Ask the Expert
EM - Challenges to Streamlining EMS: Daniel Patterson
Ambulances and emergency rooms are two things that every American takes for granted. But the Center for Medicare and Medicaid Services – the primary payer for EMS transport in the country – estimates that the amount paid annually for unnecessary emergency service pick-up reaches into the hundreds of millions.
While there are dozens of EMS calls that can be identified as inappropriate, some of the most common examples are also the most obvious: ambulance trips to the ER for earaches and respiratory infections, and sprained or broken limbs.
To provide some insight into the epidemiology of EMS utilization, Daniel Patterson, research assistant professor, Emergency Medicine program and Director of Research for the Center for Emergency Medicine of Western, PA. Inc., discusses some of the challenges to streamlining EMS.
Q: How many EMS calls are there per year in the US?
A: We don’t really know; a single national dataset of all EMS transports and responses does not yet exist. What we do know is that about 16 percent of the 115 million annual Emergency Department visits begin with an EMS transport and if you account for transports that occur between nursing homes, ambulatory care centers, and other health care establishments, this adds up to roughly 30 million EMS transports each year.
Q: How many of these calls can we qualify as “legitimate” emergency calls?
A: Again, it’s very difficult to say. Until 2004 there were no universally agreed upon criteria for identifying unnecessary calls – so we really don’t know. Part of my work has been operationalizing these criteria into measures that will help us provide broad answers to this question. Long answer short, we really don’t know.
Q: What were the criteria that were created and how do you predict they will affect the current level of over utilization?
A: In 2004 the Neely Conference Criteria for Determining Medically Necessary EMS responses and transports was developed and published in the Prehospital Emergency Care Journal (PEC) – coincidentally based right here at Pitt, giving all students and faculty at the University free electronic access to the journal.
We still have yet to determine the full extent to which the report will impact EMS utilization. Few studies have actually used these criteria since their publication in 2004. However, the Centers for Medicare and Medicaid Services (CMS) take the study very seriously and will ultimately utilize the results the most. They are the largest payer for health care services in America and spend roughly $3 billion annually on EMS transport. Finding ways to reduce unnecessary EMS use is a high priority for an agency spending in the area of $402 million annually on EMS transports that don’t meet their criteria for medical necessity.
Q: What have been some of the preliminary findings of your research? What do these results mean to the average consumer?
A: In 2004, I studied unnecessary EMS transports using the Neely Conference Criteria. Part of my work was examining 2.25 years of EMS transports in three counties in one southeastern U.S. state. I focused my efforts on children ages 0-17 years. One of my significant discoveries was that 16.4 percent of the 5,693 transports over that period of time were potentially medically unnecessary.
Overall, diagnoses given in the emergency department for those unnecessary transports varied across age. Common diagnoses for the younger children included otitis media (a common ear ache) or acute upper respiratory infection. For the older children, conduct disturbance and drug abuse were among the most common diagnoses.
These results provide clues and new hypotheses that we can test in future research that will include a larger sample of EMS transports from a more diverse geography. The most striking result is the low frequency of unnecessary use compared to prior studies. As many as 61 percent of transports were identified as unnecessary in one study prior to mine. But my study was limited; I only examined three counties in one state. To truly understand the issue on a grander scale we need bigger studies with more EMS agencies across more states to tell us if the trends identified in this study are similar across the country. Only then will we be able to truly make recommendations that affect policies on EMS utilization and transportation.
Q: What impact would streamlining the system have on the health care system as a whole?
The most pragmatic way to think about this issue is to imagine you are running a business with an annual budget of $1 million. Imagine, too, that $300,000 of your annual budget could be linked to inefficiencies in your agency such as high turnover, wasteful practices, and unnecessary wear and tear on your equipment. If you could eliminate only a fraction of these problems, you could save your business a lot of money. Now imagine that your business was supported by the local county government and funding from the federal government your tax dollars. So the most obvious initial fix is to reduce unnecessary use and solve some of the other problems that are a drain on resources.
Second, many EMS clinicians (EMTs and paramedics) can easily identify unnecessary use. Several studies suggest that unnecessary use has a negative impact on job satisfaction and can even lead to turnover which, in turn, affects the staff morale and has other lasting impacts long after the individual has left. Finding ways to appropriately identify unnecessary EMS utilization and appropriate ways of dealing with it would reduce costs and a slew of other negative outcomes.
Q: Are there policy measures in place that could potentially restrict hospitals, health care institutions or insurance providers from cutting back on EMS services based on this misuse?
A: That’s a complicated question. Policies and practices vary dramatically across institutions and agencies and, naturally EMS departments. Orange County EMS in North Carolina, for example, uses a quick response paramedic vehicle dispatch scheme and allows their paramedics to make transport decisions in the field, with medical oversight of course. The system works, but it was borne from a desire to decrease the unnecessary use of the services. In many cases these decisions need to be made on a local level.
When it comes to insurance agencies and Medicare and Medicaid, there have been cases where insurers have denied payment to an EMS agency because the transport was deemed medically unnecessary based on their criteria. In most cases, however, the EMS agency improperly completed their documentation, giving the insurance agency an easy way to deny payment. Often this results in a reapplying of the payment, but in some cases the patient is left with a bill from the EMS agency that can top $1,000. It is not uncommon at all for patients to be left with an EMS transport bill because the transport was denied by their insurer. This latter case is extremely unfortunate for the patient – especially for the elderly population living on a fixed income. It will be important moving forward for EMS leaders to find ways to help people in the field (on-scene) to avoid placing EMS out of service for hours on an unnecessary call and placing the patient in a real financial fix.
Q: How long do you believe it will be before any of the changes you recommend are realized?
A: The simplest answer is that we’re probably years away from substantive changes on a federal level. However, as local agencies find success in reducing these unnecessary calls their models will be recycled elsewhere. In the end, most inefficiencies eventually are corrected and that’s the greatest thing we can hope in this situation. It will lead to happier EMS workers and better – and more cost-efficient – overall service.