Designing a patient-centered EMS system:
Barriers and opportunities
Tony Farias Project Mentor: Brendan Carr, MD,MS
LDI SUMR
Our project Aim: To identify barriers and determine opportunities to
develop a patient-centered pre-hospital care system
How the project started
Literature review and synthesis
Meeting in DC with HHS policymakers
Elaborated policy brief on EMS design and reimbursement
Outline
Background Emergency care Why is it unique? What is wrong with it?
EMS: what role does it play in emergency care?
How could it be better designed ? Patient-centered EMS
Funding and reimbursement Solutions
What makes Emergency Care unique
Time-sensitive , unscheduled acute care Recommended wait time for emergent
cases: <14 minutes EMTALA ~30% of patients on Medicaid or
uninsured (IOM, 2007)
Surges in demand
40 minutes (GAO, 2009)
Recent challenges
# of EDs decreased while patient visits increased 200 EDs less, 12,000 more patients (2001-2006)
Limitations in inpatient beds 90% of California EDs overcrowded (Derlet, 2004)
Increasing first-contact care in ED (Kellerman, 2011) 30 % of patients ED doctors <5% , but treat a quarter of acute care cases
ED crowding
EMS
~15% of ED visits nationally (Burt, 2006)
What are Emergency Medical Services?
What it is: Ambulance that responds when you call 911
What it’s not: Transport between hospitals Scheduled transports to a home
19 million+ medical transports a year
Less than 1% the cost of healthcare
How is EMS contributing to ED overcrowding?
Prudent layperson How would you react if you felt chest pain? Encouraged reaction
What will paramedic say?
Must give alternatives to prudent layperson Opposed incentives
Current EMS design
Do you want medical attention ?
YES NO
ED Sign AMA form
Event trigger (usually 911 call)
EMS arrives at your location
<10%
911
Medical Attention?
AMA Triage
ED
Treat at home Minute
clinic
Primary care physician
NO YES
Patient-centered EMS design
Challenges to design reform Liabilities
Patient acuity can be unclear
Confidence in paramedic qualifications
No central EMS authority in the US
EMS funding and reimbursement:
Paramedics don’t get paid unless they drive you to the ED
Identity crisis in EMS funding Is EMS a public good? Is it like police and fire ? But is a billable service
High fixed costs Garages Vehicles Funding
Crash course in EMS history Contemporary EMS began in 1960s to address
trauma injury, particularly car crashes
Extensive federal government funding through block grants given to states More than 800 EMS systems set up This was how infrastructure was paid for
In the 1980s, federal funding started to dry up
Reimbursement: fee-for-service (no limits)
Current EMS funding No federal funding
Local tax-support
Reimbursement > 50% of total EMS revenue New reimbursement structure in 2002
Reimbursement Medicare industry standard
Patient falls into 1 of 7 categories depending on provider/ drugs
“Mileage, not medicine” Distance from pick-up to hospital
Adjustment for extreme rurality
Does not cover costs 6% loss for every Medicare payer (GAO, 2007) Increase limited by inflation
Funding Reform
Necessary for system redesign Lift restriction on payment exclusively on transport To implement new programs, more revenue needed Current revenue is not covering costs Innovation impossible
To increase revenue, must solve identity crisis
Private Public
New solutions in financing Private
• National Contractors • Rural/Metro • EMSCorp
• $3.1 billion
Public
• Santa Ana --“Insurance”
• Tax supported
Summary EMS provides an opportunity to address ED crowding The current EMS design creates ED crowding Design reform necessary Need to better conceptualize what this means
Identified possible barriers to change Funding and reimbursement Currently makes change impossible
Thank yous Dr. Brendan Carr
Katie Wolff
Rama Salhi
Joanne Levy
Lissy Madden
LDI Staff
SUMR Scholars
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