Emer­gency med­i­cal ser­vices face their own trau­mas

Emer­gency med­i­cal ser­vices sys­tem faces myr­iad chal­lenges, in­clud­ing over­haul of re­im­burse­ment struc­ture

Modern Healthcare - - FRONT PAGE - Paul Barr

Emer­gency med­i­cal tech­ni­cians, first re­spon­ders and paramedics—the back­bone of emer­gency med­i­cal ser­vices—have worked for decades un­der a re­im­burse­ment sys­tem that ef­fec­tively keeps their pay low and gives them an in­cen­tive to not al­ways pro­vide ef­fi­cient, qual­ity care. That re­im­burse­ment model may be in for re­vi­sion, though, a move that would be wel­comed by many in the in­dus­try.

At the cen­ter of the prob­lem is a 1960s-era re­im­burse­ment model that EMS ex­perts say no longer fits with how the EMS com­mu­nity wants to pro­vide care. Un­der the cur­rent model, which was de­vel­oped when am­bu­lances were used for trans­porta­tion only, an am­bu­lance ser­vice gets paid only if a pa­tient is trans­ported to a hospi­tal.

An EMT or para­medic who spends the time and ef­fort to ap­pro­pri­ately sta­bi­lize a pa­tient in a home or at the scene of an ac­ci­dent gets re­im­bursed noth­ing if the pa­tient feels well enough to de­cline a trip to the emer­gency room. But if that same pa­tient—who may not need ad­di­tional care—de­cides to visit the ER, then not only does the am­bu­lance ser­vice get paid, but the hospi­tal ER does too, un­leash­ing a string of bills that pos­si­bly could have been avoided.

That kind of re­im­burse­ment for a ser­vice de­signed to be ready to go at any time makes it dif­fi­cult to sup­port the in­fra­struc­ture and over­head of EMS. It also en­cour­ages in­ef­fi­cient use of health­care re­sources.

“There’s a dis­in­cen­tive to not take peo­ple to the hospi­tal,” says Skip Kirk­wood, pres­i­dent of the Na­tional EMS Man­age­ment As­so­ci­a­tion and chief of the Wake County Emer­gency Med­i­cal Ser­vices di­vi­sion, Raleigh, N.C. Kirk­wood and oth­ers say that EMS pro­fes­sion­als do their job to the best of their abil­ity, but EMS providers could do more, sav­ing the health­care sys­tem money by pro­vid­ing ad­di­tional care up­front. But the cur­rent re­im­burse­ment model ef­fec­tively dis­cour­ages pre­ven­tive care by not giv­ing agen­cies the re­sources to pro­vide it, Kirk­wood says.

And while the coun­try has come to ex­pect the use of tax money to pay for the readi­ness of fire pro­tec­tion, am­bu­lance ser­vice is not al­ways sub­si­dized with taxes. There isn’t an au­to­matic ex­pec­ta­tion that the gov­ern­ment should back EMS providers. That means am­bu­lance ser­vices of­ten may run on a shoe­string or may sub­si­dize emer­gency care with none­mer­gency care, such as trans­fer­ring pa­tients be­tween health­care fa­cil­i­ties.

In fact, the trend among public am­bu­lance providers is to pull back, ex­perts say.

“We’re ac­tu­ally los­ing jobs” in the mu­nic­i­pal and county are­nas, says Con­nie Meyer, board pres­i­dent of the Na­tional As­so­ci­a­tion of Emer­gency Med­i­cal Tech­ni­cians and EMS cap­tain for John­son County (Kan.) Med-act, a public EMS provider. “We’re try­ing to make the case that we’re a vi­tal part of the health­care sys­tem,” she says. “EMS is a safety net for the health­care sys­tem.”

As a re­sult of the cur­rent re­im­burse­ment model, regions in which emer­gency med­i­cal ser­vices don’t have well-sub­si­dized fund­ing from the com­mu­nity tax base are more likely to pay their EMS per­son­nel less and strug­gle to keep per­son­nel in the field for a long time, in­dus­try ex­perts say.

Com­pen­sa­tion and re­ten­tion

Re­cent data from a fed­er­ally backed 2010-11 sur­vey of mem­bers of the Na­tional As­so­ci­a­tion of State EMS Of­fi­cials, or NASEMSO, shows that EMS salaries can be low given their im­por­tance in the clin­i­cal-care spec­trum. That sur­vey found emer­gency med­i­cal tech­ni­cians earned a me­dian of $25,066 to $28,600 a year, while some­one with the more-ad­vanced des­ig­na­tion of para­medic earned a me­dian of $38,000, ac­cord­ing to the sur­vey, which for this por­tion re­ceived re­sponses from 26 to 29 states.

A sep­a­rate re­port from the U.S. Bureau of La­bor Sta­tis­tics, which groups EMTS and paramedics into one clas­si­fi­ca­tion, es­ti­mated their 2010 me­dian pay to be $30,360 a year. EMS work­ers who do dou­ble duty as fire­fight­ers gen­er­ally earn more. The me­dian salary in 2010 for a fire­fighter was $45,250 a year, ac­cord­ing to the BLS. Both fall short of the me­dian salary of reg­is­tered nurses, which was $69,110 as of May 2011, ac­cord­ing to the BLS.

“There is a re­ten­tion prob­lem be­cause (EMS) is what peo­ple con­sider a low-pay­ing job,” says Wil­liam Brown Jr., ex­ec­u­tive di­rec­tor of the Na­tional Reg­istry of Emer­gency

Med­i­cal Tech­ni­cians, which of­fers pro­fes­sional EMS cer­ti­fi­ca­tion. The re­im­burse­ment needs to in­clude a com­po­nent that cov­ers the “readi­ness” re­quired of EMS, Brown says. “How are you sup­posed to sup­port the de­liv­ery of EMS to 300 mil­lion Amer­i­cans when you do not get paid for a lot of the work and readi­ness that you do?” Brown asks.

While EMS per­son­nel in ur­ban set­tings gen­er­ally get paid a salary, there are still a large num­ber of EMS re­spon­ders who get paid lit­tle or noth­ing as vol­un­teers. That cre­ates some ten­sion in the in­dus­try, with some want­ing to boost en­try-level EMS stan­dards. The U.S.’ stan­dards are among the low­est of English­s­peak­ing coun­tries, Kirk­wood says, while com­mu­ni­ties re­ly­ing on vol­un­teers of­ten op­pose it. Vol­un­teer EMS per­son­nel are al­ready be­ing asked to do a lot, and rais­ing stan­dards would make it even more dif­fi­cult to at­tract and re­tain vol­un­teers, he says.

“Peo­ple who do it for free want to do it with min­i­mal in­vest­ment,” he says.

Chang­ing cer­ti­fi­ca­tion

The Na­tional Reg­istry of Emer­gency Med­i­cal Tech­ni­cians is in the process of re­work­ing or re­nam­ing its cer­ti­fi­ca­tion lev­els, elim­i­nat­ing some of the cat­e­gories and in­tro­duc­ing a new one. Once all of the changes are in place by the end of 2013, the num­ber of cer­ti­fi­ca­tion lev­els will stand at four: emer­gency med­i­cal re­spon­der, emer­gency med­i­cal tech­ni­cian, ad­vanced emer­gency med­i­cal tech­ni­cian and para­medic.

The emer­gency med­i­cal re­spon­der cer­ti­fi­ca­tion, which will re­place the first re­spon­der des­ig­na­tion, al­lows the holder to pro­vide front­line EMS care though they can­not care for pa­tients in the back of an am­bu­lance, ac­cord­ing to the NREMT. EMTS can treat pa­tients in an am­bu­lance us­ing med­i­cal equip­ment such as au­to­matic de­fib­ril­la­tors as well as de­liver trauma care; EMTS are also ed­u­cated in sim­ple meth­ods to treat in­juries and dis­ease.

An ad­vanced emer­gency med­i­cal tech­ni­cian re­quires EMT cer­ti­fi­ca­tion plus ad­di­tional ed­u­ca­tion, al­low­ing the holder to pro­vide more ad­vanced care. The para­medic cer­ti­fi­ca­tion also first re­quires EMT cer­ti­fi­ca­tion, and they pro­vide the high­est level care of the EMS pro­fes­sion­als. Not all EMS sys­tems will be af­fected by the changes be­cause NREMT cer­ti­fi­ca­tion is op­tional and some states of­fer their own ex­am­i­na­tions or rec­og­nize only some of the cer­ti­fi­ca­tion lev­els.

De­mo­graph­ics of the coun­try also may be work­ing against EMS by pos­si­bly cre­at­ing a short­age of these staffers.

“We’re go­ing to face in­creased chal­lenges in the fu­ture be­cause of all of the baby boomers grow­ing older,” says Gary Lud­wig, deputy fire

chief for the city of Mem­phis, Tenn. Mem­phis is putting a greater amount of em­pha­sis on EMS care and is in­creas­ing its work­force and fund­ing for it, Lud­wig says.

Some in­flu­en­tial groups are tak­ing a look at these core prob­lems with how emer­gency med­i­cal ser­vices are pro­vided and paid for, and changes could oc­cur given health­care’s shift­ing of more fo­cus on a pa­tient’s en­tire con­tin­uum of care and re­ward­ing providers for im­proved qual­ity.

Dia Gainor, ex­ec­u­tive di­rec­tor of the NASEMSO, says there are a num­ber of is­sues that in­dus­try stake­hold­ers are work­ing to solve, in­clud­ing a work­force count; cre­at­ing na­tional def­i­ni­tions for what con­sti­tutes an EMS worker—paid or vol­un­teer; and the in­dus­try’s ap­proach to re­im­burse­ment, which gen­er­ally is be­low the cost of pro­vid­ing the ser­vice.

Work to re­view the EMS model is un­der way at or­ga­ni­za­tions such as the U.S. Depart­ment of Trans­porta­tion’s Na­tional High­way Traf­fic Safety Ad­min­is­tra­tion, the Na­tional EMS Ad­vi­sory Coun­cil and the Medi­care Pay­ment Ad­vi­sory Com­mis­sion as well as the NASEMSO.

The NHTSA, which has pri­mary over­sight of EMS as a re­sult of its his­tory as a trans­porter of pa­tients, com­mis­sioned a se­ries of ma­jor re­ports on the EMS work­force. The most re­cent of which, re­leased last year, aims to high­light the is­sues fac­ing the in­dus­try. Called The Emer­gency Med­i­cal Ser­vices Work­force Agenda for the Fu­ture, the re­port out­lines goals re­gard­ing EMS work­force: health and safety; ed­u­ca­tion and cer­ti­fi­ca­tion; plan­ning and de­vel­op­ment; and data and re­search.

The dearth of data on the EMS work­force was pre­vi­ously ad­dressed in a 2008 NHTSA re­port, and was sum­ma­rized in the more re­cent re­port. “The most ba­sic work­force sta­tis­tics, such as work­force size, can­not be ac­cu­rately es­ti­mated us­ing avail­able data,” the re­port au­thors wrote. The BLS doesn’t dis­tin- guish be­tween EMTS and paramedics, does not iden­tify EMTS cross-trained as fire­fight­ers, and does not cap­ture vol­un­teer EMS work­ers, ac­cord­ing to the re­port. Oth­ers note that many EMS work­ers have more than one job, which also com­pli­cates the cal­cu­la­tion of an in­dus­try work­force to­tal.

“It’s very hard to count this work­force,” Su­san Chap­man, one of the au­thors of both re­ports, says in an in­ter­view. There have been dif­fer­ent at­tempts to cal­cu­late work­force to­tals, but the stud­ies’ re­sults pro­duce di­ver­gent num­bers, says Chap­man, di­rec­tor of al­lied health work­force stud­ies at the Univer­sity of Cal­i­for­nia at San Fran­cisco’s Cen­ter for the Health Pro­fes­sions and an as­sis­tant ad­junct pro­fes­sor at the UCSF School of Nurs­ing.

Ef­fects of re­form

An­other ef­fort by the Nhtsa-af­fil­i­ated Na­tional EMS Ad­vi­sory Coun­cil is study­ing the ways the EMS seg­ment could par­tic­i­pate in the kind of ini­tia­tives be­ing im­ple­mented as a re­sult of health­care re­form, such as pay-for­per­for­mance and shared-sav­ings pro­grams, says Marc Gold­stone, a mem­ber of the coun­cil and vice pres­i­dent and as­so­ci­ate gen­eral coun­sel for a re­gional di­vi­sion of Com­mu­nity Health Sys­tems Pro­fes­sional Ser­vices Corp., Franklin, Tenn., the man­age­ment ser­vices unit of for-profit hospi­tal chain Com­mu­nity Health Sys­tems.

“The coun­cil has been very ac­tive,” and is ad­dress­ing a num­ber of is­sues, in­clud­ing at­tract­ing and retaining good em­ploy­ees, Gold­stone says.

MEDPAC’S in­ter­est in EMS is driven by an or­der from Congress that was part of the Mid­dle Class Tax Re­lief and Job Cre­ation Act of 2012, which calls for the ad­vi­sory group to re­search whether the Medi­care am­bu­lance fee sched­ule—which pro­duced fees of $5.2 bil­lion in 2010—should be reformed in the long term and for shorter-term is­sues re­lated to ru­ral Medi­care add-on fees that were im­ple­mented in 2008 to try to al­le­vi­ate some re­im­burse­ment prob­lems.

MEDPAC mem­bers ex­pect to get at least an ini­tial draft of a re­port from staff mem­bers be­fore the add-on fees ex­pire at year-end, though the final re­port isn’t due un­til June 15, 2013, ac­cord­ing to a tran­script of an April MedPAC meet­ing.

And just last week, a group of in­dus­try stake­hold­ers con­vened by the NASEMSO was set to meet to move for­ward with the Nhtsa-funded project ti­tled EMS Work­force Plan­ning and De­vel­op­ment Guide­lines for State Adop­tion.

The goal is to pro­duce “an in­for­ma­tive

doc­u­ment to pre­pare state EMS of­fices to prop­erly col­lect and ag­gre­gate Ems-spe­cific work­force data in a man­ner con­sid­ered ap­pro­pri­ate by the work­force de­vel­op­ment plan­ning in­dus­try, and pro­vide the state EMS of­fi­cials with enough depth and lit­er­acy to be en­abled to en­gage their state depart­ment of la­bor, state work­force de­vel­op­ment com­mis­sion, or oth­ers to ini­ti­ate a sec­tor-based strat­egy for work­force plan­ning and de­vel­op­ment,” ac­cord­ing to the meet­ing in­vi­ta­tion.

Al­ready be­ing tested in ur­ban and ru­ral set­tings is the con­cept of com­mu­nity paramedicine. The con­cept is based on giv­ing spe­cially trained paramedics the abil­ity to work as pri­mary care­givers in se­lected sit­u­a­tions and set­tings. The move­ment aims to draw on ex­ist­ing skills and ap­ply them in new ways, pro­vid­ing well­ness care or per­form­ing fol­low-up vis­its for pa­tients who could ben­e­fit from as­sis­tance in the home but may not re­quire a tra­di­tional home health visit (Aug. 22, 2011, p. 28).

The ap­proach re­quires a more ex­treme re­work­ing of re­im­burse­ment. Min­nesota has ap­proved a form of that type of care for ru­ral Med­i­caid par­tic­i­pants and test projects are in place in sev­eral other parts of the coun­try.

Some providers have taken it into their own hands to boost EMS care. In parts of Ken­tucky and Ten­nessee, an As­cen­sion Health-owned chest-pain net­work has trained EMS per­son­nel to try to im­prove out­comes in the regions it serves, says Ra­nee Cur­tis, di­rec­tor of re­gional net­work ser­vices for Nashville-based St. Thomas Health, which runs the St. Thomas Chest Pain Net­work.

In de­vel­op­ing the net­work, St. Thomas found that there were a va­ri­ety of pro­to­cols and pro­ce­dures in place among var­i­ous EMS providers, while re­sources and ed­u­ca­tion were lack­ing. As a re­sult, the net­work cre­ated train­ing pro­grams for EMS work­ers and other care­givers to try to stan­dard­ize care within the net­work, Cur­tis says.

St. Thomas net­works have trained about 1,200 EMTS and paramedics in crit­i­cal care, ven­ti­la­tion trans­port and other types of pre-hospi­tal care, a spokes­woman says. The net­work also has de­vel­oped the first state-ap­proved crit­i­cal-care para­medic course, ac­cord­ing to St. Thomas. EMS played an in­te­gral role, Cur­tis says. “We want EMS to be a value to the com­mu­nity.”

EMTS from the Mem­phis (Tenn.) Fire Depart­ment tend to an in­jured pas­sen­ger. EMS is get­ting in­creased em­pha­sis, one city of­fi­cial says.

Source: Na­tional EMS As­sess­ment, Na­tional As­so­ci­a­tion of State EMS Of­fi­cials

Of­fi­cials of St. Thomas Health, Nashville, par­tic­i­pate in an EMS train­ing ex­er­cise.

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