This is an edited version of an email response to a recent NEMSMA Google group inquiry.
By David Shrader
EMS response times have always been and remain publicly important because political people, the press and citizens are all qualified to read a clock. It is about the only thing about EMS and its reimbursement that most people really understand.
About 6 percent of 911 patients have time-sensitive ALS needs. But, for those patients time can be a critical issue of morbidity and mortality. Ninety-four percent don’t have a clinical time-dependent issue, but they are still expecting rapid customer service. Imagine if it took McDonalds half an hour to cook your fries. You would go somewhere else.
So response times are more than a clinical issue, they are also a customer service issue. Regardless of the service model — voluntary, third service, private, corporate, hospital-based, fire-based or public utility model — here are the reasons that response times matter for all EMS calls.
Customer satisfaction with response and care
Emergencias and ECCO are two premier EMS providers in Argentina. They both provide EMS on a house call basis with physician-staffed ambulances and have remarkable response time reliability, transporting very few patients to the hospital. Both are subscription-based and have some of the best customer service and survey programs that I’ve seen in healthcare.
The only healthcare providers in the United States who come close to matching their satisfaction levels are veterinarians who have to compete for your business. Competition is one of the reasons that If I take my dog in for an issue, I get a call, without fail, the next day to see how my dog is responding to treatment. Oh, if people care were so caring and responsive!
Many companies use patient surveys that are sent with their bills. When I was at Medevac in California, many years ago, every bill contained a survey. A majority of them were returned and they were around 98 percent positive. If a patient said we broke their screen door or lost their pillow or egg crate mattress pad, I sent a supervisor out immediately to replace or pay for the loss. When reporting our performance to the county, that 98 percent and a bunch of thank you notes carried huge political influence.
Helping improve throughput makes receiving facilities happy
Receiving facilities will be most happy if you bring them the paying patients and take the deadbeats to their competitors. Most hospitals and skilled nursing facilities are more focused on the time issue for interfacility transports.
If you can get the patient out on time and before they have to feed him another $4 lunch that makes the facility happy. Sometimes they will ask for an ASAP or emergent call, just because they want the patient out and the bed cleared. If it is a Medicare Part A patient serving another meal may count against them in their internal accounting and prevent them from serving a meal to a new Part A patient, thereby getting paid more and sooner for the new patient. Much like the restaurant business, there is a focus on turnover now that reimbursement is based more on condition than the length of stay.
Improving throughput at certain facilities is important. In one California county, we were awarded one of the largest facility ambulance contracts because of a radiology tech that was about to lose his job. The problem was that patients were arriving and leaving late, giving him a clinical staffing problem and a long queue for his CAT scanner and MRI. It was effectively a patient traffic jam. We cleaned it up with a performance contract, doubled the throughput and saved his job. The facility made a lot of money and paid us pretty well.
Efficient interfacility transports impact 911 response
In one Texas community, we dealt with an EMS diversion problem by giving interfacility exclusivity with performance standards to the 911 contractor. That meant that the patient from the medical surgical unit to the SNF on time and the patient from the step down unit could go to med-surg and the patient from CCU could go to the step down unit and the patient in the ED could get a bed in CCU. That all meant less wall time for EMS crews waiting for a bed. It only took about 24 hours to flush through the system and make everyone more efficient.
Exclusivity is not the only solution either. When I ran an operation in Orange County, California, with a number of competing providers, if a hospital asked for a transport and you responded that it would take longer than 15 minutes to get there, they would call someone else.
In another California contract, as we were about to close a five-facility deal with a Catholic Integrated Delivery System, their CFO asked how we maintained our ambulances. We started touting our predictive failure program as similar to airline maintenance and he stopped us. He wanted to know if we employed mechanics or farmed it out. We told him we ran our own shops.
That led to solving his biggest headache. It seems they had a fleet of ‘nunmobiles,’ sedans that the nuns drove until they broke down. Then they were towed to the nearest gas station and fixed at a premium cost. As a result, on the day we opened shop, we had one wheelchair car, one BLS ambulance, one critical care ambulance and leased the system’s 105 ‘nunmobiles.’ Our people had fun teaching the sisters to drive and comply with the then FailSafe driving system!
What about the cost of rapid response?
As far as costs are concerned, many systems either don’t care or don’t effectively measure them. Many public systems do not include many significant costs in their calculation. A few years ago, during a cost survey one city publicly claimed an actual cost of $1,800/transport, but did not include capital, station, utility, human resources, legal, insurance, dispatch and a host of other costs. At last look they billed around $900/transport and collected around $200. When asked what their subsidy per call was, they said they did not understand the question.
In contrast, the public utility model systems are all very good at measuring and defining costs. Most private providers are pretty good as well, but often less willing to share specific information. Hospital-based systems often face problems with expenses and revenues that get mixed with the bigger hospital budget.
Additional ems cost considerations
One large hospital system with which I’ve worked actually credits their in-house transport program with retained revenue by keeping the patient in the system. Before they doubled the number of hospitals through acquisition, they ran 29,000 ambulance runs annually using ALS interfacility units, five kinds of critical care units and a helicopter within one state. They do not do 911, unless requested in a disaster. Their director once described them as “One Big Hospital with really long hallways.” Now, some of those hallways are more than 150 miles long.
Response times matter
There are some people out there looking at the right stuff. They are just not that easy to find.
Do response times matter? Yes!
For a small subset of patients, EMS response times are a critical matter of morbidity and mortality. We just don’t know if the next patient will be one of those.
In the customer service arena, response times are crucial. Frankly, most policymakers will not know if you are delivering 90 percent of responses in 8 minutes or 10 minutes, but they will notice the outliers, the long calls. The thinner the resources and longer the response standard, the more likely those outliers will happen in many communities. One 30-minute response time with a bad outcome on the front page of the paper will invite significant and maybe even unfair scrutiny as the public becomes outraged.
Finally, response times are politically important. The very worst thing any EMS system can do to its stability is to embarrass the local legislative body (county or city council, district board, etc.) and create a specific public relations threat to the elected or appointed overseers. That often creates motivation to “do something” and that often means changes in people, budgets and providers.
About the author
David Shrader was the president of The Polaris Group, an international public safety consulting company that specializes in EMS and fire system design. He worked in the field as an EMT, paramedic, flight medic, SWAT medic and law enforcement officer, special rescue technician, training officer and EMS chief in a public system. During his time in private and hospital EMS, he served in several capacities including regional CEO of several large operations. David has also served as a volunteer in EMS and fire and until recently was deputy fire chief in his local community. During his career, he has worked in voluntary, third service, private, corporate, hospital-based, fire-based and public utility model EMS systems. Shrader, 62, passed away at his home October 26, 2017.