| Gary Ludwig |
Get Ready For
Pathway Management
| Gary Ludwig is the Chief Paramedic with the St. Louis Fire Department. He has been involved in EMS and fire delivery in St. Louis for 19 years and is a nationally known speaker at EMS and fire conferences throughout the country. |
This article can be found on
page 60 of the Mar/Apr 1997
issue of 9-1-1 Magazine.
By some estimates there were 55 million unnecessary emergency room visits in 1995. If the average emergency room visit cost $1,200 - an estimated $66 billion in unnecessary health care cost was incurred by medical insurance providers last year.
Treatment in an emergency room is probably one of the most costly methods of delivering health care. Ask any medic - out of every 10 patients transported to an emergency room, how many actually needed an emergency room to receive the level of care they needed? Most will answer two or three out of ten. To further demonstrate this point, a Non-Emergency Ambulance Transport Study (NEATS) done by the American Ambulance Association in 1996 showed that only 8.4 percent of those patients transported by ambulance to an ER actually needed definitive care capable of being rendered by an emergency room. Another study done on Medicare patients showed that 94.6 percent of all Medicare patients transported to an ER could have received treatment at another resource.
Managed care organizations realize this and, in essence, are not attempting to manage care but to manage their money.
Seizing this opportunity, managed care organizations, health maintenance organizations, physicians groups, etc., have formed partnerships and alliances with predominantly private ambulance companies to seek alternative methods for delivering care. Responding to this need, many of the private ambulance companies have designed models to accommodate this method of health care delivery in the revolving managed care environment. This new concept is called "pathway management," and can be defined as the process that seeks to ensure customers/patients receive the appropriate care/service, in the proper place, at the right time, based upon their needs.
Comprehensively speaking, EMS organizations can play the "gatekeeper" role for the MCOs and HMOs. The "gatekeeper" role starts in the communications center where the initial phone call is received. The "gatekeeper" can be defined as the initial provider who makes decisions whether referrals and other healthcare services are warranted for a given patient. Some of these systems will be established through 9-1-1 systems or alternative communications centers with special 800 and 888 lines to accommodate the patients of managed care organizations that they are aligned with.
Control either the 9-1-1 system or the 800 lines and you manage the "pathway" of the patient, while controlling costs for MCOs and HMOs. Pathway management will include using the proper resource (i.e. ambulance, wheelchair van, convalescent van, transportation vans, and even taxis) to move patients to the proper health care facility (i.e. emergency room, urgent-care center, doctor's office). Other forms of care may include expanded scope of practice scenarios with paramedics or physician assistants, nurses, and even doctors providing home health care instead of transporting.
The Phoenix Fire Department is currently operating a pilot project using a van, staffed with a physician assistant and one EMT, to deliver home health care within a five mile radius of a hospital in Phoenix they have partnered with.
The "Big Three" (Medtrans, AMR, Rural/Metro) are all currently working on pathway management models. Most of these models will integrate pricing and the service provisions of emergency departments, all forms of transport with more uses of the communications center.
Rural/Metro is currently working to develop a pilot project in either Yuma (AZ) or Waco (TX). Once developed, they will expand the concept to Ohio and upstate New York. Late last year, Rural/Metro signed into partnership with Aetna of Ohio, which serves 550,000 members. Rural/Metro operates in all major cities in Ohio and where they do not have operations they have subcontracted out to 22 different ambulance providers to take care of Aetna patients' needs.
The communications center will play an integral role. A conference in September of 1996 just on emergency medical dispatching had such topics as "Pathway Management: A Process for Managing System Access," "The Super Communication Center: Medical Access Point 2001," and "Privatization of 9-1-1 Center Operations."
AMR has developed a centralized call-taking and dispatch center that coordinates non-emergency transport in central California. This control point is called "Private Call Answering Point" (PCAP) and is currently processing 35,000 phone calls each month. Special call operators who have 240 hours of training take calls over 800 or 888 lines to determine what level of service and transportation mode is required. Late in 1997, a pilot program will start to have managed care members even schedule appointments with their primary physicians. AMR has plans to open PCAPs in other parts of the country, beginning in Aurora, Colorado.
Let us not forget that the patient is the number one priority. The patient receiving the best possible care should be the foremost emphasis in the delivery of emergency medical care. Even though managed care seems to be managing money more than care - the emphasis should remain on the customer.
Therefore, if an EMS agency gets involved in alternative delivery models, it is important to remember that the needs of the patients should be balanced between the EMS agency and the managed care organization or HMO. If the emphasis of the care, or in this case, the money, is slanted toward the managed care organization or HMO - the patient suffers!
There needs to be a zero balance between the EMS agency and the managed care provider. If the EMS agency gives in to the whims and financial needs of the managed care organization or HMO, then the patient suffers. Bypassing four clinics to go to another clinic because the managed care organization gets a discount is not in the best medical interest of the patient.
In essence, an emergency medical service delivery system should not be HMO- or MCO-driven. The transporting agency should remain in control of the operations and decision-making process regarding patient care. If an EMS agency succumbs from pressure from HMO or MCO to shift a financial advantage in the HMO or MCO's favor, the delivery of prehospital health care in that specific community will certainly deteriorate.
