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