New Paradigms of EMD
COMPETITION
AROUND THE CORNER
A PSAP's Guide to Surviving Managed Health Care
by James O. Page
| Jim Page has worked in and around fire and EMS services for more than 40 years. He has served as a chief officer in three California fire departments. A member of the California Bar since 1971, he also was Chief of EMS for the State of North Carolina. In 1980 he founded Jems Communications and currently serves as publisher of JEMS (Journal of Emergency Medical Services) and Fire-Rescue Magazine. He is an Emeritus member of the National Academy of Emergency Medical Dispatch. |
This article can be found on
page 32 of the Mar/Apr 1997
issue of 9-1-1 Magazine.
During the 1996 Presidential election campaign, the candidates were making promises with wild abandon. As they frantically tried to connect with voters on "bread-and-butter" issues, a White House aide got wind of an interesting experiment in Baltimore. Within days, President Clinton asserted that the 9-1-1 emergency number system is completely overburdened. He proposed "a new national community policing number that's just as simple and easy to remember as 9-1-1."
It's been almost 30 years since the first 9-1-1 call was received by a public safety answering point (PSAP) in the U.S. Complemented by entertainment television, the persistent effort to acquaint the public with this quick and convenient access to emergency services has become North America's most successful public education campaign.
For some people, dialing 9-1-1 has become the only way to get any kind of a quick and positive response from the establishment. It's quick and it's toll-free. Even the most destitute of humans can make big things happen by dialing 9-1-1 and uttering the right words. As a result, some of those people dial 9-1-1 when they shouldn't.
At the other end of the spectrum are those who are never without their cellular phone. They've become addicted to instant everything. While stuck in a traffic jam, they're likely to dial 9-1-1 to ask what's holding them up. While planning a picnic, some of these people might call 9-1-1 to inquire about weather forecasts. Every PSAP has a host of 9-1-1 abuse stories from both ends of the spectrum.
There are parallels in other fields. For example, when the airlines established toll-free numbers for making reservations, they also had regular seven-digit numbers to call for other information. Before long, however, lots of people were calling the toll-free numbers to find out when Aunt Mabel's plane would arrive in Des Moines, whether the airport parking lot was full, or whether they should pack an overcoat for their trip to Buffalo.
In the world of PSAPs, many have reacted to the problem by labeling and scolding callers who don't use the system in compliance with our version of the rules. In some communications centers there's a culture of scorn and ridicule that seems to revolve around "stupid" people who call with "stupid" problems. This has an erosive effect on morale and it usually gets worse over time. It seems to be worst in places where call volume has multiplied but the number of consoles and dispatchers has remained the same.
There are those who feel that public education is the answer. However, an expensive, months-long, multi-media, city-wide campaign in Dallas was intended to educate the public on how to use 9-1-1 without abusing it. The net result of this public education effort in the 1980s was a significant increase in total 9-1-1 calls, including inappropriate calls. Reportedly, a campaign in Detroit had similar results.
The overburdened systems referred to by the President are actually few in number. Eventually, in those places, a cascade of overloaded circuits, inappropriate or abusive calls, angry dispatchers, delayed responses and citizen complaints (or lawsuits) will get some high-level attention. Like most political solutions, however, the reaction most often is a strategic band-aid (such as a separate three-digit number for non-emergency calls).
What did the airlines do when people started using their toll-free reservation numbers inappropriately? Did they scold them, create pet names for them, and get angry over "abuse" or "improper calls?" Of course not. They recognized it as an opportunity for improved customer service, they trained their people to meet customers' needs, they added personnel and phone lines to meet the increased demands, and they figured the additional expense as a cost of doing business.
There are a number of obvious differences between PSAPs and airline information centers. One of them is competition. If American Airlines scolded a customer for calling a reservation line for the wrong kind of information, that caller probably would fly United the next time. If a 9-1-1 operator treats a caller rudely, who are they going to call with their next emergency?
For some kinds of emergencies, they may soon have an alternative. Competition, in the form of managed health care and some nationwide private ambulance companies, is just around the corner. They intend to encourage (or require) people with medical emergencies to call their toll-free number instead of dialing 9-1-1.
The Competitive Edge of Managed Health Care
Three of four insured people in the U.S. are already enrolled in managed care plans, including health maintenance organizations (HMOs). Managed care is intended to reduce the cost of health care. The membership of such plans includes people in large geographic areas, usually bigger than a single county. By contrast, 9-1-1 PSAPs usually are set up to serve only those people within a single city, town, township, county, etc. Thus, when somebody dials 9-1-1 to report a medical emergency, the typical response "scrambles" the managed care system.
Let's say Adam County PSAP receives a 9-1-1 call reporting a person who had temporarily lost consciousness. They dispatch Adam County Fire's first responders and ambulance. At the scene, it's found that Mrs. Jones has a blood-sugar imbalance, lives alone, and is a member of the Miser HMO. Miser wants to see Mrs. Jones at their hospital in Baker County (30 miles distant).
Adam County Fire doesn't transport people out of county. Instead of taking Mrs. Jones to Miser's hospital in Baker County, they take her to a local hospital so they can get back in service as soon as possible. Before the day ends, the local hospital has conducted some expensive tests on Mrs. Jones and Miser has arranged for a private ambulance to repatriate her to their facility. Miser or Mrs. Jones (or both) will end up paying a thousand dollars or more for this scrambling of the system.
The Miser HMO and other managed care plans throughout the country are busily designing a different arrangement. Two large corporations, controlling about 25 percent of all ambulance service in the U.S., are arranging to meet the needs of the plans. A central feature of their proposed arrangement is the diversion of plan members from 9-1-1 as their access point for emergency medical services.
Using the Adam County example again, Miser HMO will be trying to contract with one medical transportation provider for all their members in Adam, Baker and Charlie counties, and the southern two-thirds of Delta County. Let's say Miser has 100,000 members in that area. Let's say they want to "capitate" those members and pay their contractor prospectively (up front). For example, Miser might offer to pay a private ambulance company $2 million ($1.67 per member per month) for all the medical transportation services required by all 100,000 members during a contract year.
If the ambulance company can do it for less than two million dollars, they keep the difference. If they spend more than two million dollars fulfilling their contract, they eat the difference. In order for Miser and the ambulance company to gain enough control over costs, they need to eliminate the problem of "scrambling." So, they'll probably notify all their members to call a toll-free "nurse-assist" number when they feel they have an emergency. Probably, that call will go directly to the ambulance company, which also will be selling phone triage services to the HMO.
The big ambulance companies know that their survival depends on meeting the needs of managed care. That means de-scrambling the response to medical emergencies. Managers of many PSAPs, meanwhile, are portraying their 9-1-1 services as overburdened and abused. "Customer service" is foreign to their vocabulary. Unless something changes drastically and soon, it's not hard to see how this competition will end.
How PSAPs Can Respond
Why can't PSAPs and public safety agencies meet the needs of managed care? The only real obstacles are ignorance and attitude. PSAPs should be able to provide or subcontract for all or most of the services that the private companies are proposing to managed care organizations. Public fire departments and EMS agencies should be able to work with neighboring providers and create a seamless system that gets the patient to the right bed the first time.
But no organization can compete in the arena of customer service as long as they are at war with their customers. No organization will be competitive if they look at tomorrow as just another yesterday.
Surely there are those among the family of 9-1-1 dispatchers who might say "good riddance" to emergency medical calls. Those calls represent only about ten percent of a typical PSAP's volume (but about 90 percent of true life-threatening calls). Consider the fact that a lot of jails and prisons have been privatized. If the private ambulance companies succeed in their challenge to the 9-1-1 universal emergency number, why couldn't they privatize police and fire communications as well?
If that challenge doesn't impress you, consider the prospect of an investor-owned company with the opportunity to increase its profits by rationing emergency services. The universal emergency number 9-1-1 was intended as a safety net. In the interest of economy and profit, some folks are trying to enlarge the holes in that net.
Let's recognize the potential for 9-1-1 PSAPs to serve as a safety net while meeting the needs of managed health care. Managed care plan members should not be diverted to alternative private sector entry points. Public sector communications system managers should explore the possibility of serving as the combination entry-and-triage point for all medical emergencies (eliminating the need for non-emergency triage centers). Performance of these services actually could produce enough revenues to pay for the necessary personnel, training, hardware and software.
It's very important at this time not to let the discussion about "overloaded" 9-1-1 systems obscure future opportunities. Who's going to offer an opportunity for expanded service to people who are complaining that they can't handle what they've already got?
