1. Designing a patient-
centered EMS system:
Barriers and
opportunities
Tony Farias
Project Mentor: Brendan Carr, MD,MS
LDI SUMR

2. Our project
 Aim: To identify barriers and determine opportunities to
develop a patient-centered pre-hospital care system
 How the project started
 Literature review and synthesis
 Meeting in DC with HHS policymakers
 Elaborated policy brief on EMS design and
reimbursement

3. Outline
Background
Emergency care
Why is it unique?
What is wrong with it?
 EMS: what role does it play in emergency care?
 How could it be better designed ?
Patient-centered EMS
 Funding and reimbursement
 Solutions

4. What makes Emergency Care
unique
 Time-sensitive , unscheduled acute
care
 Recommended wait time for emergent
cases: <14 minutes
40 minutes (GAO, 2009)
 EMTALA
 ~30% of patients on Medicaid or
uninsured (IOM, 2007)
 Surges in demand

5. Recent challenges
 # of EDs decreased while patient visits increased
 200 EDs less, 12,000 more patients (2001-2006)
 Limitations in inpatient beds
 90% of California EDs overcrowded (Derlet, 2004)
 Increasing first-contact care in ED (Kellerman, 2011)
 30 % of patients
 ED doctors <5% , but treat a quarter of acute care cases

6. ED crowding

7. EMS
~15% of ED visits nationally (Burt, 2006)

8. What are Emergency Medical
Services?
 What it is:
 Ambulance that responds when you call 911
 What it’s not:
 Transport between hospitals
 Scheduled transports to a home
 19 million+ medical transports a year
 Less than 1% the cost of healthcare

9. How is EMS contributing to
ED overcrowding?
 Prudent layperson
 How would you react if you felt chest pain?
 Encouraged reaction
 What will paramedic say?
 Must give alternatives to prudent layperson
 Opposed incentives

10. Current EMS design
Event trigger
(usually 911 call)
EMS arrives at your
location
Do you want medical attention ?
YES NO <10%
ED Sign AMA form

11. Patient-centered EMS design
911
Medical Attention?
NO
YES
AMA
Triage
Treat
at Primary
home Minute care
clinic physician
ED

12. Challenges to design reform
 Liabilities
 Patient acuity can be unclear
 Confidence in paramedic qualifications
 No central EMS authority in the US
 EMS funding and reimbursement:
Paramedics don’t get paid unless they drive you to the ED

13. Identity crisis in EMS funding
 Is EMS a public good?
 Is it like police and fire ?
 But is a billable service
 High fixed costs
 Garages
 Vehicles
 Funding

14. Crash course in EMS history
 Contemporary EMS began in 1960s to address
trauma injury, particularly car crashes
 Extensive federal government funding through block
grants given to states
 More than 800 EMS systems set up
 This was how infrastructure was paid for
 In the 1980s, federal funding started to dry up
 Reimbursement: fee-for-service (no limits)

15. Current EMS funding
 No federal funding
 Local tax-support
 Reimbursement
 > 50% of total EMS revenue
 New reimbursement structure in 2002

16. Reimbursement
 Medicare industry standard
 Patient falls into 1 of 7 categories depending on
provider/ drugs
 “Mileage, not medicine”
 Distance from pick-up to hospital
 Adjustment for extreme rurality
 Does not cover costs
 6% loss for every Medicare payer (GAO, 2007)
 Increase limited by inflation

17. Funding Reform
 Necessary for system redesign
 Lift restriction on payment exclusively on transport
 To implement new programs, more revenue needed
 Current revenue is not covering costs
 Innovation impossible
 To increase revenue, must solve identity crisis

18. Private
Public

19. New solutions in financing
Private Public
• National • Santa Ana --
Contractors “Insurance”
• Rural/Metro
• EMSCorp • Tax supported
• $3.1 billion

20. Summary
 EMS provides an opportunity to address ED crowding
 The current EMS design creates ED crowding
 Design reform necessary
 Need to better conceptualize what this means
 Identified possible barriers to change
 Funding and reimbursement
 Currently makes change impossible

21. Thank yous
 Dr. Brendan Carr
 Katie Wolff
 Rama Salhi
 Joanne Levy
 Lissy Madden
 LDI Staff
 SUMR Scholars