Healthcare Reform & the Triple Aim

Healthcare as we know it is experiencing a transformation. The Patient Protection and Affordable Care Act was a key trigger, but momentum in the industry was already causing changes. Although cable news fixates on a few attributes that keep the left and the right pundits in a frenzy, the folks on the frontline have known for a long time that the U.S. healthcare system is broken and needs to be fixed. Unequal access, variable quality and allocated health costs as a percentage GDP at nearly twice our peer countries is no longer sustainable or acceptable.


In-hospital, leaders are crunching the numbers, making plans and piloting innovations that target improved quality and reduced costs. In the prehospital environment, there have been small pilot examples of innovative thinking (e.g., community health paramedic programs), but most organizations have not begun the process of preparing to meet the needs of the transforming system. The EMS industry is late to the game and it’s time to get to work.


One area of healthcare reform that offers some exciting hope is the work focused on innovation, much of which has evolved from an initiative started by the Institute for Healthcare Improvement (IHI). IHI’s Triple Aim–which heavily influenced the framework of the Centers for Medicare and Medicaid Services (CMS) Innovation grants–optimizes the health system by focusing in on three dimensions: the health of a defined population, the experience of an individual and the reduction in per-capita healthcare cost.


Let’s look at how three EMS organizations are doing work today in these dimensions.


Population health
Making a measurable and sustainable difference in the lives of patients requires focused action. Each branch of the healthcare system typically has key care areas where targeted intervention and reliable care delivery can save lives. EMS systems were originally designed to focus on emergency care, specifically trauma and sudden cardiac arrest. Today, we benefit from 40-plus years of knowledge, best practice and published research that demonstrates EMS can make a difference in core care areas.


In 2012, American Medical Response, Inc. (AMR), under the leadership of Ed Racht, MD and Scott Bourn, PhD, RN, EMT-P, developed a nationwide program called Caring for Maria. Based on the Esther Project in Sweden, the initiative brings AMR communities from across the country together to collaborate on improving several areas of ambulance care that are believed to make a clinical difference, including sudden cardiac arrest, pain and suffering, stroke, respiratory distress and ST-elevation myocardial infarction (STEMI) identification.


Their improvement collaborative mirrors IHI’s Breakthrough Series Collaborative model and uses methods from improvement science to test change concepts, implement reliable care processes and spread innovations. The end result will be a change package that can be brought to any community to improve the quality and reliability of paramedic care in specific clinical areas.


Patient experience
A paradigm shift for many in reform is the emphasis on patient experience and system designs that enhance value for the patient. Although this includes the direct customer experience, it also incorporates dimensions of healthcare performance identified in the Institute of Medicine (IOM) Crossing the Quality Chasm report, which included: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.1 Ambulance services have worked on one or more of these dimensions, but few as a whole system.


In 2012, Mecklenburg EMS Agency (a.k.a, Medic), serving the Charlotte-Mecklenburg County (N.C.) metro area, embarked on an ambitious initiative. Based on a concept of W. Edwards Deming, PhD, and further explored by the Associates in Process Improvement, Medic mapped its organization as a system of linked processes.2,3 By identifying the relationship of its pieces, the agency was able to create a multi-layer view of its system, identify its many processes, and discover gaps in reliability, measurement and attention.


Through cross-team discussion and objective assessment, Medic has developed a strategic plan aimed at improving core business processes to improve outcomes, reduce variation and control or reduce costs. The resulting plan includes a portfolio of projects across the functional areas of the organization that will improve care from the customer’s perspective.


Per-capita cost
In the past, an organizational focus on being lean or reducing costs was solely associated with a private ambulance profit margin. Rarely has there been an industry-wide discussion focused on improving quality, reducing waste and, as a result, reducing cost. Today, that aim is a key element in healthcare reform and needs to be included in improvement thinking going forward in paramedic-based care systems, regardless of system design or provider type.


One of the exciting healthcare reform initiatives at the federal level to roll out in 2012 was the CMS Innovation Grants. The concept was to solicit proposals from providers for ideas to improve quality while reducing costs, with a commitment from CMS to fund select pilot projects. Many ambulance providers applied and three were selected, including the Regional EMS Authority (REMSA) in Reno, Nev. REMSA proposed developing a multi-driver approach to navigate low-acuity patients to the most appropriate care, reduce readmissions and support the emerging medical home model that seeks to reduce the potential number of patients with chronic diseases who will require emergency department (ED) care or hospital admission.


REMSA predicted in its grant proposal that navigating low-acuity patients to ED alternatives such as urgent care, physician’s office or clinics could result in a per-patient total care savings of $1,500—$1,750. Considering REMSA sees approximately 10,000 Medicare and Medicaid clients annually, the predicted savings are significant.


Next steps
Healthcare reform is a significant opportunity for paramedic-based care to contribute in new ways, producing new revenue potential, improving patient access and care quality, enabling innovative partnerships with other healthcare providers, and creating a new horizon for the future of the profession. Leaders must get engaged quickly if we hope to have a say in how our practice evolves. If we continue to stand by and observe, others will shape our future for us. Jump in. It’s worth it!


1. Institute of Medicine. Crossing the Quality Chasm: A new health system for the 21st century. National Academy Press: Washington, D.C., 2001.
2. Deming WE. Out of the Crisis. Massachusetts Institute of Technology, Center for Advanced Engineering Study: Cambridge, Mass., 1986.
3. Langley GJ, Nolan KM, Nolan TW et al. The improvement guide: A practical approach to enhancing organizational performance (2nd edition). Jossey-Bass: San Francisco, 2009.

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