Planning the Future of EMS: Can Managed Care and the Public Safety Net Coexist?
Planning the Future of EMS: Can Managed Care and the Public Safety Net Coexist?
What if you called an ambulance and no one came? That’s the scenario that Diane Akers, RN, MBA, Provisional Director of the Alameda County (CA) Emergency Medical Services District, presented to her county’s board of supervisors in 1994.
Earlier in the year, the board had been forced to bail out its contract ambulance provider after it suffered a $2.5 million loss, largely due to an organized effort by managed care companies to pull their members out of the 911 system.
Their crisis may become a common one for EMS systems across the country as more MCOs develop their own transportation and demand management systems in an attempt to control the cost of prehospital care.
"It is a possibility," Akers now says of the threat she presented to the supervisors three years ago. "I don’t think it’s a probability from a public health perspective. But, the service may not be performed at the level we have it today."
Developing Integrated Systems
With several studies showing that between 30% and 70% of 911 calls are inappropriate, MCOs are taking steps to divert their members away from EMS in much the same way they try to steer them away from the ED, says Michel Sucher, MD, Vice President of Medical Affairs and Chief Medical Officer for Rural Metro Corp. in Scottsdale, AZ. The problem, he says, is uncontrolled access.
"Anybody can call 911 and get an ambulance with a paramedic and lights and sirens to their door in 8-10 minuteswhether they have a hangnail or a heart attack," he explains.
By using medical advice lines and alternate medical transportation, MCOs are effectively removing the less-acute, but paying, patients from the traditional EMS system.
In the same way that many EDs have developed new product lines such as observation units and urgent care centers, EMS service providers must also adapt to meet their customers’ demands, says Sucher.
Rural Metro, primarily a private ambulance and fire company, recently entered into an agreement with a nurse triage medical call center and is positioning itself to contract with emergency medicine groups. Their goal is to offer "one-stop shopping" for emergency medical services.
"This lets you go to a health plan with one price," Sucher says. "Say, for a single price, we’ll manage all of your episodic, unscheduled events and we’ll take the risk for doing that, whether it’s on a case basis or capitation basis."
A call to the nurse triage line will bring a recorded voice that says, "If this is an emergency please hang up and dial 911," Sucher says. If the person remains on the line, a nurse asks a standard set of questions using detailed medical protocols to determine the appropriate level of care and the appropriate setting for that care.
If the person needs to go to the ED, an ambulance can be sent. If not, the nurse can refer to their PCP and make an appointment for them or refer them to a less acute facility and send a medical van or some other form of transportation, Sucher says.
"Going a step beyond the call center as a stand-alone, it needs to be integrated into emergency medicine delivery of care, urgent medicine delivery of care, and emergency medical transportation to get the most efficiency, and that’s the kind of system that we are putting together."
Rural Metro plans to develop a system of contractual arrangements to link these services under one umbrella, though some companies are attempting to diversify through ownership.
"One of our competitors, American Medical Response, has recently acquired an emergency physician group," he notes.
The Future of 911
But, where does this leave 911?
Either struggling to survive or planning its own version of an integrated delivery system, according to Akers.
Over an 18-month period in 1994, large MCOs in Alameda County pulled approximately 2.5% of their patients out of the public EMS system.
To understand why this had such a devastating effect, you have to understand the payment structure in the community, Akers says. "The reality is that very few people pay 100%. About a fourth of our patients are Medicaid, a fourth are Medicare, a fourth are private coverage, and a fourth have no coverage whatsoever."
A huge volume of money is generated by private insurance and Medicare, she says. Losing even a small percentage of these patients means drastic reductions in revenue.
"Out of the 25% of the no-insurance people, we get maybe 4-5% of the funds for the whole system," she explains. "So, what they pay back for what they use is nothing. Then, out of the paying side, the good paying side, comes 2%, [which is offset] by no insurance [patients] or Medicaid, which pays awful. It tips the scales enough to cause a crisis of significant magnitude."
Unfortunately, the problem can be hard to detect until it reaches crisis proportions, Akers says.
Only small numbers of patients were pulled out of the system over a fairly long period of time,
"You’re probably looking at one-tenth of a percent per month," says Akers. "It’s very small increments and it doesn’t look like anything until you see it on a graph."
When the ambulance provider sought relief from the board of supervisors, the board instituted several measures, including raising ambulance subsidies and fees and lengthening the required response time.
Though the exact figures aren’t public record, the EMS district knows the provider lost $1.5 million before the board could address the problem and probably another $1 million before any changes were implemented, Akers says.
The supervisors then set up a task force to redesign the EMS system.
Weeding Out Non-Emergent Cases from Emergency Response
The resulting model is similar in many ways to the system described by Sucher. It calls for 911 dispatchers to send medical assistance calls to a consolidated "emergency triage center." The operator at the center will use medical protocols to evaluate whether the situation warrants ambulance and paramedic response, Akers says.
If the situation is deemed non-emergent, calls would be routed to a non-emergency triage center. A dispatcher there would ask the caller more questions to determine how the complaint should be handled. The dispatcher would be able to send a non-emergency ambulance, refer the patient to a doctor’s office, clinic, or urgent care center, or arrange a social service referral, Akers says. If further questions reveal that an emergent situation does exist, the call could easily be re-routed through the emergency triage center.
Once on the scene, paramedics would evaluate whether the patient needed emergency transport or could use non-emergency transport, she says. The paramedics would also have the ability to transport to a step-down facility, such as a specialty care center or the health plan’s hospital, if the situation permits, she notes. Currently, the paramedics are only allowed to transport to the nearest acute care hospital, and, once called, the ambulance must transport unless the patient refuses and signs a form, Akers says.
Under the new plan, if the paramedics determine that transport is not appropriate, they could call the non-emergency triage center and arrange a referral for the patient.
Ensuring Safety
Medical protocols for determining emergent vs. non-emergent complaints can be developed without at all compromising the care of patients, say both Akers and Sucher.
"You have to start by erring on the side of safety and getting the patient to a higher level of care than may be necessary," Sucher says. "It’s only when you have data and experience that you can increase your management of a particular scope of service.
Under the Alameda plan, a medical oversight committee would develop the protocols, but the paramedics would not implement them immediately.
"Before we ever, ever implement it to where the patient’s transport is changed, we can test it," says Akers. "We can change the questions that the paramedics ask, and then have them fill out a chart as if they patient were going somewhere else. But we would still transport them [to the hospital] and we could check retrospectively what happened in the emergency department with that patient."
Once enough data were obtained to show that the patient could have been treated at another level of care, that protocol would be "turned on," she says. "We don’t have to go at-risk with patients."
When health care providers begin talking about evaluating emergent vs. non-emergent complaints, it makes some people very nervous, Akers acknowledges.
"Everybody panics and says, Oh, no! Chest pain patients.’ We aren’t starting with chest pain patientswe are starting with the guy over there with the hurt finger," Akers explains.
The EMS services must still be wary of the initial mistakes made in the early days of managed care oversight, warns Sucher.
"If you go back to the early days of HMOs, when they started thinking Gee, people with chest pain don’t really need to go to the emergency room, people with chest pain don’t need EKGs,’ it wasn’t long before you had people with cardiac chest pain going to doctor’s offices, walking out the door, and dropping dead," he says.
There is plenty of room to start with other complaints and still provide savings in emergency medicine, Sucher believes.
"You take the obviously simple things and then you work up from there as you learn more," he explains. "You don’t take marginal or clearly critical or severe cases and try to manage them at different levels of care."
Linking Public and Private Health Care
Alameda can’t afford to own and operate the different components of its EMS model, running both emergency and non-emergency triage centers and providing alternate medical transportation, but there are organizations that can make money providing these services, Akers says. It’s just a matter of finding them and figuring out how to link up.
Sucher also envisions his system as working together with the public 911.
"In a linked system, if you call 911 and say, I’m having chest pain,’ they would send an ambulance. But if you say, I have a sore throat,’ they would say, Wait a minute, let’s get you to talk to our nurse’ . . . That’s where we’re headed."
"We’re trying to be proactive and solution-oriented before managed care continues with their initial strategy of cutting prices and cutting benefits or denying payment."
The trick will be in figuring out a way to pay for the indigent and under- or uninsured patients in this system.
Alameda hopes to do this by forming a brokering entity to offer a "laundry list" of emergency services to the MCO.
"The reality is, Kaiser is not going to come in here and contract with five different ambulance services in this county. They should be paying for all of this because it is a benefit. And, if we make it an even better benefit by pulling some of these people out of the transport piece and giving them back to the advice nurse, then they should be willing to share in what their cost reduction is. That’s how we plan to do it."
The pool of dollars saved could then go into a pool to cover the cost of the uninsured, she says.
ED Physicians and EMS: Ensuring Medical Oversight
Emergency physicians must take a leading role in guiding the development of new EMS systems and protocols in their communities if the needed changes are to be driven by clinical considerations as well as financial motives, says Kristi L. Koenig, MD, FACEP, the former EMS Co-Director in the ED at Highland General Hospital in Oakland, CA, and the founder and former chair of Emergency Physicians of the East Bay.
Koenig, now working as a consultant to the Accident and Emergency Department at St. George’s Hospital in London, was one of only two emergency physicians who served on a county-wide task force charged with re-designing emergency medical services in Alameda County, CA. In addition to her work in her own community, she has also written clinical papers and contributed chapters in medical texts on the subject of emergency medical services.
"The most important role for emergency physicians as these new systems and protocols are developed is to get involved!" she says. "We have the expertise. Who else deals routinely with unscheduled access to care’ and the management of systems? We must participate in the changes that will occur so that we can make sure they are medically appropriate."
For example, emphasizes Koenig, many on the Alameda task force originally wanted a separate "non-emergency" number set up and an education program developed that would encourage people to call that number if they did not have a "true emergency."
"I felt strongly that anyone with a perceived emergency should call 911 and at that point the person could be directed to the appropriate level of care," she says. "I pointed out that even emergency physicians were having a difficult time defining [the term] emergency and that we could not expect the lay public to distinguish between indigestion and an MI."
The task force eventually recommended a model where 911 is initially called, but then the caller may be transferred to a non-emergency triage call center if the operator, using a standard protocol, determines that the situation is non-emergent.
Fragmentation May Lead to Poor Outcomes
One of her biggest concerns as an emergency physician was that MCOs would develop their own systems for prehospital care and pull patients out of 911, thereby crippling the system and encouraging the establishment of 911 alternativesnumbers to call for non-emergencies.
The integrity of current 911 systems must be maintained and system fragmentation discouraged, Koenig believes.
"There would be inevitable delays in accessing emergency care for those who truly need it," she says. "The raw numbers of critical patients will be small since there is a small number of people who need immediate interventions, such as defibrillation, yet these are exactly the patients we cannot afford to miss."
Though she believes MCOs are justifiably fed up with subsidizing care for the uninsured, if they pull the paying patients out of the system, the emergency safety net will collapse, says Koenig.
At the heart of the problem is the fact that the main priority of managed care is to provide cost-effective medical care by emphasizing health maintenance and attempting to match resources to medical need, but EMS systems were established to provide rapid emergency health care access regardless of the patient’s geographic or financial status, she says.
These two divergent goals must be coordinated.
"I believe the system can benefit from change. Currently, we do a very good job of providing rapid, episodic emergency care," she says. "However, it is expensive, and, from a public health perspective, it does not necessarily provide what the population needs."
Right now, if the patient who calls 911 does not have a life-threatening emergency, the person’s problem goes unaddressed.
"You either get a standard emergency response or nothing," she says.
Who Will Provide Medical Oversight?
Another major concern as new systems evolve is determining who will be responsible for providing medical oversight for the entire EMS system.
Currently, medical oversight is provided by a physician employed by the local government, says Koenig. But, as new systems bring new contractual arrangements and entities, exactly who bears responsibility for oversight could become unclear.
"The physician with the responsibility should also have the statutory authority to enforce it, and we must ensure that there is medical oversight for all pieces of the system and couple that authority with responsibility," she says.
Enlisting the help of state and local medical societies has been useful in Koenig’s experience, and she feels it is important to make sure they are educated about EMS, the issues, and what is at stake as changes begin to be debated.
Expanding the Duties of Paramedics and Other Medical Personnel
Part of the original model for the Alameda County EMS involved the option of allowing paramedics to "treat and release," notes Koenig. This was eventually changed to "treat and refer" to ensure appropriate follow-up and determination of patient outcome.
Though there are some cases where it is appropriate for paramedics to treat and release patients, there is still a need to track outcomes to ensure it is done appropriately.
"Some physicians are resistant to the idea [of treat and release], but, as anyone who has ridden with paramedics knows, it occurs all the time anyway; it is simply not sanctioned or tracked," Koenig says.
In addition to giving new responsibilities to paramedics, these new systems also involve giving new responsibilities to other providersparticularly nurses, who will be giving advice and triaging patients over the phone.
"In reality, I believe we are talking about a new type of provider," she says.
For example, the original purpose of paramedics was to provide rapid, life-saving interventions and transport, not to evaluate a sore throat and rule out epiglottitis.
"Often it seems we are trying to fit existing providers without the requisite skills and training into a new paradigm or role," Koenig says. "To do this right, we need to look at a new provider who actually has the job description and the training for what we are trying to accomplish."
This would be difficult to accomplish in the short term, she acknowledges, so providing additional curricula for existing personnel is the minimum that should be done when these systems are implemented.
With the task force, Koenig says she made it clear that, in order for paramedics to provide treatment without transport, for example, they would need pilot projects, data collection systems, CQI, and a new training curriculum.
Destination Decisions and Interfacility Transfers
As managed care evolves and attempts are made to keep patients within systems, determining the appropriate setting for treatment will be one of the biggest challenges.
"We often have insufficient data to determine which patients need specialty receiving centers, such as trauma or burn centers," Koenig says. "As medical knowledge changes, these decisions become even more complex. For example, should the patient with an MI in cardiogenic shock be transported to a hospital with a cath lab? Such a hospital may not be the closest hospital or the managed care plan hospital."
The bottom line is that the emergent needs of the patient must prevail in any destination decision, she says.
Interfacility transfers (IFTs) are another concern. IFTs will probably increase dramatically as MCOs repatriate their patients in an effort to keep them within their system of care.
This is an ill-defined area both in terms of the level of paraprofessional is medically qualified to perform the transfers and in terms of who is held medically accountable, she emphasizes.
"We are transferring patients we would have never considered putting into an ambulance even a couple of years ago," she says. "A clearly designated physician must have oversight authority and responsibility for all such interfacility transfers, and we must collect outcomes data."
EDs Must Adapt
As the EMS systems develop, ED volume will go down and the department will likely start seeing sicker patients, Koenig predicts. But, the ED will still have its role as a safety net for mistriaged patients.
"In some communities, it might make sense for us to become the gatekeepers. We have the expertise and are available 24 hours a day."
ED volume will be dependent on charges, says Koenig. If the departments can convince the hospital to stop some of the cost shifting that drives up ED charges, they will be able to better compete in the new marketplace.
"We could position ourselves to provide unscheduled access’ to care either by direct contact in the ED, through running advice lines, or even making house calls."
Overview
The concept of a new EMS delivery system is actually simple and makes a lot of sense, Koenig says.
"There is little question that dispatching a fully equipped, paramedic-staffed ambulance to the majority of 911 calls, often with subsequent obligatory transportation to the nearest ED, is not medically, operationally, or fiscally justified," she says.
The advantages of a new model would be in the reduction of overall health care delivery costs and the ability to match resources to the needs of the patient.
However, communities still have a lot to learn about whether or not proposed changes will actually result in decreased costs and which alternatives are medically safe, she says.
Emergency physicians are uniquely qualified to participate both in the development and medical oversight of these new systems.
Those physicians "stuck" in a hospital-based practice paradigm may feel threatened, but they will likely lose patient volume if they continue to practice business as usual, says Koenig.
"If we simply try to protect the status quo, someone else will change it for us without our input. This would be potentially dangerous for patients and for our specialty."
Additional Information
For additional sources of information on emergency medical services and managed care, please see:
• Koenig KL. Unscheduled access to health care: Reengineering the 911 system. Acad Emerg Med 1996;3:989-991.
• Jones D. Health care trends forecast. EMS Insider 1995; June 6-7.
• Koenig KL. Quo vadis: "Scoop and run," "stay and treat," or "treat and street"? Acad Emerg Med 1995;2:147-149.
The California chapter of the American College of Emergency Physicians, the American College of Emergency Physicians and the California Medical Association also all have issued position statements on EMS and managed care integration.
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