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This Weekend’s Homework Assignment

For many years, fire departments (many, but not all), have had their capabilities rated by the Insurance Services Office. These ratings, formally referred to as Public Protection Classifications,  graded fire departments on a set of standardized benchmarks on such things as response times, coverage area size, water pressure, number of hydrants, etc., as well as proficiency in the technical aspects of fire suppression. The better a department measured up, the higher their rating. A CLass I rating is considered a badge of honor for fire departments.

Now, the benefit to the citizenry came in the form of lower homeowner's insurance premiums. The higher your local fire department's PPC, the lower your premium. Thus, fire departments had incentive to provided the best services possible, and fire chiefs could point to tangible benefits to the homeowners they served when it came time to pass, increase or renew taxes to support department operations.

Now imagine, if you will, a similar mechanism for EMS systems. If your system boasts stellar cardiac arrest survival rates, or great response times, or pioneered a new sepsis alert protocol that lowered mortality in your area for sepsis patients, or just purchased CPAP devices that dramatically reduced the number of CHF patients getting costly ventilator care in your local ICU's, why shouldn't there be some break in health insurance premiums for the citizens you serve? For that matter, why not pay for performance? Should systems that perform exceeedingly well get better reimbursement than low-performing systems?

That way, your local EMS system would have incentive to provide top-notch care, and citizens would have tangible reasons to support your operations with tax dollars.

So, your homework assignment is as follows:

  1. What would be necessary to implement such a system?
  2. Who should administer it?
  3. What benchmarks should we require? And no vague answers like "response times." Response times are arbitrary and meaningless for the vast majority of EMS calls. If that's a benchmark, specify a a target response time for a particular type of call.
  4. What are the obstacles to implementation, and how might we overcome them?

Feel free to give me your ideas in the comments, or if you prefer, use this as fodder on your own blog, and post a link back here.

I'm interested in hearing your thoughts…

Comments - Add Yours

  • http://www.facebook.com/wpluhar Wayland Pluhar

    An obstacle that would hinder uniform implementation would be the large number of volunteer EMS groups that provide service to rural areas. Many of which are glad to have enough people that really are JUST ambulance drivers to make a run.

    • Ambulance_Driver

      So those communities default to the lowest rating, whatever it is. If/when they decide to better fund and equip the volunteers, or go to a paid system, ratings go up and premiums go down.

      • trixie77

        Deliberate (IMHO) Lack of oversight leading to lack of accountability in the volunteer system is the overwhelming obstacle to having this work. No one wants to be the bad guy. If we upset the volunteers, another option to provide emergency services is necessary-who will pay for it? the taxpayers? The general population is completely ignorant( and content to stay that way ) about the way in which EMS is delivered until they need it. No politician is going to take one for the team on this front. I agree with you in principle 100% but I dont know who is going to be our Don Quixote for this fight.

        • http://www.facebook.com/profile.php?id=1088829873 Skip Kirkwood

          How about some politician that WE get elected with this task in mind?

          Oh, never mind – that would mean that we have to join our associations and work together – and EMSers just don’t do that!

        • MidwestMedic

          Maybe it’s time to start moving away from the smaller, independent type of ambulance services that dominate many areas, fire based EMS that ends up using billing money to pay for multi-million dollar suppression apparatus, and independent private services, and move towards hospital based, or large scale county based third services. I’ve been around and known people that work for these kinds of strictly ambulance operations and they have nowhere else to put their money except back into EMS in some way, shape, or form. And it helps with the problem of having people on the ambulance that would rather be on the big red truck. No, it does not mean that every one of these services is the end-all-be-all but it’s a step in the right direction. And as far as upsetting the volunteers, I’m all for having full time staff with a number of volunteer/POC types to bring in for shift coverage, or for utilizing extra ambulances on the occasion where it is necessary. Provided they keep up with training standards, of course.

    • Jayme

      With out volunteer EMS groups like the one that I belong to (as a soon to be AEMT) there would be a massive portion of the population that would not have any emergency care except for the county coroner coming to pick them up when they die from what could have been a ‘savable’ event. We run with 2 EMTs (or higher) on any of our ambulances at all times. We are not JUST ambulance drivers.

      • Vudumedic

        I am sure there is no malice behind that comment. Anyone from a rural area realizes that without those volunteers there would be no service at all. We all applaud you for being able to give the time and effort to provide that service. However if there was an incentive for those areas to move to a paid service where they didn’t have to rely on a volunteer only base for their care providers then maybe they would be able to see a medic on every unit and the equipment that medic needs on every ambulance. We could move from being the proverbial “redheaded step child of a Firefighter and a RN,” and be seen for what we truly are healthcare professionals not ambulance driver’s.

        • Ambulance_Driver

          I believe there are some communities that *can’t* support a full-time paid EMS system.
          I also believe that there are many more communities that *won’t* support a full-time paid EMS system, because they know that they can always find someone to do it for free.
          We have to figure out some way of doing away with the latter while preserving the former if we’re going to move forward.

  • http://www.facebook.com/profile.php?id=1007243313 Christie Lea Hale

    What would be necessary to implement such a system?There would definite need more progressive continuing education and not the same old stuff every four years. Medicine is ever evolving and if a service is going to taut themselves as “stellar” or “progressive” or some other moniker that denotes exceptional service they will need to make much more of an effort than currently exists. Also valid research needs to be done on what is beneficial and applicable to the patient populations that EMS represents. EMS is too under researched currently although some progress is made there is much much more to be done. Active physicians directly involved in the system would be an absolute must. Our partnership with the rest of the healthcare world is broken and would be so much more beneficial if every community had physicians actively participating in EMS programs rather than perpetuating the disconnect.Who should administer it?I personally have no preference on administration of such a program. Civil and private services should employ personnel with the qualifications that include leadership, clinical excellence, and progressive action rather than retroactive action traits.What benchmarks should we require? I think the benchmarks should be reflected from clinical improvement of procedures performed by medics as well as statistics regarding patient outcomes. If a service as included CPAP as a treatment for CHF then statistics should reflect improved patient outcomes throughout the healthcare systems i.e. shorter hospital stays, lower hospital bills. What are the obstacles to implementation, and how might we overcome them?Medics- they hate education and fight it every step of the way.Dinosaur medics- I have always done it and will always do it this way.City politics- ’nuff said.Instituting the program and keeping it rolling and progressive. EMS professional have lots of great ideas and this is one of them but we pretty much suck on the follow through of these ideas.
    My two cents…
    Christie Hale
    Cross posting on my blog..

  • http://www.facebook.com/profile.php?id=1088829873 Skip Kirkwood

    So here’s a messy question. When a fire department saves a building from destruction, it saves money because the insurance claim is smaller. When EMS saves a person from death, it costs the health insurance company MORE money – because they have to pay for the medical care, not for the improved health that comes out of it. It’s really cheaper for them if the patient dies.

    Maybe we should be talking to the LIFE insurance companies!!!

    • Ambulance_Driver

      Excellent point, at least for cardiac arrest resuscitations.

      But surely there are ways we can lessen morbidity and hospital stays, too? Like CPAP, for example? STEMI care, maybe?

    • MLG

      Great point, here the benchmark could be an agencies participation in community outreach and prevention.

  • Matt Landry

    4. In order for this (*ahem* or any *cough*) reform to have a proper incentive effect, health insurance would have to be something typically purchased by individuals or families, as opposed to employers or the government.

  • Bob Sullivan

    The Eagles evidence-based performance measures are a good place to start. It includes things like the number of intubations that can be prevented with CPAP, as well as the number of future heart attacks or strokes prevented with regional STEMI programs. That demonstrates real healthcare cost savings, and most it’s from medicare. You can read them here:
    http://informahealthcare.com/doi/full/10.1080/10903120801903793

    Speaking of advocacy, the study of down-stream cost savings from EMS care are a major part of the Field EMS Bill. Right now we have no way to objectively measure what type of EMS delivery system is best, or what parts of each type is effective. This is a step towards figuring that out and setting standards for all models. You can read the whole bill here:
    http://capwiz.com/naemt/webreturn/?url=http://thomas.loc.gov/cgi-bin/query/z?c112:H.R.3144:

    Let’s make noise with our representatives this election year and move it forward.

  • BH

    It only works for fire insurance rates because a house doesn’t (typically) move- that house will always be protected by the same fire department. People move around- and I’ll bet everyone here physically moved between different types of EMS systems in their everyday life, just on their commute to work each day. Why should my health insurance rate be either increased or decreased based on where I live, compared to where I work, or go to the gym, or go grocery shopping?

    Depending which way I go, I could be in 4 different types of EMS systems within 5 minutes of leaving my house- some just by walking. I could live in a Class 10 town, but get hit by a bus in a Class 1- and now I’m getting better care than my insurance company is basing my rates on.

    (Sorry for injecting logic into the discussion, carry on.)

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  • mpatk

    The problem is that Emergency medicine is set up for life saving, not cost saving. If EMS has to get involved, then the patient is already very sick; improvement in emergency care will improve their quality of life after recovery, but do comparatively little to reduce costs. The cost benefits of keeping people OUT of the hospitals will dwarf any savings from reducing the hospitalization time.

    From the health insurer’s perspective, sending a CHF patient home two days sooner doesn’t do any good if it just means they return to the hospital with emergent exacerbation of CHF two days sooner than they otherwise would. Saving more lives, without doing anything about readmission rates, is what Skip says: a life insurance dream and a health insurance nightmare.

    What will get the health insurer’s attention is getting out in the community to prevent chronic diseases from becoming emergencies. That *should* (knock on wood) mean 911 calls are fewer but higher acuity. With that higher acuity, we can show the need for higher standards for paramedics, etc…

    Or maybe I’ve got the chicken and egg mixed up; and we need to have higher standards before we can get out into the community for prevention. All I know is that health insurers aren’t likely to support improved emergency care without improved prevention.

    • Ambulance_Driver

      “All I know is that health insurers aren’t likely to support improved emergency care without improved prevention.”
      That may well be true, but that is not to say that EMS cannot fill that role. Current system models may be ill-suited for it, but that’s the point of this exercise.
      If the EMS system of the future could practice preventative care, help reduce expensive ED visits and funnel patients toward more appropriate and cost-effective avenues of care, and shorten hospital stays, wouldn’t that be an incentive for insurers to reward those systems with increased reimbursement and lower premiums for citizens than those systems that do none of those things?
      And your bounce back CHF admission has more to do with lack of adherence to their treatment regimen than it does with discharging the patient too soon.
      And if the patient is going to go back to eating pork rinds and salted pistachios by the bagful as soon as they are discharged, they are going to engage in that behavior whether it was a five day hospital stay or a ten day one.
      CPAP has been shown to reduce costs, both for insurers and for hospitals by reducing uncompensated care. Intubated patients are a HUGE money loser, and a source of significant increased morbidity.
      CPAP is only one example of how we can improve outcomes while simultaneously lowering costs.
      Surely we can find others?

      • mpatk

        By all means, I think that EMS doing more preventative care, and having the ability to send patients to more appropriate destinations, would lead to reduced healthcare costs the insurance companies might reward with lower premiums. What I was trying to get at with my example was getting EMS out in the community and heading off some of these problems before they require an ambulance and ED visit. In the CHF example, perhaps noting lower leg edema and elevated blood pressure, and either getting them to a clinic/PMD or just convince them to be a bit more compliant on diet and meds before their lungs fill up. Granted, CHF isn’t the best example, exactly because a non-compliant patient can go from OK to acute pulmonary edema with that big bag of pork rinds.

        Maybe I’m being a bit too much of a nay-sayer. I certainly would love to see improvements in patient care; in new technologies, new pharmaceuticals, and improving education and standards in general. I’d like to think that we’d improve our profession because it will improve patient care and outcomes, rather than to save a few bucks; and maybe I’m depressed that the only way to get support and funding for EMS improvements is to reduce costs for the insurance bloodsuckers (sorry, I used to do hospital billing).