Transformation: Showing the Value of EMS

America’s healthcare system is undergoing one of the most significant transformations in history. Fee-for-service payment models that financially reward providers for activities instead of outcomes are rapidly transitioning to payments based on patient outcomes and the quality performance of healthcare providers. Economic models such as accountable care organizations (ACOs), value-based payments, shared savings and bundled-payment methodologies are rapidly being implemented by the Centers for Medicare & Medicaid Services (CMS) and other payers. CMS has announced its desire to have 90% of Medicare payments tied to quality-based measures by 2018 and is rapidly moving toward that goal by implementing programs such as the Hospital Readmissions Reduction Program and Bundled Payments for Care Improvement initiative.1–3

Additionally, the frenetic merger and acquisition activity on both the payer and provider sides of the healthcare equation demonstrates the race to gain negotiating leverage by increasing the patient populations covered by payer groups and the provider populations included in delivery networks. While we may never have a true single-payer system like most economically developed countries in the world, it appears we may be headed toward an oligopolistic system with a few payers and a few providers who will negotiate healthcare delivery to the majority of the U.S. population.

This healthcare transformation has been referred to by many industry experts as “Healthcare 3.0” because it represents the third major evolution of healthcare finance and delivery, and hints that there will be more evolutions to come.

EMS 3.0 Explained

Modern emergency medical services essentially began soon after the National Highway Transportation Safety Administration published its landmark paper Accidental Death and Disability: The Neglected Disease of Modern Society, which among other things detailed the inability of EMS systems to effectively respond to vehicle crashes and other trauma incidents.4

Largely as a result of the deficiencies highlighted in the report, Congress passed the EMS Systems Act of 1973.5 The act essentially made federal grants available for the development and evaluation of enhanced and coordinated EMS systems.

Prior to its passage, ambulance service was delivered largely by a patchwork of untrained and uncoordinated providers who were not integrated into the overall healthcare system. In fact, nearly half of ambulance services were provided by funeral homes. We can call this period EMS 1.0. Since then advances in EMS delivery systems, provider training and clinical processes of care have largely improved the reliability and coordination of EMS delivery. However, payment for transport has been essentially unchanged as the primary reimbursement model. EMS is generally paid to transport patients to the hospital—we are a transportation supplier, not a healthcare provider system. This model rewards EMS for and incentivizes us to drive up healthcare system costs by using the highest-cost transportation resource (an ambulance) to transport patients to the highest-cost healthcare provider (an emergency department) without any real proof of the value of that model for most patients. Consider this EMS 2.0.
While we were improving the delivery of EMS, we spent very little time studying the effects of what we were doing. While there is a robust library of published research on the process of care delivery, there is a dearth that shows better patient outcomes as a result of these enhancements. As an example, even after investing billions of dollars to reduce the time from sudden cardiac arrest to the initiation of CPR, the national survival rate for out-of-hospital cardiac arrest has barely changed.
Proving Value
With the changing focus of payers and providers to reward outcomes and value, the EMS profession needs to transform how we integrate our services into the healthcare system. And that goes way beyond the concepts of community paramedicine. We need to prove the value we bring to patients, healthcare providers and healthcare payers if we are going to not only survive but thrive in the healthcare 3.0 environment—hence the need to transform to EMS 3.0.
The EMS 3.0 transformation is envisioned by leaders from eight national associations who have come together to drive the initiative—each leading within their specific area of expertise and influence but with the true alignment we all need to move in the same direction together. For the associations participating and areas they’ll lead, see Figure 1.
Advocacy Goals
A criticism of EMS during legislative initiatives has been the lack of a unified voice speaking for the industry. The process of developing this shared vision of the future and EMS’ role in it has brought these associations together. All agree on a general direction for our industry. In fact, several participants have invited other association representatives to join committees of their associations to share ideas and collaborate.
We hope this initiative, and the education afforded to the industry through forums such as this supplement, will help inform our internal and external EMS stakeholders on the changing overall direction of EMS from a simple mechanism for patient conveyance to a fully integrated, patient-centered provider of medical care that demonstrates value to the patient and the rest of the healthcare system.