| Sheldon Gilbert |
EMS System Redesigns - Do We Really Need to Change?
| Sheldon D. Gilbert is Assistant Chief, EMS/Fire Administration, for the Alameda County Fire Department (CA), with over 14 years in EMS. He is the California Fire Chiefs Association EMS representative to Managed Care, a past president of the Northern California Fire Chiefs EMS section, and Chair of the Alameda County EMS system redesign - Non Emergency Triage Center and Alternate Transportation Destination Committee.. |
This article can be found on
page 80 of the May/June 1998
issue of 9-1-1 Magazine.
As we approach the 21st century, EMS systems around the country are planning for change and system redesigns. These changes range from expanded protocols for emergent and non-emergent patients to complete EMS system reconfigurations. Much time and effort has been spent explaining the different components of change and what it entails. It is helpful to understand the premise and reasoning behind these changes.
In 1966 The National Academy of Sciences-National Research Council determined that the national rate of accidental death and disability was unacceptable. These findings and recommendations were spelled out in the The EMS White Paper of 1966, Accidental Death and Disability, The Neglected Disease of Modern Society. In response to this report, attention was focused on the development of Emergency Medical Service in America. The EMS White Paper served as a catalyst that helped establish the Highway Safety Act of 1966, which not only provided the momentum for the development of EMS services but also secured federal funding to help with the formation of this valuable service.
In the early 80's, EMS systems throughout the nation underwent significant change. The federal funding was exhausted and local EMS systems began to organize and develop under similar ideals established by the feds. These EMS systems were born based on the needs of the truly emergent patient. EMS planners established that individuals who have a life-threatening injury or medical condition should receive an immediate response. The concept of pre-hospital care in the field emerged.
As systems matured it was reported that approximately fifteen to twenty percent of the persons who activated 9-1-1 required Advanced Life Support (ALS) intervention and transport. It was also reported that only 2-10% of the patients seen have an immediate life threatening condition. The financial support for these high performance EMS systems was being provided by the insurers who traditionally paid for nearly all ambulance transports at a rate that was commensurate to the cost of ambulance operations. In addition, tax-based ALS and BLS first response systems were formally integrated and expanded to support the EMS transportation infrastructure.
During this time both of these concepts were implemented and were successful. EMS system change did not become a reality until the early `90s. The health care establishment was forced to acknowledge an important economic factor. Significant rate increases without a commensurate increase in plan services would no longer be accepted by the larger purchasers of health care programs such as retirement plans and government. This realization resulted in a push by Managed Health Care to facilitate the transport of their patients to the appropriate facilities by creating efficiencies through demand management. In addition, a national agenda was established to provide health care to all Americans. While some say this plan failed, others say that the implementation and engineering shifted from a government policy to the health care market. Whatever the case, an era of managed care and a search for health care efficiencies was established. The old way of doing business had changed. Currently, approximately 75% of the insured population in this country belongs to managed care organizations.
In an effort to realize efficiencies, a new approach developed in the delivery of medical care. These principles were being carried out in health care delivery as a whole and rapidly worked their way into EMS services. EMS providers all over the nation are identifying the need to integrate out-of-hospital services with main stream health care.
Managed care organizations are requiring their patients to be transported to the appropriate assigned facility the first time. The old EMS practice of transport to the closest facility is no longer desired, and in many cases, is not reimbursed except in cases of true emergency.
Medicine is changing to require evidence for reimbursement. The health care system is refusing to authorize treatment unless they are supported by quantitative, statistically valid data. The question is no longer "can we?" but "should we?" The days of doing it because it sounds like it might work (anecdotal medicine) are rapidly disappearing.
Health care is actively pursuing the concept that the prevention of injury and disease is much more efficient than to treat the treatment of emergent states. Prevention and education is a major focus for the future of EMS.
These approaches have changed the way medicine is viewed, delivered, and reimbursed. The demand for diversified services by EMS systems is increasing. The trend for future EMS reimbursement is in the form of tax dollars and capitated payments (receiving all revenue up front). The days of fee for services reimbursement are numbered.
If the modern EMS system does not provide a system to cost-effectively deal with the non-emergency patient, managed care organizations may pull them out of the EMS system. This fact could confuse the public as to which system to activate. It could also jeopardize opportunities for making EMS systems more cost effective. The goal of EMS system redesign projects should be the creation of methods that allow health care providers to work within the EMS System rather than competing against it. We should work hard to preserve the sovereignty of 9-1-1 services and EMS responses that have developed over the past few decades. EMS systems have an obligatory and primary mission to provide a safety net for the patients who need immediate response and treatment. These systems also have an opportunity to diversify and improve health care access and effectiveness in the communities that they serve.
