Insights
?Insights into the IOM Report - EMS at the Crossroads?
Jul 21, 2006, 15:56
In 1966, the National Academy of Sciences/National Research Council?s published it?s infamous report; ?Accidental Death and Disability: The Neglected Disease of Modern Society?. That publication revolutionized pre-hospital emergency medical services.
Now, forty years later, the Institute of Medicine has released it?s landmark report on the state of emergency care in the United States. The EMS component of the IOM report, ?Emergency Medical Services at the Crossroads?, affords the leaders of our troubled industry the opportunity to capitalize on many of the recommendations made by the IOM.
Discussing the report with several colleagues, I?ve heard some incredible comments. One of my favorites was ?Well, now the wool is really off the sheep.? Here?s another good one, ?Why are they being so critical of us.? But here?s my favorite, ?There?s nothing in that report we did not already know?. That one statement completely sums up what really is ailing EMS systems across the country. We know what is wrong, but are either too apathetic or feel we are too powerless to fix it.
Before the dust starts to collect on the report as it sits on some shelf in Washington, D.C., why not invest a few moments to take a deeper look into some of the recommendations contained in the report and perhaps, just perhaps, use them to effect change in our local communities and across the country?
{WARNING ? the words you are about to read are not for the faint of heart ? they are carefully crafted to stir enough controversy to hopefully foster substantive dialogue in across the EMS industry.}
IOM Recommendation:
?The Department of Health and Human Services and National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for EMS, EDs, and trauma centers based on adult and pediatric service capabilities.?
?Evidence-Based???!! Hmmm, EMS leaders have been saying for years that we need more research data to see what we do that works and what doesn?t work. Since we have not done it as an industry well, HHS and NHTSA will do it for us. This is a good thing??
IOM Recommendation:
?The National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based model pre-hospital care protocols for the treatment, triage, and transport of patients.?
?Evidence-Based??? Dang, here we go again with the ?proving our worth? stuff. So, if HHS and NHTSA come up with ?national?, evidence based protocols, is that now the national ?standard of care?. What happens to EMS agencies who don?t use them?
IOM Recommendation:
?The Department of Health and Human Services convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance.?
Well now, those two words just keep popping up, don?t they? Wonder what ?evidence-based performance indictors? means?
Response times (including ALL times) perhaps? Do YOU know what your TRUE response times are? From the time the phones rings at your primary PSAP, to the time you arrive at patient-side?? Some systems actually do and use it for quality improvement. For example, a city fire agency in Volusia County was concerned about the lengthening of their ?activation? times (call taking complete ? to unit enroute) and realized that the process of sending ?alert tones? for the response units added unnecessary time to the activation times, so they eliminated them during non-sleep times. This means everyone has to actually listen to the radio, but it shaved valuable seconds off their response times.
How about ALS skill proficiency? Do you think that a procedural intubation proficiency rate of 50% is more or less beneficial to patient outcome than say, a proficiency rate of 85%? Hopefully, implementing this recommendation will finally force all of us to objectively look at the WHAT and WHY we do the things we do.
Reviewing the list of the six clinical and 12 system delivery research topics, it is very clear that the IOM is seriously looking to see if what we do, and how we do it, is clinically and economically sound. Here?s a short list of the recommended studies:
? Impact of EMT training level on the patient?s conditions at hospital arrival and long-term outcomes
? Identification of the safest and most effective way for EMS to manage respiratory insufficiency
? Time-interval modeling identifying when, where and what in EMS changes outcomes
? Testing administration of IV fluids to correct hypotension before trauma surgery
? Impact on outcome of EMS medication administration for selected medical conditions
? Safety and impact of EMS treat and release programs
? Incremental value of advance life support over basic techniques in trauma care
Are YOU ready for the answers to these questions??
IOM Recommendation:
?Congress [should] establish a lead agency for emergency and trauma care within two years of the publication of this report. This lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of EMS, emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital EMS (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency care.?
This issue has been contentiously debated for the past year with opposing views on where a federal lead agency should be ?housed?. One camp felt that a federal EMS agency should be in the Department of Homeland Security, while others felt it should be as is in the National Highway Traffic Safety Administration. In my very first ?Insight? column, I proffered the concept that EMS is HEALTHCARE. Guess the IOM agrees. HHS is the appropriate location for a federal EMS agency due to the clinical nature of the services we provide, not to mention the fact that for most EMS agencies that charge service fees, about 45% of their revenues come from CMS, which is another agency within HHS.
IOM Recommendation:
?The Centers for Medicare and Medicaid Services (CMS) convene an ad hoc work group with expertise in emergency care, trauma, and EMS systems to evaluate the reimbursement of EMS, and make recommendations regarding inclusion of readiness costs and permitting payment without transport.?
Two fundamental issues here. First, during the Negotiated Rule Making sessions for development of the Ambulance Service Fee Schedule, CMS repeatedly resisted the concept of reimbursement for the cost of readiness arguing that this cost is most appropriately borne by the taxpayer. CMS does not pay a physician for being ready, nor are the hospitals reimbursed for costs associated with being ?available? 24/7. Years ago, when Medicare was on a cost-based reimbursement method, cost associated with ?operating? the hospital or other covered service could be built into the cost-basis. It has been more than ten years since Medicare used cost-based reimbursement because it caused providers to increase costs to increase reimbursement. This mal-alignment of incentives nearly bankrupted Medicare. Most providers today are reimbursed on either a fee-schedule, or diagnosis-related-group (DRG) basis. Don?t hold your breath waiting for cost of readiness reimbursement.
However, payment for non-transport has sound basis in economic and clinical reality. Recently, several Florida managed care organizations were approached about the concept of paying for treat and release, or treat and refer programs. Without exception, they all felt this was a logical enhancement. There motives were that if the patient is always transported to a hospital, the MCO will have to pay out the ambulance bill (typically $400 - $700), plus the emergency department charges (typically $2,000 - $4,000). If the patient could be SAFELY treated at the scene and referred to their own physician, the MCO would save thousands of dollars. Further, allowing the patient to seek care from the healthcare professional who actually is familiar with their medical condition is an enhancement to their medical care continuum. To them, investing in a treat and refer fee of $200 - $300 made sense. CMS may deduce the same reasoning and allow this practice.
IOM Recommendation:
?The Department of Health and Human Services should adopt rule changes to the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Health Insurance Portability and Accountability Act (HIPAA) so that the original goals of the laws are preserved but integrated systems may further develop.?
Arguably, EMTALA laws dramatically changed the face of emergency medical care and at the time the law was passed, there was sound reasoning for this public policy. However, there have been many unintended consequences. Allowing safe relaxation of the EMTALA statutes would allow EMS systems (including hospitals) to develop more appropriate service delivery models. By focusing on the ?right patient, right time, right facility? concept, we will be able to design more effective, efficient and creative service delivery models.
What to do Now:
Historically, Congress listens to the IOM and acts on their recommendations. My gut feeling is that many of the recommendations WILL be enacted by Congress. But where EMS counts is at the local level. Local communities should use the media and political awareness created by the trio of IOM reports to further their causes on a local level.
In my area, a coalition consisting of the hospital association, emergency physicians, EMS Medical Directors and EMS has been formed to bring about changes in our state based on the IOM report. The plan is a three-part strategy. First, develop a year-long public education campaign focusing on when to call EMS or go to the ED, as well as the issues facing these healthcare safety-net providers. Second, put together a legislative package to implement some of the IOM recommendations locally in our state, using the public education component to build grass-root support for legislative changes. Third, to develop a series of best practices which have been implemented to alleviate issues such as emergency department delays and diversions, and inappropriate EMS use to be a ?self-help? resource.
Dramatic change is on the horizon my friends. Those who embrace the changes and help shape the future will have a hand on the ship?s wheel. Resisting appropriate changes will eventually lead to the use of a life jacket.
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