Administration and Leadership, Columns, Commentary

Show Me the Money: Is there a connection between agency funding and patient non-transports?

Issue 5 and Volume 43.

The Research

Déziel J. Effects of emergency medical services agency ownership status on patient transport. Prehosp Emerg Care. 2017;21(6):729–733.

The Science

This study examined the Virginia State EMS database for an association between EMS ownership/funding type and patient non-transport.

The author categorized the agencies as publicly funded if they were government non-fire or fire departments and privately funded organizations if they were private nonprofit, private for-profit or hospital-owned.

Between 2009 and 2013 there were 4.6 million 9-1-1 responses, with public agencies responding to 70% and private agencies responding to the remaining 30%. Patient transport occurred in 61.75% of the government non-fire organizations, 56.48% of government fire, 73.6% private nonprofit, 89.51% private for-profit, and 79.98% of hospital- owned services.

The author claims that private for-profit services were 4.5 times more likely to transport a patient than publicly funded agencies. Private nonprofit organizations were twice as likely to transport, and far less likely to allow for patient refusal or to treat and release at the scene.

He concludes, “Given the reimbursement practices of medical insurers, private ambulance services are incentivized towards patient transport. Operation revenue for these services is not generated through public budgeting processes but through user fees. Thus, private agencies are more reliant on billable services than are their publicly funded counterparts.”

Doc Wesley Comments

Wow. Really? I’m almost speechless. With all due respect to Dr. Déziel, the conclusion isn’t supported by the data. This paper states that there’s a difference in agency transport rates as categorized by the author. But association isn’t cause-and-effect.

There isn’t data to support the conclusion that the higher transport rate of privately owned agencies was “incentivized.” This issue is far more complex than simply who owns the service.

First, the author assumes that the government agency transport rate is clinically appropriate. There was no review of those not transported to determine if that decision was correct. In fact, the author notes a study that concluded that 16% of EMS transports may be handled more appropriately by other means. If that’s correct, then 84% of transports are appropriate. The private for-profit rate of 89% is much closer to this “appropriate” rate than the 56% rate of fire-based.

Secondly, it assumes that all agencies serve similar patient populations. Fire-based EMS, being disproportionately urban, encounters more patients with social issues, such as homelessness and crime, that often result in non-transport. They also respond more commonly to motor vehicle crashes which frequently result in non-transport.

Third, it assumes that each service responded to separate patients, when, in fact, many large fire-based services have contracts with private BLS agencies to transport patients after receiving an ALS fire-based response.

Finally, there was no accounting for the priority level of responses. How many fire-based services were BLS and only responded to alpha and bravo level calls—conditions which have a higher non-transport rate?

The author suggests that, according to his calculations, 56,049 transports were the direct result of agency ownership. He then goes on to imply that Medicare may have paid more than $25 million because of the EMS agency’s ownership status. This isn’t only wrong, it’s disingenuous to the EMS profession and portrays the author’s bias. This paper is simply reporting a statistic. As Vin Scully said, “Statistics are used much like a drunk uses a lamppost: for support, not illumination.”

Medic Wesley Comments

I thought of starting with the comment, “What he said,” but I have a few observations of my own. The numbers presented in this paper represent transport versus non-transport in private, municipal, and non-profit ambulance services.

There’s no proof of reimbursement causation in private service transport. The author himself claims that “medical insurers have clearly defined which ambulances services will be reimbursed.”

As I see it, private services would be at a higher financial risk of transporting patients who didn’t meet the reimbursement requirements, thus incurring a loss of revenue.

The author claims that future studies would benefit from qualitative analysis of individual provider attitudes and decision- making processes. He further states that “reviewing medical billing data may be more effective in detecting inaccuracies in insurance billing due to inflated patient acuity.”

There are a lot of assumptions made about huge inaccuracies in insurance billing without sufficient evidence. This further exposes his bias.

As far as numbers for transports go, the study provides those, but the conclusion seems only to reflect the author’s opinion.