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The Devil Is in the Details


The era of debating health reform solely in philosophical and policy circles is over. As health reform nears reality, so does the impact on the EMS community. This summer, we witnessed the health-reform debate move from Washington to town hall meetings in communities nationwide where emotionally charged constituents voiced their concerns. Washington officials are now back to work: The administration, legislators and their staffs are hashing out the nitty-gritty details of various reform packages.„

Each proposed reform package strikes a different balance in attempting to solve the infamous health-care "trifecta" -- access, cost and quality. With the potential "perfect storm" of the economic crisis, an aging baby boomer generation poised to flood the Medicare entitlement program, and a politically aligned Congress and president, some kind of health reform seems possible at this time. Keeping a pulse on the daily markups and amendments to reform packages confirms that although it's impossible to predict what a final health reform package may include, the EMS community may be impacted. Let's discuss the three significant ways.„

Increased Coverage

First, health insurance coverage for the millions of Americans who currently lack coverage stands as a primary goal for the majority of health-reform packages. Ensuring that more Americans have health insurance isn't likely to occur overnight, but even reducing the number of uninsured by half could have a dramatic effect on EMS. Increasing the proportion of compensated care for EMS has the potential to improve the financial viability of EMS organizations that bill for their services -- so long as reimbursement rates and the mix of payors for EMS services are not adversely impacted by health reform or other policy changes.„

Expanding coverage may also encourage Americans to access more affordable and preventive primary care services, thereby reducing the use of our emergency system. The EMS industry could see a drop in calls, or a reduction in the rate of call growth, as the use of emergency services decreases. This reduction in utilization could also alleviate emergency department overcrowding and associated ambulance diversion issues. Nonetheless, any call-rate decrease may prove difficult to measure because the potential expansion in the insured population will likely occur simultaneously with the expansion of the elderly population.„

Taxes, Income & Expenses

Second, paying for health reform is a hotly contested issue, especially the concept of creating a public plan in addition to or as an add-on to the Medicare and Medicaid programs. Proposed tax increases, increases in direct taxes on certain individuals, taxes levied upon insurers and manufacturers, and taxes levied on high-cost insurance policies have been fiercely debated. Cuts in Medicare spending and increases in insurance premium costs are also often cited as concerns in the health-reform debate.„

With limited exceptions, most of the proposals contain both employer and individual coverage mandates that include penalties for those who aren't covered. How individuals, small businesses, large businesses, and governments will collectively pay for health reform is still unclear. Ultimately, the phrase "nothing is free" comes to mind, and all of us are likely to bear the costs. EMS organizations may feel the impact through:

  • Increases in health insurance premiums;„
  • Penalties for those organizations that provide limited or no benefits;„„
  • Increases in the costs of pharmaceuticals and medical devices;„„
  • Decreases in Medicare reimbursement;„„
  • Changes in the mix of payors for EMS services; and„„
  • Increases in income taxes.„„

Individual EMS providers may also face:

  • Increases in health insurance premiums;„
  • Penalties for not maintaining health insurance; and
  • Increases in income taxes.„„„„„

However, EMS providers may have access to additional, and potentially more affordable, health insurance options.„

Focus on Quality

Third, each health-reform package details initiatives for improvements in the quality of both individual health and the health-care system, which have the potential to impact the EMS community. At the outset, each of the health-reform packages focuses on prevention and wellness (e.g., reducing cost sharing for certain preventive treatments; encouraging employers to provide wellness programs; developing national public health programs and targeting obesity, sedentary lifestyles and smoking). Such programs may incentivize both EMS providers and their patients to stay healthier. These initiatives have the potential to reduce health-care costs overall, as well as for EMS organizations and providers through lowered insurance premiums.

Additionally, most of the proposals also include greater focus on comparative effectiveness research and patient-centered outcomes research. Although not new concepts in health care, greater incentives to evaluate the impact of different options that are available for treating (or not treating) a given medical condition have the potential to change the way in which EMS providers render care. Further, many proposals incentivize the integrated delivery of health care through bundled payment systems and "accountable care organizations", and are increasingly tying hospital and physician reimbursement incentives to quality measures. These trends may be bellwethers for other reimbursement initiatives, including reimbursement initiatives for the EMS community. At least one proposal includes the concept of providing grants for improving health-system efficiency through the design and implementation of regional emergency care and trauma systems. Most recently, there have been proposals to revisit state civil litigation systems, which have the potential to reduce malpractice litigation exposure and associated costs, such as medical malpractice insurance. Like other aspects of health reform, it's still unclear what quality initiatives will ultimately be adopted, but if change is coming, it's expected that there will be an impact on "quality."„


If a health-reform package is approved in Washington, it's likely to include a number of changes that may impact the demands on EMS and the way in which the EMS community focuses on the quality of our health and health care.

As the health-reform debate continues, the phrase "the devil is in the details" seems appropriate. If changes are made, we may find ourselves serving as a different kind of first responder -- as a litmus to gauge whether or not health reform really improves our communities.„

Jason B. Caronis an attorney in the Washington, D.C. office of Epstein Becker & Green, P.C., where he focuses on issues impacting the health care industry. He also worked as a critical care paramedic for an affiliate of a large health system and as a law clerk for the U.S. Department of Health & Human Services, Office of General Counsel. He can be reached atJCaron@ebglaw.com.

Kelly A. Carrollis a third-year law student at Saint Louis University, where she is also a candidate for a PhD in health care ethics.

Epstein Becker & Green, P.C. represents a number of„medical transportation„stakeholders. The views expressed in this article are those of the authors and do not necessarily represent the views of Epstein Becker & Green,„P.C. or any of the firm_s clients. This article has been provided for informational purposes only and is not intended and should not be construed to constitute legal advice.


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