EMS and health care experts delivered five messages to 250 EMS leaders at the third annual EMS Transformation summit. The Washington, D.C. event, hosted by the NAEMT, was held in conjunction with the 2017 EMS on the Hill Day and designed in part to prepare attendees for their Congressional visits.
EMS Transformation Summit participants learned from an esteemed faculty group about medical direction and oversight, new service delivery and economic models, cybersecurity, education, research, and the current political climate in Washington.
Here are the top five messages delivered by the expert presenters.
1. Shared vision and industry alignment
EMS leaders who have had the opportunity to visit congressional offices in the past have often been told that it is confusing for elected officials to understand issues that are important to the EMS industry because we don’t always have the same message. If we are going to be successful changing public policy, it is important that the various EMS associations have a unified and consistent message.
Thankfully, when it comes to EMS 3.0, many of the major associations have endorsed the overall concept. In fact, the following groups are among the numerous associations that have formally endorsed the EMS 3.0 concept.
- National Association of EMTs
- American Ambulance Association
- National Association of EMS Physicians
- National Association of State EMS Officials
- National EMS Management Association
- National Association of EMS Educators
2. New payment models
The health care industry is moving from volume to value-based economic models. EMS agencies should continue to diligently investigate how this shift could impact them and perhaps even embrace the concept early. The foundation of this process is to assure you fully understand your cost of service delivery (per hour, per call and per transport) and revenue (billed and collected revenue and payer mix).
Some EMS agencies, especially agencies that have dual role community functions, have indicated in the past that determining service delivery cost is problematic, specifically when it comes to personnel costs. One way to start the cost analysis for your agency to deliver EMS is to honestly answer the question: “If we were to stop responding to EMS calls at all, what costs would we avoid?”
Obviously, all costs related to ambulance services, but also the EMS costs related to first response to EMS calls such as training, certification and premium differentials, medical equipment and supplies, as well as wear and tear and fuel costs related to EMS responses. With that understanding, you can work with payers to investigate reimbursement models that are based on the value you bring as opposed to whether or not a patient was transported to the hospital.
Some EMS agencies are already in negotiations with payers to change the reimbursement models. These models include payment for the response, regardless of transport, capitated per member/per month models that pay the EMS agency each month regardless if they respond to calls or not, or payment for an assessment and referral of patients to alternate destinations. Each of these models decouple the EMS payment from transport, allowing the EMS personnel to make decisions based on the needs of the patient as opposed to whether or not they will get paid for the call.
3. Data Integration and cybersecurity
EMS agencies have been in search of the data integration “Holy Grail” for years. Like the rest of the health care system, integrating patient and payer data across divergent system is not technologically difficult, but there often seems to be two main hurdles. First, demonstrating to the partner agency that sharing data is valuable and second, meeting their cybersecurity requirements.
There are a few strategies to overcome the first hurdle – demonstrating value of data sharing. Explain that data integration will allow valuable EMS utilization to be shared across the care continuum in nearly real-time. This means no more faxed EMS charts a couple of days later or time spent on by the partner organization’s staff searching for the ePCR.
Also, if discrete data elements can be received by the hospital, it could facilitate the population of various registries hospitals need to populate such as trauma, STEMI or stroke. This saves the hospital time and money.
Finally, a bi-directional data exchange that provides patient outcomes limits the number of phone calls from the ESM QA department and the hospital staff, as well as the time associated with searching for those patient outcomes.
The second hurdle – meeting cybersecurity requirements – is more problematic, especially on the payer side. Payers have a much different view of cybersecurity than most EMS agencies.
While negotiating an alternate payment model with a payer, we found that to even qualify to receive data from the payer, we needed to comply with 15 pages of their cybersecurity policies. Some were harder to comply with than others. For example, a requirement was that any non-employee in the facility where the payer data will be stored must be escorted by an employee. Another policy required all computers to have an automatic lock feature after five minutes of inactivity. For the routine business functions, that was not a huge issue, but we also operate a 9-1-1 PSAP in our facility – if a call taker has five minutes without a call, they would then need to log back in to the system to take a 9-1-1 call. That was obviously problematic for us, so we were able to negotiate a 15 minute lock out feature for the 9-1-1 work stations only.
Start asking your stakeholders early about their cybersecurity requirements so you can start planning.
4. Education to become clinicians
The achievement of our desired role in the health care system will likely require higher training and education standards. Agencies using community paramedics typically put those EMTs or paramedics through additional education and clinical rotations. For decades EMS has been expected to respond, assess, treat and transport patients to definitive care that in almost all cases is a hospital emergency department.
To become effective patient navigators, with the ability to assess whether or not a patient needs to go to and ED, or can be safely managed in an alternate setting, will require enhanced skills and experience. In other countries that use paramedics as care providers and navigators, such as the United Kingdom, Australia and Canada, paramedic education is a three-year degree, minimum. Oh, by the way, those paramedics are paid a lot more because of the understood value of paramedic patient navigation to the payers.
If we are going to be successful with new EMS 3.0 roles, we are going to have to get serious about moving away from a 1,500 hour training program for technicians toward education for clinicians. Herein lies the chicken and the egg issue – which comes first, the education or the pay? It’s likely the education will have to come first, then, as more employers use the higher trained paramedic clinicians to demonstrate improvement in patient outcomes and experience of care, and reduced costs though navigation to alternative receiving locations, the pay will follow.
5. Evidence and research
Sadly, there is a dearth of peer-reviewed research that demonstrates that a patient with a fractured leg that goes to the emergency department by ambulance has a better outcome than going by private car. The same can be said about virtually 95 percent of the calls EMS responds to. There is research that indicates a STEMI or stroke patient taken by ambulance, with early notification to a STEMI or stroke center reduces patient mortality, but most other call types, there is little evidence what we do makes a difference.
Conversely, there are published studies that indicate trauma patients taken to an ED by police car have better outcomes than going by ambulance. Another study indicated that cardiac arrest patients treated by BLS care have better outcomes than patients treated with ALS care.
There have been studies – California community paramedicine pilot projects, innovative approach to patients with chronic conditions, advanced illness management, and expanding patient’s choices beyond traditional acute-care settings – published that demonstrate MIH and patient navigation improve patient’s experience of care and reduces the expenditures, but the EMS industry needs to focus on outcome-based research that demonstrates patient outcomes and experiences are better with a traditional EMS intervention.
Next steps for the EMS 3.0 transformation
To become part of the EMS 3.0 transformation, there are five action steps you should take now:
1. Strengthen your competencies
In all professional levels grow your knowledge and capabilities to effectively provide the services that the community needs. Do this by:
- Subscribing to the information sources, such as EMS1, the NAEMT and NASEMSO MIH-CP list servs, and the AIMHI e-mail news distribution lists.
- Attending national EMS conferences such as EMS World Expo and EMS Today. They typically have substantial content on EMS 3.0 and MIH-CP service delivery.
2. Embrace reimbursement linked to clinical outcomes
Continuous quality improvement and striving to adopt pay for performance/value based purchasing reimbursement linked to clinical outcomes is the wave of our future. It’s better to be on the bus than run over by it.
3. Advocate for EMS 3.0
Utilize all opportunities to advocate for how EMS 3.0 supports the health care transformation with anyone who will listen – hospitals, payers, elected and appointed officials, even your own agency personnel.
4. Know EMS 3.0 services
As EMS leader you need to be able to clearly articulate the types of services that EMS 3.0 can offer to improve patient outcomes and lower costs. An important infographic to help you with this is available for download on NAEMT’s EMS transformation website.
5. Integrate EMS services
All of your organization’s services need to be integrated into a well-coordinated, medically directed and performance-measured EMS 3.0 package of services provided by professionals at basic and advanced levels. Make sure to include the tracking and reporting of EMS quality and outcome metrics.
