one or two managers or chiefs. In many cases, these managers have been “off the streets” for years—often just driving a desk. These types of managers can be out of touch with the real, evolving world of EMS and not in synch with what’s projected for the future.

A few examples of how many systems have fallen behind the pack over the past five years include electronic patient care report and computer-aided design integration; robust data collection and system reports; patient compartment re-design; continuous positive airway pressure use by EMTs; and the adoption of therapeutic hypothermia. It’s funny, but the root cause of an EMS systems decline is often one top-level manager or medical director who isn’t keeping up with the times or is resistant to implement changes or enhancements.

If your agency doesn’t have a strategic plan for the future, you need to start the development of one now for implementation in late 2013 and beyond. And if you don’t believe in strategic planning or preparing for future changes in the delivery of health care services in America, I can assure you that other EMS agencies or organizations are doing so and will benefit from your inactivity.

I am not calling those agencies “competitors” because, to have a competitor, you have to be prepared to compete. The athlete who fails to prepare for and train in any sport usually ends up in second place or worse. In EMS, it’s important for you to realize that anything below first place makes you the de-facto loser.

Let me get more specific. The 1,000-plus pages of the Patient Protection and Affordable Care Act do not specifically reference or name EMS, emergency responders, fire first responders, rescue services, mass casualty response, disaster preparedness or hospital surge. That, in itself is a bad sign because the authors of the legislation appear to have forgotten us or at least not viewed emergency and out-of-hospital response resources as a high priority in the healthcare chain.

However, rest assured, we are (or can be) a big part of the future healthcare delivery system if you read between the lines, plan for integration and adjust your operations and workforce to ride the healthcare wave instead of being pushed aside or drowned by it.

Incentives, and disincentives, that will result from the new healthcare regulations will hit hospitals where they feel it the most—in their budget. If a patient returns to their hospital within 30 days after discharge, the hospital will be penalized financially. So they now have a financial incentive to work with you or another agency to deploy community practice paramedics to check on Aunt Mabel in her home or have an automated system that alerts one whenever there are abnormalities in vital signs of the programmed device “predicts” that an untoward effect is on the horizon.

The same type of penalties will be incurred by hospitals if they don’t have a 360-degree data exchange and review system in place with all of their “affiliated partners.” Although satellite facilities, affiliate doctor groups and other heal centers are named in Patient Protection and Affordable Care Act and EMS is not, people in the know tell me that EMS will be considered an affiliated member of each hospitals care network.

So I and others think secure linkage to a hospital’s patient record system is probably in your future. And if you can’t afford to do it, I’m betting that hospitals will eventually become convinced that it’s cheaper to pay to have you linked than to receive reduced reimbursements for not having you linked to their system.

Best wishes for a safe, happy and well-planned New Year! 

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Related Topics: Administration and Leadership, Leadership and Professionalism, planning for new ems reimbursement models, Obamacare, new healthcare, ems resolutions, Jems From the Editor

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A.J. Heightman, MPA, EMT-P

JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.


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