Administration and Leadership, Columns, Mobile Integrated Healthcare

Managing the Cost of Care and the Future of EMS

Issue 11 and Volume 42.

Stop responding to penny problems with $100 solutions

The call comes in … it’s 9 p.m. “What’s your emergency?”

“Well, I took my blood pressure; it’s 160/100 and I ran out of my medicine.” The caller then shares that she’s been out of her medication for three days-and that she has no symptoms, but wants to go to the ED tonight so she can get another prescription.

The solution for most EMS systems across the United States is to send an ambulance, and maybe a fire apparatus, followed by transport to the hospital.

The problem with this scenario: We have a $100 solution for what is, essentially, a penny problem. The cost of the ambulance trip alone may have paid for a supply of her hypertension medication … for life!

Transporting or Navigating?

As we discussed in the September column, our job in EMS is no longer simply transporting patients to the ED. Rather, our job now involves navigating patients to the appropriate resource.

Over the past decade, EMS systems across the U.S. have created mobile integrated healthcare and community paramedicine (MIH-CP) programs, among others, to address these navigation-related challenges, which usually involve sending a paramedic for evaluation.

Although in-person paramedic evaluation may be necessary for some patients, there may be other circumstances, like medication refills, that can be handled without ever sending anyone. “Hear and treat,” rather than “see and treat,” is an option that doesn’t involve turning a wheel, and is a much less expensive solution for these low-acuity calls.

The “hear and treat” solution is one that’s been booming across the U.S. over the last several years.

Virtual EMS

As telemedicine legislation in many states has loosened, we’ve seen the development of physician-based telemedicine programs that charge a fee for telephone or video consultation. Physicians can then call in a prescription, complete a medical note based on a virtual physical exam with the assistance of the patient and provide recommendations for follow-up with a primary care physician.

These programs have not only been championed by the for-profit companies, but also by insurance companies searching for a lower- cost solution to more expensive urgent care and ED visits.

There are several essential questions to consider when thinking about the applicability of these programs in the EMS setting.

The first is regarding quality. Is telemedicine as safe and effective as in-person physician or paramedic evaluation? The answer is … not sure! The better question to ask is, “Is it good enough?”

There’s a reality we must come to realize in America: We can’t have healthcare for all and maintain our current spending habits on healthcare; it’s simply not sustainable. This includes EMS. We must look for opportunities to decrease expenses for the large number of low-acuity calls while still maintaining our ability to respond quickly to life-threatening emergencies.

The second question is how would paramedics fit into this telehealth era of EMS? Although we’ve experienced some notable advances in EMS telecommunications over the last 40 years, the most significant changes will occur over the next 5-10 years.

We’ll see some paramedics of the future sitting behind a console interacting with patients, perhaps collecting data from in-home wearable medical monitors.

We may see paramedic practitioners examining patients through their tablets and writing prescriptions that can be emailed to the pharmacy. “Virtual EMS” will be the reality for at least a portion of the population who calls 9-1-1 for help.

An EMS Transformation

This innovation in healthcare could be transformational for EMS-and one that could ensure its future as we look for solutions to address population health.

There will always be a need for rapid response of highly-skilled paramedics to a wide variety of emergencies in our communities, but we must also meet the other healthcare needs of our community. In some circumstances, connecting directly to a practitioner, rather than sending a unit, may be the best solution.

EMS is uniquely positioned to be advocates for population-based health initiatives, health promotion and health management. Just like other medical practices, we need to develop multiple levels of capabilities, so that we can better meet the needs of our community.

EMS telehealth gives us the ability to not only interact with our population at the time of the emergency call, but also to engage them in activities and behaviors that promote good health.

Well-insured patients have access to many options to address their healthcare needs. The uninsured and under-insured members of our community need other options beyond expensive ambulance transport and ED visits.

They need affordable and effective options to help them through their emergency, to manage their ongoing health maintenance. EMS has an opportunity to lead the way and to leverage its trusted place in the community to engage it like never before.