May 2004 Letters

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The Politics of PUMs

Although I would like to comment on many of the inaccuracies in the eighth article on EMS Mythology by Dr. Bryan Bledsoe (EMS Myth #8: Public-Utility Models Are the Most Efficient Model for Providing Prehospital Care, October 2003), I will limit myself to just a couple.

First, a small correction: The MedStar system in Ft. Worth is indeed a public-utility model, not a failsafe franchise model. The system was a franchise model for its first two years, but in 1988 it was restructured as a public-utility model when more than a dozen cities wanted to take part in the system Ft. Worth had created.

The evolution of the MedStar system raises the issue of why the model, according to Dr. Bledsoe, “fizzled in the 1990s.” I would submit that the model’s growth, or lack thereof, has nothing to do with the quality of the design, as implied by Dr. Bledsoe, but rather the enormous political will a community must possess to create such a system in the first place.

In creating a PUM, the cities served grant exclusive market rights to the PUM to provide all emergency and non-emergency ambulance services. Doing so eliminates any existing provider. A city’s decision to do this carries great political risks. If its current EMS provider adequately serves the community, there is little likelihood a city would take the enormous step to fix something that’s not broken. That, in my opinion, is why PUMs have not proliferated.

In the case of Ft. Worth, the EMS system in place prior to MedStar was seriously broken—enough so that community political leaders were willing to close the businesses of several providers serving the community at the time.

Dr. Bledsoe states, “Many cities have found difficulty backtracking from the PUMs.” In MedStar’s case—and, to my knowledge, with all the other PUMs—there has never been an attempt to backtrack. These PUMs have continued to exist not because of any difficulty in dismantling the system, but rather because they continue to do the job for which they were created: providing quality patient care with economic efficiency.

Jack D. Eades, Executive Director
MedStar Area Metro. Ambulance Auth.
Ft. Worth, TX

Bryan Bledsoe, DO, FACEP, EMT-P, replies: The writer is correct that MedStar was changed from a failsafe model to a public-utility model. There were several reasons for this, political and economic, but I will not address those here. MedStar is in my hometown of Ft. Worth, and I am familiar with the system and the players.

The writer’s second point is unclear. He seemingly infers that there have been no new PUMs created because communities no longer have the “political will” to create these models. I would maintain that the reason PUMs are falling into disfavor is because the model has failed. Communities now have public-utility models to look at and can clearly see the problems inherent in them. Virtually every PUM has sought increasing subsidies to stay afloat. The PUM in Kansas City, MO, MAST, is on the verge of bankruptcy, and the authority recently took over operation of the ambulance service from the contractor. In most PUMs, pay and job satisfaction remain low, and EMT and paramedic turnover remains high. In their present form, PUMs are simply “stepping stones” by which EMTs and paramedics can get experience before they move on to better-paying EMS jobs.

In summary, the writer is correct when he says PUMs are economically efficient. But that efficiency comes on the backs of EMTs, paramedics and dispatchers who work in those systems.

Myth-Informed

I am responding to Parts 7 and 8 of Dr. Bledsoe’s EMS Mythology series. I spent nearly 20 years providing or managing pre-hospital services in both urban and rural environments, and I find Dr. Bledsoe’s comments some of the most ill-informed I have ever read.

Re. Part 7 (EMS Myth #7: System Status Management Lowers Response Times and Enhances Patient Care, September 2003): I submit that all EMS organizations have a system status plan (SSP). Their plan may be fluid or static, but a plan does exist. Dr. Bledsoe appears to not understand the concepts behind system status management (SSM). If he did, he would not have made such ill-informed comments about its use. First, SSM is a tool used by competent managers, not a “computer,” to ensure that enough resources are deployed to handle the historic call volume predicted for that hour of day for that particular day of the week. A SSP, on the other hand, is a tool used to ensure that the resources employed are positioned so they can reduce response times and improve their effectiveness—e.g., placing units to respond against rush hour traffic instead of having to flow with it.

It is true that Jack Stout introduced the term system status management to the world of EMS, but it is hardly true that Stout claimed his concept improved response times simply by adopting a plan of moving ambulances around a community. Moreover, Dr. Bledsoe seems to indicate that if the federal government had not gotten involved with moving people around a community, predictions of demand for services would be accurate, and therefore his statisticians would be wrong concerning the data required for demand predictions. No one has ever said that predicting calls was an exact science. But I submit that if you ask those who stake their livelihoods on prompt response times with fiscal responsibility, they will swear by their methods.

Re. Part 8 (EMS Myth #8: Public-Utility Models are the Most Efficient Model for Providing Prehospital Care, October 2003): Dr. Bledsoe once again is misinformed. Based upon the concepts and sound economic theory, the public utility model (PUM) was developed. He should attend some basic economic training and learn the concept of a regulated monopoly. Moreover, if Dr. Bledsoe really understood basic prehospital medicine, he would recognize that competition for service to the community must take place before the emergency occurs. If competition is left to the retail level, consumers are left thumbing through a telephone directory in a time of crisis. A PUM can ensure appropriate levels of education, licensure and certification.

Dr. Bledsoe suggests that a government agency such as a PUM will simply add cost. He asks, “When has a governmental entity done anything but increase costs and grow?” Well, whom does he expect to deliver the prehospital services? An unregulated for-profit entity seems out of the question. It surely cannot be a fire department, as they are governmental agencies that will only increase costs and grow (I do not dispute this in regard to fire-based services).

Further, Dr. Bledsoe seems to complain of subsidy, yet at the same time complains about any suggestion to improve an organization’s productivity, thereby reducing its operating costs. A small subsidy to a fee-for-service program is much more palatable than an all-subsidized program.

Let’s look at all of this from Dr. Bledsoe’s position. As the author of a book, his maximum profit is gained from the sale of each book (putting a booking at each fixed location). From the consumer’s point of view, his maximum profit comes in the form of spreading the cost of Dr. Bledsoe’s book over many users (otherwise known as efficiency, many users using one book). Now let’s evaluate an EMS system using the same concepts. Which is better: having many unused resources spread all over a community, costing some dollar figure for each hour deployed, or resources deployed, at some dollar figure, in a strategic manner (flexible plan) so many consumers may employ the same resources, thereby increasing each resource’s productivity and driving down the cost per user?

Dr. Bledsoe is simply wrong. He offered no alternatives to any “myth” he presented, and it appears he simply has an axe to grind for not being allowed to watch his favorite sitcom during the evening shift. It is amazing that Dr. Bledsoe would leave an impression that it is important for providers of EMS to have time to watch the television or take a nap during their shift! I agree that reasonable people can disagree on the methods of delivering EMS, but I don’t agree with the bashing of fiscal responsibility that Dr. Bledsoe has chosen to employ.

Rodney Dychey, BS, JD (candidate 2004)
via e-mail

Broken Premise

I’ve been following with great interest the EMS Mythology series written by Dr. Bledsoe. He introduced the series by saying, “When the scientific method is applied to EMS practices, some have shown benefit and some have not. Based on the results of scrutiny, practices that do not show significant patient benefit should be discarded, while practices that show enhanced benefit should be embraced.” I absolutely agree with this premise. I just wish his articles stayed true to his declared intention.

Dr. Bledsoe is one of the most respected clinical educators and authors in this industry. His experience as a physician and a paramedic gives him a rock-solid foundation on which to discuss clinical myths like the use of steroids for the treatment of acute spinal cord injury. However, his September (EMS Myth #7: System Status Management [SSM] Lowers Response Times and Enhances Patient Care) and October (EMS Myth #8: Public-Utility Models are the Most Efficient Model for Providing Prehospital Care) columns bring into question his experience and education as a system designer and leader. His claim that in SSM systems, “Ambulances and personnel are much cheaper than [when based out of] fixed ambulance stations” makes me wonder if he’s ever looked at a budget for any EMS system.

While his statement, “there is no scientific evidence to support the practice” of SSM or the PUM design is correct, it implies that better alternatives exist. These articles mix facts from the scientific literature with misinformation and emotion.

Let’s start with his article on SSM. The art and science of SSM is practiced by all EMS systems in America. The goals of SSM are simple: Make sure sick and hurt people get the help they need as quickly as possible, and match the supply of resources with the demand for services. Every time a fire station is built in a new subdivision, someone somewhere has decided that more resources are needed in order to meet the new system demands—that’s practicing SSM.

Jeff Clawson’s dispatch protocols guide the action of 9-1-1 call-takers as they guide callers in the provision of care to the patient until EMS arrives. The protocols put forth by an EMS system’s medical director guide the clinical care provided to patients by the paramedics. SSM is the protocol for what a system does with its EMS resources when they are not on a call. As Dr. Bledsoe implied, most fire-based systems use a system status plan that says when you’re done with your call, you go back to your station.

The statisticians cited by Dr. Bledsoe said it could take 20–40 years or 100 years of data to make a reasonably accurate probability prediction as to call location and timing. Then he follows by saying, “We can state that the probability of an ambulance responding to a nursing home, assisted-care facility or neighborhood with a high percentage of elderly residents is greater than in other areas.” Why would Dr. Bledsoe use statisticians to debunk the ability to predict demand and then claim he can make the same predictions? Didn’t his statisticians say it would take decades?

In his article on PUMs, he says, “When has a governmental entity done anything but increase costs and grow? Furthermore, when it comes to healthcare, governmental entities have a horrible track record.” What does Dr. Bledsoe think the fire department EMS systems he touts in Phoenix, Los Angeles, Seattle, New York, Chicago, Dallas and Houston are, private hospitals? They are governmental entities that provide healthcare with no system of performance or fiscal accountability. Why does he imply that these systems are better when, as he would say, there’s not a shred of scientific evidence to support that claim?

What concerns me about these articles is not that he criticizes SSM and the PUM design for their lack of scientific research, it’s that he strongly implies that fire-based EMS with fixed stations and 24-hour shifts that allow, as he says, “some of the best days of my life,” are better. He makes this implication in violation of the entire premise of his series, which is debunking common practices that have no scientific support.

I strongly agree with his conclusion to the PUM article: “With the shrinking healthcare dollar, we must ensure that we are helping a maximum number of people with the resources allotted to us.” Jack Stout always said, “High-performance EMS systems are designed to provide the best possible service for the dollars available.”

My guess is that one of the intentions of Dr. Bledsoe’s articles was to spur more research. We’ll get busy doing that on system design and SSM. In the meantime, readers need to be careful not to change their systems based on emotion.

H. Stephen Williamson
President/CEO, EMSA
Tulsa/Oklahoma City, OK

Bryan E. Bledsoe, DO, FACEP, EMT-P, replies: You bring up several good points, and I will attempt to address them one by one. I have to agree that my area of expertise, as a physician, is more focused on medicine and the scientific practices of EMS. But I also had nearly a decade of experience as an EMT and paramedic prior to attending medical school, and I’m familiar with EMS.

The system medical director is ultimately responsible for all patient-care activities within an EMS system. Operations impact patient care. In his recent book on EMS systems, Walsh wrote, “The [medical] director is involved in system design, education, protocols and quality management.” This position is supported by the National Association of EMS Physicians.

Next the writer suggests I should not have tackled SSM and PUM because I lack “experience and education as a system designer or leader.” Where does one go to obtain such education? Define a “system leader.” Many EMS consultants have degrees in unrelated fields (e.g., a PhD in psychology). Does that make them uniquely qualified to be “leaders” or consultants? My statement that ambulances and personnel are much cheaper than fixed stations is correct. That is, ambulances and personnel are much cheaper than ambulances and personnel and fixed stations. That is the logical comparison.

All businesses respond to customer demand. Cities build fire stations and schools in areas of growth. UPS sends out more brown trucks around Christmas time. Wal-Mart hires outdoor workers during the summer. Is this system status management? In the SSM column, I was specifically addressing the model proposed by Stout and utilized by numerous so-called “high-performance” systems. I recognize that fire departments move assets in response to need. In fact, I have a picture of a Fort Worth fire station with a Dallas Fire Department engine staffing it. The point I was making is that in pure SSM, there are no stations, no break rooms, no bathrooms and such for personnel. They continually post to try to meet perceived demand (which is statistically impossible to predict).

The writer questioned why I made a statement about ambulance responses to nursing homes, assisted-care facilities and parts of town where there are high numbers of elderly. Actually, this information came from a research article I referenced in that column. The authors examined data (age >65, median income, percent living below poverty line, emergency responses and emergency transports) and concluded that economic and demographic variables are related to demand for ambulance service. I encourage the writer to obtain and review that study. This study provides evidence to support what seems intuitive—that the poor and the elderly use ambulances more than other segments of the population.

The writer later questions some statements about PUMs and argues that fire department operations do not have “performance or fiscal accountability.” This is a common statement many of my PUM-advocate friends use. All fire departments are accountable to city government, to taxpayers and to their medical directors. The degree of accountability varies, but a blanket statement saying they are unaccountable just is not accurate. They may not use the catchy phrases and terms used to describe accountability in “high performance” systems, but they are accountable. If accountability in PUMs is so great, why was the PUM authority in Kansas City, MO (MAST) recently required to take over ambulance operations and now has openly discussed the possibility of having the PUM file for bankruptcy? Some on the Kansas City city council are calling for Kansas City to withdraw from this PUM. Evidently, MAST had recently received a fairly clean bill of health from a national consultant who specializes in EMS. Where was the accountability in Kansas City?

I think the best models are the statewide models you see in Australia. I realize we will never see those systems here. Some communities (through reasoning or tradition) may choose a FD model, some may choose a volunteer model, some may choose a hospital model and others may choose a private model. Where the PUM fits into this is unclear. An attorney friend recently summed up PUMs well when he called them “labor-management entities.” Proponents of PUMs tout accountability as if only they know the secret handshake. But when you closely examine the PUMs, you will see what I described: a young, relatively inexperienced, relatively poorly paid work force that is itinerant and has low morale, high turnover, poor benefits, excessive fatigue and many employees with a desire only to “get experience” until they can get a job with a more traditional system. PUMs may be the panacea Stout said they were. They looked good on paper—but so did the Ford Edsel. Their track record has been less than stellar. The burden of proof that they are an effective model of EMS system operation rests with the proponents, not those who are skeptical.

Thanks for a great letter. Your last paragraph was correct—I have intentionally taken stands on some emotional issues in the Mythology series (some of which I didn’t completely agree with) in order to spur thought and research. We will never solve the problems of EMS design and operations in the pages of a trade magazine. But we can stimulate thought, and I feel we have. Now I’m ready to get back to some bread-and-butter medical topics.