The concept of community paramedicine, also called mobile integrated healthcare, is taking EMS by storm. Numerous articles have been published and considerable discussion has occurred regarding community paramedicine at many EMS conferences. But, what is it and why is it occurring?
When the first discussions of community paramedics came forth, I tried to get a handle on exactly what this concept was and what it would accomplish. This was easier said than done. Some thought it was a strategy to decrease EMS utilization by targeting frequent users. Other programs worked with local hospitals in an effort to decrease readmission of high-risk patients such as those with congestive heart failure, chronic obstructive pulmonary disease and similar maladies. There have been other iterations of community paramedicine that have included primary care, home healthcare and other nontraditional EMS roles. Despite this, the definition of community paramedicine remains nebulous.
First, let me say that I strongly support an expanded scope of practice for paramedics. I was among the first to put two paramedics on a medical helicopter in the late 1990s—a move that caused quite a stir in the medical community. I've been a strong proponent for the development of critical care paramedic programs. I have endorsed and supported the use of paramedics in the emergency department setting. During my work with the large Burning Man event in northern Nevada, we integrated field EMS personnel with hospital personnel almost seamlessly. It really was a thing of beauty. But, I am not sure where this concept of community paramedics is going. Also, I have some concerns.
The concept of using paramedics in a nontraditional primary care role is not new. Between 1995 and 2000, a special project in Taos, N.M., called the Red River Project used three specially trained paramedics to provide primary healthcare for this region after physician recruitment failed.1 Ultimately, the Red River project failed for several reasons. One of the biggest problems was the constant turnover of personnel. In addition, it was generally held that the education program was inadequate to provide the necessary care. The most fundamental flaw was the fact that the system was never integrated with the local medical community.2
When one examines each of the goals of community paramedicine there are worthy points and counterpoints. Let's look at some of these in detail:
Reduction of unnecessary transports: Every EMS system, regardless of size, has people who use the system unnecessarily. These people are often colloquially referred to as “frequent flyers” or “super users.” These patients do tax resources and can indeed take needed resources away from other patients who actually need the EMS system. Numerous studies have been conducted to identify these super users. They tend to be male patients and patients who use alcohol to excess.3 They also tend to have chronic somatic and mental health issues.4 However, no specific strategy has been especially successful in eliminating EMS system abuse. This is primarily because of the types of diseases and conditions encountered and the limited insight of the patients. Furthermore, some EMS systems don't want to limit patient utilization, even if it borders on the abusive. A chance to transport is a chance to bill. Although conventional wisdom suggests that many of the super users are uninsured, many actually do have some form of healthcare insurance—often government-sponsored programs such as Medicare or Medicaid. Thus, one cannot say that reducing super user utilization is supported by all EMS systems.
Reduction of readmission of chronically ill patients: The readmission of patients with chronic illnesses to the hospital is costly and generally thought to be avoidable. The Centers for Medicare and Medicaid Services (CMS) now penalizes hospitals for readmission of high-risk patients within 30 days.5 Over the last several years the amount of these penalties has increased, thus prompting hospitals to look for strategies to reduce the readmission rate of these high-risk patients. However, in a recent study of 43 different intervention strategies, only 16 were deemed effective in reducing readmission, and no single one was consistently associated with being effective.6 One of the strategies hospitals have used to reduce readmission has been the use of community paramedics. Community paramedicine seems to be a good fit because the EMS system is already established in the community and the EMS system has been looking for ways to expand the scope of practice. But, the real issue is financial. EMS providers are among the poorest paid providers in the U.S. healthcare system. Thus, using EMS providers is much cheaper than nursing and other healthcare providers. While community paramedicine visits may reduce some EMS transports, the primary beneficiary of the community paramedicine care is the hospitals who do not want the readmissions (primarily for financial reasons). Certainly the EMS system may garner some revenue from a community paramedicine program but the amounts are not significant. But, in the overall scheme of things, hospitals are looking for the most economical way to protect their bottom line and paramedics are the cheapest of the available healthcare professionals.
Primary care: The U.S. healthcare system is broken. Unlike other developed countries, there is limited primary care access in the United States. This is especially true in rural communities and poorer areas. The current reimbursement scheme for U.S. physicians actually drives physicians away from primary care (e.g., family medicine, internal medicine, pediatrics). Specialties that are highly procedurally based (e.g., cardiology, gastroenterology) pay considerably more than primary care specialties. Thus, medical students who face several hundred thousands of dollars in medical school debt are driven into more lucrative specialties. Many primary care residency programs (e.g., family medicine, internal medicine, pediatrics) are not attracting U.S. medical school graduates and are often filled with graduates of foreign medical schools. Alternative models such as community paramedicine are an option and should be considered, but is community paramedicine the best approach? One would be naïve to believe that a brief educational program in primary care for paramedics would give them the necessary skills for primary and chronic care. The advanced practice provider (e.g., nurse practitioner, physician assistant) programs are exponentially longer and more comprehensive.
This brings us back to my initial question: The U.S. healthcare system is broken. So, in order to fill the gaps in primary care, we are turning to paramedics who are among the lowest paid medical professionals in the country. We are asking them to step outside their traditional emergency role and begin providing primary care. Why should paramedics be forced to carry the burden of the failed U.S. healthcare system? Is this in the best interest of EMS? In my experience with the community paramedicine concept, I have noted similar problems to those encountered in the Red River Project. That is, not many paramedics have much interest in primary care and there is a significant turnover. In addition, because paramedics are generally not recognized as approved providers by insurance companies and CMS when outside their traditional role, there is no easy way to obtain reimbursement for the services provided.
In summary, I fully support expanding the roles and responsibilities of paramedics. I hope the coming years will better demonstrate the role of paramedics in primary care and the community paramedicine initiatives. But, we must first fix the inherent problem with EMS before we assume more responsibilities. These include improved education, improved pay, self-governance and full licensure, and true recognition as bona fide healthcare providers. Let’s fix EMS first. Then, we can look for expanding the role. For now don’t ask poorly paid EMS personnel to shoulder the failed U.S. healthcare system.
1. Shoup S, Red River Project. Expanded scope program for New Mexico medics. JEMS. 1995;20(12):43-47.
2. Hauswald M, Raynovich W, Brainard A. Expanded Emergency Medical Services: The Failure of an Experimental Community Health Program. Prehosp Emerg Care. 2005;9:250-253.
3. Hall MK, Raven MC, Hall J, et al. EMS-STARS: Emergency Medical Services “Superuser” Transport Associations: An Adult Retrospective Study. Prehosp Emerg Care. 2015;19(1):61-67.
4. Knowlton A, Weir BW, Hughes BS, et al. Patient demographic and health factors associated with frequent use of emergency medical services in a midsize city. Acad Emerg Med. 2013;20:1101-1011.
5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. -
6. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528.