Economic Reality: Crisis or Opportunity for EMS?

By Mark Bruning

For many people, the struggle with rising health care costs has already reached a critical point. More than two of every five American adults under 65 had trouble paying their medical bills last year, according to a study by the Commonwealth Fund, a New York-based health policy research group.

Doctors and hospitals are also struggling to survive the credit crunch; they endure some $60 billion in unpaid medical bills each year according to a report last year from the consulting firm McKinsey & Co. With out-of-pocket health costs rising (the $250 billion price tag in 2005 is expected to exceed $420 billion by 2015), the percentage of unpaid bills will likely increase as we move further into a new economic reality.

So what does all of this mean to the EMS and ambulance industry?

First, the long standing belief that health care, and EMS in particular, is somehow “recession-proof” is being exposed as more myth than fact. The depth and scope of this recession has resulted in unprecedented behavioral changes that are affecting our industry, such as:

• Americans driving fewer miles. About 1 billion fewer miles were driven from October 2007 to November 2008 than the previous 12 months.
• Fewer elective medical procedures and lower hospital censuses. A recent report released by the American Hospital Association in late 2008 noted that elective medical procedures have dropped 6 percent below projected levels, while hospital admissions were down 9 percent.
• Greater numbers of unemployed workers without insurance. This often translates into less frequent, if any, primary and preventative care — usually resulting into patients turning to emergency response and treatment as part of the nation’s health care safety net.

Second, many municipalities are facing severe budgetary cuts, including in public safety, which has previously escaped much of the brunt of cost cutting. In fact, an article in Best Practices in Emergency Services included the following quote from Leonard Matarese, the Director of Public Safety for the International City/County Manager Association:

That same survey of 450 fire and EMS managers across the US also reported that “64 percent of agencies responding are forgoing capital purchases of equipment and vehicles, 47 percent are reducing overtime, 40 percent are cutting non-essential services, and 25 percent are reducing training.”

So what fundamental changes do we, as a collective public and private EMS industry, face and what opportunities does this backdrop of economic downturn present for EMS to reinvent itself?

It would appear that we can no longer sustain the costs of maintaining expensive, inefficient, all-ALS EMS systems that fail to produce data showing improved patient outcomes. Throwing money and resources at systems that are designed around the dubious response time criteria of a singular event, accounting for a low percentage of our total responses, is no longer an option in this economic climate.

In most communities, response time standards are based on data that is only relevant to cardiac arrest survival, despite the fact that cardiac arrest comprises of less than 2-4 percent of calls in virtually all EMS systems. This decision is extremely costly, offers dubious benefit to patients, and subjects EMS personnel and the public to unwarranted risk due to excessive use of emergent response for calls that are almost certainly non-emergent.

Our collective success over the past two decades in convincing the public and our local governments that most 911 calls require emergent lights and ALS resources — combined with a lack of empirical evidence behind this argument — have driven costs up beyond what our funding streams, public or private, can possible sustain over the long run. Systems utilizing dual paramedics on ambulances (public or private), often combined with multiple paramedics on the first response ALS apparatus, have created a dynamic of too few opportunities to perform skills and make complex critical decisions; likely preventing providers from gaining any sort of real and sustainable proficiency.

In the recent book, Outliers, by noted author Malcolm Gladwell, he opines based upon his research that the “magic number” for true expertise is 10,000 hours of practice. Gladwell writes, “Practice isn’t the thing you do once you’re good. It’s the thing you do that makes you good.”

It is really hard to imagine that today’s approach of too many paramedics across many systems can approach the requisite number of diverse medical and trauma responses and skills — accompanied by the training and learning experience necessary — required in order to achieve mastery in the way that Gladwell and others might define it.

I believe the answer lies in creating more affordable and sustainable systems — whether they are public, private, third service or a combination thereof — that address the EMS practices and politics of the past and drag them out into future of data-driven outcomes and economic reality.

This future will likely be painful for some and will require re-engineering of beliefs and systems most of us grew up with and have embraced during most of our professional careers, but it is a pain we can bear. It will require data and tangible proof of improved outcomes as the driving criteria for funding, training and system design.

In the coming months, as the debate around health care reform will likely take center stage, we will need to look critically at the new realities of today’s economic climate, and think about creating the systems of tomorrow that improve the lives of those involved in both a sustainable and meaningful way.