Designing a Patient Centered EMS System: Barriers and Opportunities

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  • Designing a patient-centered EMS system:

    Barriers and opportunities

    Tony Farias Project Mentor: Brendan Carr, MD,MS


  • 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


  • 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

  • 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 its 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

  • 911

    Medical Attention?

    AMA Triage


    Treat at home Minute


    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 dont 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


    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

    Designing a patient-centered EMS system: Barriers and opportunities Our projectOutlineWhat makes Emergency Careunique Recent challengesED crowdingEMSWhat are Emergency Medical Services?How is EMS contributing to ED overcrowding?Current EMS designSlide Number 11Challenges to design reformIdentity crisis in EMS fundingCrash course in EMS historyCurrent EMS fundingReimbursementFunding ReformSlide Number 18New solutions in financingSummaryThank yous