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Is EMS-on-demand the next big transformation for the profession?

Learn how MedStar made the jump to an on-demand subscription service that utilizes MIH/CP clinicians


Embrace the reality that many, if not most, 911 EMS responses are for people seeking “on-demand” medical care in their setting, in a reasonable timeframe, and help them figure out the best way to navigate the healthcare system by offering this service through a trusted community partner.

You’ve likely heard the term or read the book, “Emergency Medical Services at the Crossroads,” but the reality of that concept has never been more salient than it is right now.

For many EMS agencies, the current headwinds of response volumes being at an all-time high amid staffing challenges are forcing EMS agencies to rethink their service delivery model. A recent survey by the Academy of International Mobile Healthcare Integration (AIMHI) revealed that many EMS systems have transitioned away from an all-ALS ambulance deployment model to a tiered deployment model, using BLS ambulances as part of the 911 response resource deployment strategy.

Further, as part of another AIMHI study, although response volumes are increasing, the low-acuity 911 calls seem to be increasing at a faster pace than the high-acuity EMS responses. Several AIMHI member agencies also indicated they extended their response-time standards for low-acuity 911 calls, and Colorado Springs Fire Department recently announced they are no longer going to send a fire-first response or even an ambulance for low-acuity 911 calls. Instead, they will schedule a community paramedic unit to respond and assess the patient’s needs.

At the same time, mobile integrated healthcare and community paramedicine programs are finally starting to get the attention of payers. Commercial insurers, Medicaid and even local governments are increasingly willing to fund the service model to mitigate resource utilization and the expense of patients accessing 911 for low-acuity medical issues.

So, we have a decision to make – either figure out a way to create more resources to respond to low-acuity 911 calls or change our service offerings to prevent these 911 calls more effectively. There have been attempts to re-educate the public about only using 911 for emergencies, but we don’t necessarily do a very good job educating them on what constitutes a true emergency. Besides, the perception of an emergency may differ by individual.

But what about another option? Embrace the reality that many, if not most, 911 EMS responses are for people seeking “on-demand” medical care in their setting, in a reasonable timeframe, and help them figure out the best way to navigate the healthcare system by offering this service through a trusted community partner.

The MedStar-on-demand model

The concept of “EMS-on-demand” was first discussed over an early morning cup of coffee with EMS and MIH/CP guru Dan Swayze of the University of Pittsburgh Medical Center Health System. Dan and I were discussing the future of MIH/CP and the economical struggles many agencies have sustaining the model. Like most concepts rolling around in Dan’s brain, the possibility was certainly visionary, but would need some testing to see if it could bring any value. Even for MedStar, which has a history of testing new delivery models, the concept of EMS-on-demand seemed a little difficult to operationalize, let alone create an economic model that would make it sustainable in the long term.

Fast forward about two years, when we received an email from one of our well-known and well-respected independent high-rise retirement community partners, Trinity Terrace. As you can probably imagine, they had a problem they thought we might be able to solve. Their residents were looking for some type of medical care that could be available 24/7 and was not a 911 response, with all the bells, whistles and sirens that come with that, and perhaps some advice on whether they needed to go to a hospital. The owners of the facility thought that perhaps MedStar’s 911 nurse triage option might fit the bill. Sadly, we had to explain that our nurse triage resource was not available 24/7.

But what about testing a “MedStar-on-demand” model? MedStar has been providing MIH/CP services in the community for over a decade, and many of the Trinity Terrace residents have been part of that program because they were referred by area hospitals for things like readmission prevention. We already had an existing ambulance subscription program – MedStarSaver – to reduce out-of-pocket expenses. We proposed that we extend enrollment into our MIH/CP program for all residents who wanted to subscribe to the on-demand service and include enrollment in MedStarSaver.

With the on-demand model, called MedStarSaver+PLUS, the enrollee gets all the regular benefits from the StarSaver program, plus:

  • The option of two “on-demand” community paramedicine visits
  • The co-response of a community paramedic to any 911 activation

The CPs have specialized protocols that can be used for enrolled patients to potentially avoid a preventable transport to a hospital ED from the 911 activation. The StarSaver+PLUS service model would require an additional subscription fee because the cost of delivering this model is much more extensive, and much more valuable than the regular StarSaver membership, which runs $69/annually per enrolled household.

The MedStarSaver+PLUS membership is priced at $350 annually for each household, based on a cost estimate that includes:

  • Two on-demand visits
  • An annual 911 response
  • An initial enrollment visit to complete a brief patient intake for those enrolled in the MIH program to determine medical history, medications, advance directive wishes, primary physicians, etc., which is used to create a baseline medical profile for our patient care reporting system and our 911 computer aided dispatch (CAD) databases

Trinity Terrace officials liked the program details so much, that they agreed to pay the enrollment fee for any resident who wanted to enroll on a group enrollment basis! The facility offered to roll out the program by coordinating mass enrollments and initial intake visits during an all-day health fair, where we scheduled residents for 30-minute intake visits over two days.

We tested the model for two years, checking to see if:

  1. We could actually provide the service with enough reliability to make it valuable
  2. Whether or not the “demand” was overwhelming
  3. If we priced it right. The two-year clinical, operational and financial review proved the model was exceeding expectations for the residents, Trinity Terrace, and MedStar, so the facility renewed the agreement for another two years.

In September, following the success of the trial, we took the program mainstream by offering it to all community members.

The goals of the community-wide program include:

  • Delivering patient-centric care on demand for our community members
  • Avoiding preventable 911 calls by giving people the option for an on-demand visit from a MedStar community paramedic as opposed to calling 911
  • Enhancing the value and perception of MedStar, and our providers, to the community as a valuable community resource
  • Generating revenue for services that prevent a 911 call – if someone is going to get paid to reduce our revenue-generating call volume, it should be us!

A week in, the community response to the offering has been excellent, with many people seeking enrollment and even gifting subscriptions for at-risk family members. Time will tell if the community-wide offering changes the dynamic of 911 response volume, but at least it’s a way for EMS agencies to take a proactive approach to meeting community needs and creating value for community members way beyond simply responding to 911 calls.

Matt Zavadsky, MS-HSA, EMT, is the chief transformation officer at MedStar Mobile Healthcare, the exclusive emergency and non-emergency Public Utility Model EMS system for Fort Worth and 14 other cities in North Texas that provides service to 436 square miles and more than 1 million residents and responds to over 170,000 calls a year with a fleet of 65 ambulances. MedStar is a high-performance, high-value Emergency Medical Services system, providing advanced clinical care with high economic efficiency.

MedStar is one of the most well-known EMS agencies in the county, and operates a high-performance system with no tax subsidy, and the recipient of the EMS World/NAEMT Paid EMS system of the Year, and the only agency to be named an EMS10 Innovator by JEMS Magazine.

He is also the co-author of the book “Mobile Integrated Healthcare – Approach to Implementation” published by Jones and Bartlett Publishing.

He has 42 years’ experience in EMS and holds a master’s degree in Health Service Administration with a Graduate Certificate in Health Care Data Management. Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in high-performance EMS operations, finance, mobile integrated healthcare, public/media relations, public policy, transformative economic strategies, and EMS research.

Matt is also immediate past president of the National Association of EMTs, and chairs their EMS Economics Committee.