Keynote: Dr. Garza tells how EMS must evolve

To avoid extinction, EMS needs to embrace community paramedicine, value-based purchasing and look for innovative ways to improve services

WASHINGTON — The role of EMS in health care is like renting out a house. Eventually, the building needs repairs.

If you don't keep track of what was fixed, and if your contractors don't communicate, you may wind up fixing the same windows twice. Soon, you're spending more money than you expected on upkeep and have to start cutting back on vacations and other aspects of your life.

"That's health care economics right there," said Dr. Alexander Garza during his opening keynote address at EMS Today.

The former assistant secretary for health affairs and chief medical officer for the U.S. Department of Homeland Security, Garza started his career as an EMT. Drawing from his experience working at every level of the industry — including flight medic, emergency physician in the Army, and both a municipal and state EMS administrator — his overarching perspective provided insight into something many in the field have already begun to grasp.

"We can't keep going the way we are now," Garza said. "Something has to give or we're going to go bankrupt."

Do the math

In EMS, we're spending nearly 2.5 percent more than the rate at which we're growing, he said. The government allocates about $8,900 a year per person on health care, and costs have skyrocketed from $2.1 million in 1996, to $4.5 million in 2011.

Health care costs make up 22 percent of the 3.5 trillion U.S. budget, and along with social security and defense, account for 60 percent of available spending — more than half of the country's bankroll.

Meanwhile, out of the 700-page Affordable Care Act (or Obamacare), EMS is mentioned a mere seven times. But many of the national health care changes directly impact the emergency response industry, Garza said.

Value-based purchasing

Under the current EMS structure, a circular pattern continues to grind away at the system: go to the hospital, get stuff done, bill Medicare, get paid. Of those admitted to the hospital, 20 percent are readmitted within 30 days, thus continuing the cycle and draining an estimated $12 billion a year from the system.

"How about we take that $12 billion and help them stay out of the hospital," Garza said.

Focusing on patients 65 years or older with acute myocardial infarction, congestive heart failure and pneumonia, all of which often lead to readmissions, could go a long way in that regard.

"If we can control these three diseases, we’re doing pretty good," he said.

Under Obamacare, hospitals have implemented value-based purchasing programs, where incentive payments are made to those who meet certain performance standards. And if they don't meet them, they're penalized. Hospitals were fined around $280 million last year.

Implementing a similar program in EMS seems like the next logical next step, Garza said, using incentives such as EMS mortality rates. The agencies that are already doing a good job with services "are going to be the ones to compete for these resources," he said.

Running in place

The field also has to use more science and research to make informed decisions. Not long ago, tourniquets were considered a last resort, to be applied only in life-threatening situations after 15 minutes of bleeding.

Multiple wars and experience show that tourniquets really do save lives, and they're now considered a basic medical supply.

But EMS needs to constantly make such adjustments, Garza said. He talked about the Red Queen hypothesis, a theory derived in Lewis Carroll’s "Through the Looking-Glass," where Alice runs after the Red Queen, but when they stop running they haven't moved.

The Red Queen responds: "Now, here, you see, it takes all the running you can do, to keep in the same place."

"The environment is changing and you have to adapt," Garza said. "Keep running, and run really, really fast so you don't go extinct."

Ways to evolve

EMS is good at operating under an organized system and covering large populations, which perfectly positions the industry to take on community paramedicine, Garza said.

In this regard, workers need to look beyond the EMS cycle of receive the 911 call, respond, transport the patient to the hospital and wait for the next call.

"You're not going to be competitive in the world of health care with that DNA," he said. "You need to change your DNA."

Garza recalled a situation where an agency was responding to a homeless shelter 600 times a year. So they put a paramedic in the shelter. Calls fell by 60 percent.

Changing regulations that require patients go to the emergency room is also necessary, he said, especially when it's often clear that a patient who called 911 really needs a social worker to help turn the electricity back on.

"EMS takes care of people in their environment," he said. Responders are the ones who notice the lights are off because a bill hasn't been paid. They open the fridge and see there's no food. They hug moms and dads, tell kids it will be OK, and put money in the pockets of the cold and hungry.

"Sometimes," he said, "the greatest act of heroism in EMS is compassion when people are hurt, and understanding when things don't make sense."

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