What’s the mission?
This is a simple question, but one that’s quite challenging to answer for EMS systems across the world. In the 1970s through the 1990s, the answer was relatively clear: We sent crews to the location of the emergency whenever called. We provided on-scene care, and then transported the patient to the hospital to be seen by a physician.
This was the expectation from the community as well. We developed this buy-in through public service announcements after the development of an easy three-digit calling system.
“If you have an emergency, dial 9–1–1.” This was our slogan. We sold it in the media and at community gatherings. We sold it through popular TV shows such as Emergency! and Rescue 9–1–1. The result has been a staggering increase in the volume of calls for service across the United States.
In 2017, the answer to the question of the mission is much more complicated. Communities across the country are starting to become increasingly concerned about the cost of service, which is contributing to “healthcare bankruptcy.” In my 25 years in EMS, I’ve witnessed the transition of what started out as free transports from nonprofit and donation-supported ambulance systems, to charges in the range of $300–$500 in the 1990s, to bills of $1,000–$2,000 for ALS transports today.
It’s a regular occurrence to receive phone calls from paramedics about “difficult refusals,” where the issue isn’t that the patient doesn’t want to go to the ED, but that they don’t want to take the ambulance because of the cost. I’m not talking about the stubbed toe or the minor laceration. I’m talking about major trauma, chest pain and sepsis—conditions that actually need EMS.
On the other side of the coin, we have a substantial number of patients who call 9–1–1, not because they want an ambulance to transport them to the hospital, but because they want someone to check them out. Sometimes they just want evaluation and advice. Sometimes they want first aid treatment and then release to self-present to the ED, urgent care, or their primary care physician (PCP). These occurrences are a few of the many factors that indicate that there’s a mismatch between what the community expects and the services that we deliver.
We’ve developed systems that can ensure rapid response times to any emergency, just in case it’s a time-dependent crisis.
A Costly Evolution
We started out just sending ambulances. In the 1990s, we realized that if we placed AEDs on fire apparatus we could cut our response times to these time-critical events.
Since then, many communities have decided that if the fire apparatus is good for those call types, we should send them on everything because they can get there quicker than the ambulance. The problem is we have no significant data to support this approach, which drives up the cost of the system and consequently, the cost of care and transport.
If we make the math easy and consider that everyone on the fire apparatus and ambulance makes the same salary of $50,000 per year, and there are 10 calls per shift, the personnel cost per call is $110 just for sending the ambulance. If we add a fire apparatus with four-person staffing, the personnel costs change from $110 to $330 per call.
When we add personnel benefits and apparatus expenses, the cost per call increases dramatically. In many communities, the cost per call can be as high as $600–$1,200.
These costs aren’t unreasonable for those cases where patients are critically ill, but for a significant portion of calls, the cost of service eclipses the benefit to the patient.
What do Patients Want?
Although the historical mission has been “treat and transport,” today’s mission is “triage and navigate.” More and more, the public seems to be calling 9–1–1 for advice. They’re anxious and unsure about what to do. There are fewer households with extended family to ask for advice. They often turn to “Dr. Google.” Other times, they call their primary care physician, and before they talk to anyone, they hear the ubiquitous greeting: “If you have an emergency, hang up and dial 9–1–1.”
We’ve convinced the public to call us for everything, and they’ve placed their trust in us to provide the service they want. The problem is that what they want and what we want to give them are different. We largely give them a one-size-fits-all option and what they want is a menu of options. Sometimes they want to call for advice, or for us to send someone out to check on them and provide reassurance. Sometimes they want us to provide on scene care and then decide if they’ll go to their PCP, to urgent care, or to the ED. Sometimes they’ll want us to take them, other times they won’t.
One of the barriers to a flexible EMS system has been the restriction to payment based only upon transport. We need more states like Pennsylvania to demand payment for EMS services beyond the transport function. Legislative action is an important step to allow EMS to change and adapt to its new mission of triage and navigation. Change without assurance of payment means that the taxpayer bears the burden of non-payment while insurance companies continue to make record profits.