Administration and Leadership, Patient Care, Training

EMS Industry Given Chance for Redesign

Issue 2 and Volume 37.

“Because we have always done it that way.” Sound familiar? I know I’ve heard it countless times in my career—especially in the fire service, which is steeped in tradition.

|Did you know that the width between two railroad tracks in the U.S. is 4′ 8.5″? According to legend, that’s the exact measurement between the railroad tracks in England, and it was English railroaders who first started building the American railway system. England came up with that measurement because the pre-railroad tramways were that same width, and the people who built the tramways also built wagons with the same tools; wagons also happened to have the same width.

And the wagons had that width because with any other width, the wagon wheels would break because the ruts in the old and long distance roads in England were 4′ 8.5″ wide. The ruts in the old and long-distance roads in England were that size because the Romans built the roads when they occupied England more than 2,000 years ago. And why are the U.S. tracks still that width today? Because we’ve always done it that way.

One thing that we’ve always done in EMS (or for 45-plus years) is transport patients to the emergency department (ED).

Back in 1966, a group of people who established Medicare decided it would only reimburse an ambulance service if they transported someone to a hospital. The states’ Medicaid systems and private insurance companies also thought that was a great idea. So for four and a half decades, we’ve transported patients to an ED regardless of their illness or injury. However, we may be turning the corner and seeing some change to our outdated system.

This past March, President Barack Obama signed into law the Patient Protection and Affordable Care Act. On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 was signed into law. The two laws are collectively referred to as the Affordable Care Act.

In December, the Center for Medicare and Medicaid Innovation announced the Health Care Innovation Challenge. That challenge makes $1 billion available for compelling new models of service delivery/payment that have three goals: better health, better healthcare and lower costs through improved quality.

Potential for Change
The challenge is open to a wide range of healthcare providers, including EMS agencies. EMS agencies that took the opportunity to apply for a grant and submitted innovative programs for consideration in 2011 should hopefully help pave the way for future changes to reimbursement.

The door is wide open for innovation, and this significant window of opportunity to change an outdated system may not happen again for a long time. These grants and their follow-up results could provide us with an opportunity to not only change an outdated tradition of ED-only patient delivery but to also test alternative service delivery and payment models.

Imagine future EMS systems in which EMS agencies are reimbursed for treat-and-release programs and first responders are reimbursed for rendering care on the scene and then setting up a follow-up appointment at a clinic the next day.

We also need programs that focus on EMS and fire involvement in injury and health prevention programs, and care coordination with other healthcare providers. To refresh your memory, go back and read the EMS Agenda for the Future in which many opportunities are discussed. The challenge is that you tackle these non-traditional approaches to reduce call volume and affect patient care.

Currently, EMS is buzzing about community-based paramedicine. The goal for community paramedics is to assess and provide care for the underserved in rural and remote sections of the U.S. through an expansion of the EMS worker’s role where there’s difficulty accessing physicians, clinics and hospitals. Initiatives are currently underway to standardize the curriculum to train traditional emergency responders in primary care, public health, disease management, prevention and wellness, mental health and dental care.

The Innovation Challenge also encourages applicants to include new models of workforce development and deployment that efficiently support their service delivery. In EMS, this could possibly include putting a nurse practitioner and a paramedic in a vehicle to respond to low-acuity 9-1-1 calls, allowing them to treat and release the patient at the home. They could write prescriptions for them, transport them to a pharmacy or to a clinic to get an X-ray or set up an appointment for the patient to go to a clinic or primary care physician.

This is the best chance we’ve had in 45 years to change the way our EMS systems are designed and function. Unless we change our systems, we may be stuck in a rut similar to those created by those Roman chariots some 2,000 years ago in England. JEMS

This article originally appeared in February 2012 JEMS as “Turning the Corner: EMS seeks system redesign.”