More than 400 EMS leaders gathered in Miami Beach, Fla., for this year’s Pinnacle Conference. The conference featured so many powerful speakers and topics that many attendees forgot they were at beautiful, sunny Miami Beach, giving up their beach chairs for conference room chairs. EMS managers from throughout the U.S. and multiple other countries got solid advice from EMS industry leaders on how to not just survive this rough economy, but to thrive during it. The following three sessions served as a warning to EMS managers that they had better not sit dormant in their offices. It’s going to take innovative thinking to keep operations running efficiently and effectively in the face of a fragile financial and community climate and a new wave of investor-backed privatization hitting the EMS industry.
‘Wake-up & Learn from Our International Colleagues’
A powerful lecture by highly regarded EMS management expert and JEMS Editorial Board member Jerry Overton, MPA, had managers taking notes at a feverish pace. Overton told the Pinnacle attendees that they need to stop spinning their proverbial wheels and studying concepts to death.
He said they should follow the lead of their international colleagues in moving EMS forward by solving dilemmas in areas of service delivery, response time management, hospital surge capabilities, emergency department (ED) overcrowding and excessive use of ambulances by non-emergent patients.
Although past emphasis has been on the life-threatening emergencies, called the first-hour quintet (cardiac arrest, severe trauma, chest pain, stroke and respiratory distress) by the European Resuscitation Council, there has been a clear shift in the patients to which EMS responds. In fact, the first-hour quintet patients represent only 15–20% of all out-of-hospital patients.
And although that percentage remains constant, overall demand for services continues to grow at a rate of 6–12% as the requests shift to patients needing out-of-hospital care and with EMS assuming the gate-keeping role. Overton said that we’re no longer “emergency providers,” rather we’re healthcare providers. That shift has been recognized internationally but not in the U.S. As a result, we’re living in the past.
Rather than continuing to design out-of-hospital care systems for 1–2% of our patients, such as cardiac arrest, Overton advised that we follow the lead of our international colleagues into a future of better call-center function, care delivery and integration, and response models and deployment configuration that better meet the demands of 80% of our patients.
He stressed that if we don’t, our current system problems and volume demand issues are going to get much worse. These challenges include the aging of our patients, as well as their trend toward being obese and uninsured. The problems also include increasing unscheduled care and social needs, the lack of primary care centers, access and preventive healthcare and hospital overload and turn-around delays.
Overton drove home some key points to the audience:
- Demand will continue to rise in a resource-limited environment;
- Response to the “first-hour quintet” must be the priority;
- Delivery of care, as near as possible to home, should be a key objective to demand managed ED admissions;
- Organization of care systems to prevent overload as a default option is essential;
- Management of social care support must be recognized and addressed; and
- EMS should be an integral part of the healthcare system.
“Integration with other providers in the local healthcare system is critical. For emergency care services to be effective in the future, they should be part of clearly identified local healthcare systems,” Overton said.
Call Center Function
We are more than 9-1-1.
“Hear and treat,” is the hub of the out-of-hospital healthcare continuum, integrating with out-of-hours clinics, primary care clinics, poison control centers, behavioral health clinics, dentists and home care providers.
European EMS systems understand this and are doing it, while the U.S. EMS industry is still mired in the faulty logic of reimbursement for transport. This is true even though new reimbursement schedules provide for a rapidly growing gap between the return on reimbursement and the cost of a transport. Essentially, we lose money on almost every transport. U.S. administrators need to understand healthcare economics.
A “see and treat” model is necessary and can be accomplished through advanced-care paramedics.
The U.S. is no longer training paramedics to care for the majority of the patients nor the acuity levels they truly encounter. Overton noted that in some cases, the physician models in France and Germany may be better because they can diagnose, treat and release without transport.
We need, and they have, assessment and diagnosis capabilities, a specialized skill set, use of technology, accessibility to diverse clinical and social care endpoints, and health promotion for self care. We also need to consider adopting their advanced course content, commonality of training with other healthcare professionals, regulation with other healthcare professionals and quality and risk assessments. But we’re doing nothing to change.
EMS Lacks Identity
The mobile medical agencies in other countries are highly respected. Not so in the U.S., says Overton. It’s not due to a lack of vision, but rather a lack of true, sincere federal initiative and commitment to make EMS a priority focus in the new healthcare system.
Both the EMS Agenda for the Future and the Institute of Medicine Report on the Future of Emergency Care in the U.S. Health System strongly recommended this. But today, the fight continues to establish a federal lead agency, and the thousands of pages of federal healthcare plan legislation and debate didn’t even mention ambulance response or EMS systems. The U.S. EMS industry lacks identity while EMS in other countries has a strong identity within healthcare.
Overton chided the audience with deliberate sarcasm. “We’re proud to say in the U.S.: When you have seen one EMS system, you have seen one EMS system. This lack of similarity is the root of our problems; yet, we’re “proud.” Our lack of congruity really means we’re lacking equal access, standardized care protocols, reciprocity of trained providers, a national lead agency, national advocacy and national funding.”
He added that “Although we live with this [lack] in our past, the international trends include an emphasis on healthcare, fewer provider agencies, an elevated status of care providers and single-source funding models.”
He told attendees that the National Health Service in England says, “The greatest challenge over the next four years will be to improve efficiency in their resource bases although managing demand in a different way.
“In the U.S., we’re still managing the same way, to achieve unrealistic response times for an artificial mandate that has no scientific basis. Others are recognizing that a response time is an output, not an outcome. We need to reorient ourselves to achieve outcomes that include providing different clinical endpoints for the patient, delivering care closer to the patient’s home and higher patient satisfaction. We’re doing none of those, and as a result, we’re clearly not outcome focused.”
Overton says that changing to fewer models will create consistent levels of care, governmental involvement, adequate funding, increased quality assurance and innovative research. But for now, the fight continues in the U.S. over which agency should do EMS. “How can we ever progress if there’s no vision?”
Overton said he had been invited to participate in a forum in Bangkok to explain what the U.S. could offer the EMS systems in Asia as they continue to evolve. Interestingly, both his and the French representative’s response was the same; based on the current state of fragmentation, in fighting, and lack of understanding that we must move to out-of-hospital care, his answer was “Nothing.” Overton says that EMS managers should be disheartened by this response because it illustrates how complacent and dormant most EMS system have become in the U.S.
“We think the solution is to put a paramedic on every engine, run two paramedics on every ambulance, watch crews wait in EDs for 12 hours for their stretcher while overtime crews handle the backlog of calls. It’s inefficient. No, it’s absurd!”
He concluded his remarks by quoting from an article in the peer-review journal Prehospital and Disaster Medicine about the current state of out-of-hospital care in Mumbai, India, “Considering the high funding costs of EMS systems in developed countries and the insufficient evidence that prehospital field interventions by the EMS have actually improved outcomes, Mumbai must proceed with caution when implementing advanced EMS systems … Perhaps reinforcing the existing network of taxi drivers and police … could be more cost effective.”1
Overton asked, “Is this where we want to be in the U.S.? We’re focusing in the wrong areas, wasting resources, losing our reputation for innovations in prehospital healthcare delivery and continuing to allow our systems to think inside the box. Innovate and redesign your system before someone does it for you.
New Wave of EMS Consolidation
TransCare Corporation Chief Executive Officer (CEO) David White told Pinnacle attendees that unless public and private agencies learn to play together, there will be a battle that will make the ambulance wars of the 1980s “pale in comparison.” He was direct when he said fire, EMS, hospital and third-service managers in the audience need to “figure it out or there will be external forces to figure it out for us.”
White gave the attendees an ambulance industry history and consolidation lesson and then reviewed the most recent consolidations and purchases: Rural/Metro was purchased by Warburg Pincus, LLC; American Medical Response (AMR) Inc. was purchased by Clayton Dubilier & Rice; and Care Ambulance Service and LifeStar were purchased by Falck.
White said that although it may seem like a repeat of consolidation of the industry, there are some interesting distinctions from the past. He said that in the ’80s there was too much money chasing one industry. Overall, patient care didn’t improve, nor did the industry as a whole. However, there were a few advancements. For example, he said, equipment upgrades were made, safety measures improved and employee relations advanced. “There were career opportunities that would not have existed had the consolidations not taken place,” he said.
On the flip side, he pointed out how unrealistic expectations that everyone would “get rich quick” led to short-sighted decisions. A widening wage gap developed between field providers and upper-level managers. And many big corporations, thinking they knew best how to run EMS, forgot about the patient. Even worse, disputes between agencies, including ugly turf wars, played out in public, undermining the trust of the citizens for the agencies served.
White knows something about rebuilding public trust. From 2002 to 2007, TransCare hired and fired five CEOs and became embroiled in legal difficulties with the federal government. When White stepped in as CEO in 2008, his first task was to get the company back to the basics. His leadership vision started with making TransCare a place where people wanted to work. Today, TransCare has significantly lowered employee turnover rates, and upgraded facilities and equipment. It’s also profitable—with a 15% growth rate over the past few years.
White said the noteworthy differences he sees in the new wave of EMS consolidation compared to the ’80s and ’90s include the fact that everyone is expected to do more with less because costs are skyrocketing while Medicare and Medicaid reimbursements are falling. And, he pointed out, for the first time in decades, public agencies that seemed untouchable are being scrutinized for their budgetary, staffing, response and operational processes.
At the same time, he pointed out there’s more money than ever in the industry as private equity firms recognize the potential for considerable financial gains, particularly in light of what they see coming with the changes in the nation’s healthcare coverage and the rapid aging of the American population.
White said he also believes that healthcare reform and aging baby boomers will drive money into the ambulance industry. He said that although this isn’t the “big land grabs of 1992,” he expects to see more companies being purchased. He also gave public and private service managers a stern warning: “Don’t underestimate these guys. If we try to fight it, it will be ugly. If we embrace it, we could learn important lessons.”
He noted that big cities are the target, especially those under financial stress, “which is most of them. [Private equity firms] think there are gains in market share at the expense of the public [agencies],” he said.
White said he expects the consolidation to continue into 2012 with fewer but bigger deals. “[These] buyers are more sophisticated,” he said. “They’re looking for smart people who can run a good company that has a great relationship with receiving hospitals.”
He also said due diligence will be more rigorous than ever before. “They are going to be looking under every rock, guys. So be prepared for that,” he said.
White told Pinnacle attendees that because more than two-thirds of ambulance transports are non-emergent, “we have got to be the low-cost supplier to survive. They [insurance agencies and Medicare] are trying to find reasons to pay us less, not more.” He stressed that innovation must be the new watchword “Currently, we are not viewed as solution providers.”
“Call and haul doesn’t work anymore.” he said, adding this is especially true as reimbursement rates continue to decline. Companies must be able to define the value they provide. “You have a role in healthcare delivery, but you are going to have to really prove it.”
One way in which White sees EMS agencies improving their value is to help solve an increasingly thorny issue for hospitals—patient recidivism. He also advised agencies to look at improving efficiencies. “There are a lot of patients who use an ambulance who don’t need it,” he said, pointing out that agencies must also become more efficient about the number of resources they send on every call—many of which are unnecessary.
White concluded his remarks by telling the EMS managers in attendance that the entire industry has to play at a different level than before. “Things are going to have to change. We can be a part of that change,” he said. That means getting a seat at the table when decisions are being made about healthcare.
“There’s one thing I know about capital: It’s got a very cold heart,” White says. “They [capital investors and private equity firms] will make it work one way or another.”
Fireproofing Your EMS System
Taney County (Mo.) EMS Executive Director Darryl Coontz, and Janet Smith, president of EMS consulting group Janet Smith & Associates, presented to a standing-room-only crowd at a Pinnacle Power Session. They introduced themselves as “primary EMS providers, “representing agencies that are using one of the following models: private for-profit or not-for-profit; third-service municipal or third-service county; hospital-based; health-department-based; public utility; or a tribal EMS model.
They noted that all primary EMS providers are interested in engaging in the public vs. private conversation of how to protect the ambulance transport component of an EMS system from being commandeered by or merged into the local fire service.
So although this session was billed as protection from fire service takeovers, it also addressed avoiding a take-over by any other entity or agency.
Coontz and Smith first cautioned attendees about thinking they could garner the goodwill and political clout they would need during a takeover attempt the way they did in the past. They explained that increasing budgetary pressures are making politicians and the citizens they serve less tolerant of waste, inefficiencies or demands without proven results.
Coontz offered a day-by-day account of the recent fire department takeover of the Metropolitan Ambulance Services Trust (MAST) organization in Kansas City, Mo. He also offered a reality check regarding the power of institutionalized fire services and fire department associations and unions.
In the first of two examples on the power of unions in Kansas City, Coontz described how International Association of Fire Fighters (IAFF) Local 42 contributed $30,000 to eight city council members who subsequently voted for the takeover.2 He also detailed how, during the debate on whether to merge MAST into the fire department, IAFF Local 42 sent an internal memo to members advising them not to oppose the consolidation.3
Smith provided the attendees with a host of turn-key recommendations for getting involved and integrated into a community so the populace realizes the value of non-fire-based EMS beyond response and transport. She presented illness and injury prevention strategies, business partnership tactics and hospital relationship building tips. This left the attendees who hadn’t yet begun to develop their service survival strategies buzzing about “what to do next” when they returned.
Perhaps the biggest tip of the day presented by Smith and Coontz was for primary EMS providers to start early, before even the whisper of a takeover rumor and well before any city budget discussion, planning and implementing market protection strategies.
Another great tip came from a fire chief who was among the session’s attendees. He said, “If your fire chief sits through city council or county commission meetings, so too should someone from the 9-1-1 transport provider.” Smith and Coontz agreed that this is a great way to become known by government officials as the leader of the service playing the predominant role of emergency and non-emergency patient transports. They say that when policy makers see the primary EMS provider as being “in the room,” there are more opportunities for the primary EMS provider to become involved in every public safety decision and to become acknowledged as a community insider.
Smith and Coontz advised attendees to seriously consider investing the time to attend these meetings, as well as to introduce themselves before or after every meeting and to sit where they could sit eye-to-eye with elected officials and their respective staff. JEMS
1. Roy N, Murlidhar V, Cowdhury R, et al. Where there are no emergency medical services: Prehospital care for the injured in Mumbai, India. Prehosp Disaster Med. 2010;25(2):145–151.
2. The Center for Responsible Politics. Kansas Citians For Circo, Curls At Large Cmte, Friends of Beth Gottstein, Friends of Terry Riley City Council, Jan Marcason for City Council, Sharp for Council, Cathy Jolly-State Representative and Citizens for Russ Johnson. In International Association of Fire Fighters Local 42 Expenditures. In OpenSecrets.org. Retrieved from www.opensecrets.org/pacs/expend.php?cycle=2008&cmte=C00365296.
3. KMBC Staff. Some ambulance workers resist consolidation. (March 9, 2009). In KMBC.com. Retrieved from www.kmbc.com/news/18891607/detail.html#ixzz1WZPGq8LP.
This article originally appeared in October 2011 JEMS as “Pinnacle Management Tips: Key messages given to EMS leaders at the 2011 Pinnacle Conference in Miami Beach.”
2012 Pinnacle EMS Leadership Forum
Cheyenne Mountain Conference Center
Colorado Springs, CO
July 16–20, 2012