Taking it one step further, the brief paper–only 20 pages with references–offers a theoretical, evidence-based model and a five-step plan to “operationalize” the model.
The paper acknowledges the issues of ED overcrowding and the contribution EMS makes to the problem by transporting low-acuity patients to the ED. It also notes that, although the scope and practice of EMS has evolved since its inception, reimbursement mechanisms have not, leaving EMS providers with only one way to receive reimbursement for services: transport all patients, including those who are not acutely ill or injured, by the most expensive means (an ambulance) to the most costly site of care (the ED).
The authors take the argument one step further by providing a specific model for reform involving Medicare patients. Unpublished research, funded by ASPR, indicates that transporting Medicare patients to a physician’s office instead of the ED would save the Centers for Medicare and Medicaid Services (CMS) more than a half a billion dollars annually. Cost data for Medicaid patients is not available, but the savings are expected to be even greater. The downstream costs for hospitals are not calculated, but would be significant.
According to the paper, “the pre-hospital EMS system is uniquely positioned to care for 9-1-1 patients and assist less-emergent patients with transport to the most appropriate care setting based on medical and social needs. Such an approach may reduce the total cost of care, provide more patient-centered care and may reduce the burden on EDs, thus enhancing the quality of care received by all patients.”
A call to action
Eric Beck, DO, EMT-P, medical director for the City of Chicago EMS system, sees the white paper as a call to action for EMS systems, leaders, practitioners, educators and regulators–”the entire spectrum of our profession,” he says. Calling it “perhaps one of the most exciting documents for EMS to come out in a decade,” he believes that it might serve a dual purpose. “It offers us some support and it offers us a challenge,” he says. “A compelling rationale for the inclusion of EMS in healthcare dialogs at the federal, regional and local level. However it also challenges us to innovate, to think more broadly about improving the health of the patient populations we serve.”
Most importantly, he sees opportunity for systems-based innovation, not just process- or provider-based initiatives. The paper, he says, also offers conceptual support for mobile integrated healthcare practices. “Optimized integration with other providers in our communities creates potential for bringing a spectrum of care and resources to the patient in a more cost-effective way. This white paper, in a very elegant way, provides an optic for how EMS can help solve a variety of healthcare challenges,” he says.
The key is that each community will need to create its own model for integration.
Bringing together stakeholders–many of whom don’t typically sit together–to define local needs, resources and a collaborative strategy will be vital for this type of innovation to be successful. “Team-based care and problem-solving is quickly becoming our reality,” Beck says. “EMS professionals have to educate stakeholders about how EMS systems can partner–we can’t wait to be invited.”
He encourages all EMS systems to rise to the challenge. “Virtually all EMS systems, from fire-based and third service to private or volunteer, have opportunities to improve delivery models and better match patient needs with available resources,” he says. “We can seize the opportunity for innovation and create community-specific solutions.”
Getting started
American Medical Response Inc. Vice President of Clinical Practices and Research Scott Bourn, PhD, RN, EMT-P, believes the white paper is valuable for two reasons: It’s helpful to the healthcare community beyond EMS, and within EMS it breaks the cyclical thinking that has stymied so many systems. The chicken-and-egg scenario goes something like this: We can’t make changes until we can get reimbursed for them. We can’t get reimbursed until we make changes and show it’s viable.
“There has been so much buzz and so little action. This helps get people off dead center,” he says. “It says, “˜Let’s start here.'”
The paper–one part scientific justification and one part business plan–doesn’t start with the typical, lengthy literature review. Instead, Bourn says, it starts with a five-step, “Quick Start” model that stakeholders, from small fire departments to big ambulance companies, can implement. These include:
- Look at your data;
- Go to the ED to get an understanding of the patient population;
- Develop a theoretical framework to show how it will work;
- Identify and partner with resources in your community; and
- Develop a quality improvement plan to ensure continued value.
Potential challenges are discussed. Research is provided to serve as a primer for those not familiar with EMS issues. “It’s an extraordinarily skillfully written document that has something for everyone,” Bourn says.
The paper even offers an answer to the core question: “How many patients are we talking about?” Using national Medicare numbers, ASPR estimates that 15% of all Medicare patients transported to the ED by ambulance can be safety cared for in an alternate setting. Several graphs outline the cost comparisons. “A payer will be able to look at these numbers and quickly extrapolate [for their community],” Bourn says. “They can start to see EMS in a whole different light.”
Where we go from here
Dia Gainor, executive director of the National Association of State EMS Officials (NASEMSO), notes that previously, the Medicare Payment Advisory Commission had only thought of EMS in terms of the narrow wedge of the budget pie expended on ambulance transports. There was no big potential for savings if the only consideration is a reduction in payments for transport. By calculating the savings of alternative destinations for Medicare patients, the paper demonstrates that EMS is uniquely positioned to significantly reduce not only costs to CMS, but downstream ED and hospitalization expenditures as well. “This really gets to the opportunity to educate others–that to me is one of the big assets,” she says. “As a solid compilation of baseline information, it is a preliminary framework for more structured conversations.”
Gainor is particularly encouraged by the framework the white paper provides for a common methodology throughout the EMS community. “Otherwise, we don’t have the ability to have a common evaluation methodology,” she says.
Currently, the only way to learn about a community paramedicine project or other alternative model is to contact the EMS system conducting the pilot project directly. This national conversation, Gainor says, allows EMS to consider accumulating and storing data in a single repository. “That should get figured out early on and made easily accessible to all interested parties,” she says.
But first, she says, regulations must change to allow EMS to take advantage of the opportunities. Because EMS, unlike fire and law enforcement, is regulated by the state, changes to the scope of practice and license requirements referenced in the white paper must be made locally.
If there is one component missing in the paper, Gainor says, it’s the public. “We expected to see community engagement and education on the list of considerations for new delivery and financial models,” she says. She notes that successful programs have listed this as a critical element of their projects.
Gainor is particularly pleased to see a collaborative paper regarding EMS coming from multiple federal partners. “We now have an unprecedented number of EMS experts in fairly high ranking positions in HHS and the Department of Homeland Security that we’ve not enjoyed in the past,” she says. With the benefit of their EMS subject-matter knowledge, she hopes that it will lead to further opportunities and innovative choices on the part of federal partners.
Thinking strategically and taking charge
The concept of alternative transport is not new. What had been missing is both the motivation and the data. The economic pressure of this countries’ healthcare burden has provided the impetus.
“Our system is not sustainable,” says Kittitas Valley (Wash.) Fire and Rescue Fire Chief John Sinclair. As an active member of the International Association of Fire Chiefs EMS Section, Sinclair notes that the U.S. is currently spending 17.9% of its gross domestic product on healthcare, up from 9% in 1980. On a per-person basis and as a percentage of GDP, the U.S. dramatically outspends other nations. Despite this, the U.S. has the lowest life expectancy and healthy life expectancy compared to the next eight nations in terms of healthcare expenditures, and it scores lower in other key healthcare indicators.1
The authors note that the Medicare program spends $5.2 billion on 16.6 million ambulance transport claims annually. Payments per beneficiary increased 19.1% from 2007 to 2010.2 Medicare and Medicaid patients account for a larger proportion of ED visits and ambulance transports. In 2009, nearly 20 million patients age 65 and older visited an ED–more than any other demographic. Of those, 38.6% arrived by ambulance, compared to 16% in the overall population.3
The financial incentive to treat patients at the scene or transport them to a provider other than the ED is significant. The white paper outlines opportunities that would reduce annual Medicare spending by more than a half billion dollars. “I honestly think that’s on the low side,” Sinclair says. The added benefits of reducing ED crowding and unnecessary hospitalizations further argue for a different approach.
Sinclair suggests that changes such as the ones advocated in the white paper may cause a shakeup in the industry. “This sea change is going to take people out of the business. People who are progressive are going to recognize that this is the right thing to do. We don’t build EMS systems [to benefit] EMS systems. We build them for the patients,” he says. “Those who are in it for the money or who are not progressive will not survive. The overall system will filter those people out and they won’t be in the business 5 to 10 years from now.”
He says that it will take strategic thinkers who will collect data, engage their medical directors, state professional associations and work the politics. “Then we need to get the national organizations to all pull in one direction,” he adds. “This is the time for the EMS statesman. Some national leaders will emerge from each state and we will see some real progress.”
The stakes are higher than just EMS. “By working together, we have the potential to achieve something that will revolutionize not just EMS, but a significant part of healthcare and potentially the country,” he says.
The draft white paper can be downloaded from the document repository at www.emsinsider.com. Comments on the draft paper can be submitted to nhtsa.ems@dot.gov.
References:
1. Squires D. Explaining high health care spending in the United States: An international comparison of supply, utilization, prices and quality. The Commonwealth Fund, 2012.
2. Mandated report: Medicare payments for ambulance transports. (2012). Medicare Payment Advisory Council. Retrieved on July 29, 2013, from www.medpac.gov/transcripts/Ambulance_presentation_April2012%20Final.pdf.
3. Centers for Disease Control and Prevention. (2010). National hospital ambulatory medical care survey: 2009 emergency department summary tables. Page 7, Table 5. Retrieved on July 29, 2013, from www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2009_ed_web_tables.pdf.
