Why is this big news for ambulance service? For the majority of the U.S., ambulance service funding comes from two main sources: tax dollars and fee-for-service (pay-per-transport) payments from Medicare, Medicaid and private insurance. The U.S. Government Accounting Office (GAO) estimated from a survey of providers that 40% of ambulance service funding comes from Medicare, and between 2004 and 2010 there was a 33% growth of ground ambulance transport for Medicare beneficiaries.2,3 The announcement from HHS, while absent of specific mention of ambulances, is a good indication the EMS profession needs to sound the alarm and prepare for a switch to a value-based payment model.
What is value? According to the Healthcare Financial Management Association (HFMA), value is defined by quality divided by cost.4 As the Affordable Care Act has transformed CMS to pay for value, we have seen a dramatic shift in healthcare to looking at care quality, reliability and the cost itself, as well as the variation across providers. The focus is also shifting from paying for service (e.g., ambulance transport) to paying for outcomes (e.g., evidence-based stroke care).
How might we think about this shift applying to ambulance service? For our discussion here we’ll focus on reliability, outcomes and cost.
Safe and effective care requires clinicians to perform evidence-based care to every patient. A recent paper on a systematic review of the literature looked at the prehospital and emergency department adherence to guidelines and protocols, and found that adherence in the prehospital environment ranged from 7.8% to 95%. Greater adherence was found in the monitoring of patients, but lesser adherence in the actual treatment.5 This is similar to the discovery leaders at the National Health Service Ambulance Service Trusts in England discovered when they developed and began implementing evidence-based care guidelines, as did leaders attempting to improve stroke care in Massachusetts.6,7 EMS systems need to actively work to improve the reliability of assessment and care in key care pathways.
Positive clinical outcomes are directly tied to the reliability of assessment and treatment provided. Several peer-reviewed studies have looked at variation in EMS outcomes. One study that profoundly showed the disparity of outcomes found variation in sudden cardiac arrest survival from 3–16.3% across the cities studied.8 This is striking considering there are national guidelines and these cities all have the required equipment, personnel and medications. Currently, out-of-hospital cardiac arrest is the only care pathway with outcomes tracked using standard measures and reported nationwide. Recommendations have been made in the U.S. and abroad to expand the focus to include stroke, STEMI, asthma, trauma and other time sensitive conditions, but we are behind to follow through en masse.9,10
It’s time for all EMS professionals to curtail the posturing around the discussion of cost as a public-versus-private issue and accept it is now as an issue for the entire profession. EMS suffers from significant variations in cost. In the 2012 GAO report mentioned earlier, the median cost per transport was $429; excluding the lowest and highest 5%, the 90% of services remaining ranged from $253 to $924 per transport.11 In-hospital care has received rapidly increasing scrutiny for its inability to be transparent in cost and the dramatic variation in outcomes. For 20 years, the Dartmouth Atlas of Healthcare has been using Medicare data to explore the effectiveness and variation across the country in the Medicare population.12 In a recent article, I compared two cities in Texas of similar size and with similar clinical outcomes, but with very different costs per capita: $41.8 versus $52.68; that’s a difference of $23 million dollars a year.13 It’s reasonable to assume that the cost of ambulance service will become more transparent and EMS systems will be compared. It’s also safe to assume with a changing Medicare payment model and the tight belts of many communities, taxpayers and local government officials are going to awaken to the cost in comparison and be looking for value.
This switch from pay-for-service to value-based payment may be the best thing that ever happened to EMS in the U.S. as it turns attention to clinical quality and operational effectiveness and efficiency. The timelines are ambitious and will likely be very disruptive to our current state. The EMS profession is very behind on measurement and improvement methods and needs to act now to catch up. Sadly, we know some of our colleagues may not survive the transformation. Having been on the healthcare improvement side throughout the life of the Affordable Care Act passing and implementation, I believe it will be good for patients and communities for the long term, but I also know EMS is ill prepared to meet the challenge today and we need to have a sense of urgency to catch up. Roll up your sleeves; this is going to be hard before it gets better.