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February 20, 2019

Fixing 911 reimbursement is a real emergency: It’s high time for the feds to fix payment rules that incentivize trips to ERs

February 14, 2019
File Photo (iStockphoto)

The nation’s emergency medical service systems have for decades provided life-saving pre-hospital medical care to the sick and injured, stabilizing patients and then transporting them to hospital emergency departments for further treatment. This system of “treat and transport” was designed to keep patients with life-threatening injuries and illnesses alive.

But today, it is the 911 system itself that needs resuscitation.

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In recent years, EMS systems have morphed into transportation services for stable patients needing care for minor injuries or management of non-life threatening chronic diseases. Last year, the FDNY handled more than 1.5 million 911 calls, with nearly two-thirds of those for non-life threatening cases, a 25% increase in the past decade.

The annual cost to provide these services exceeds $600 million. Nationally, the cost to Medicare exceeds $6 billion. Yet reimbursement for EMS covers only about one-third the actual cost.

Sending resources to almost 1 million non-life threatening incidents each year impacts our ability to respond rapidly to the growing caseload of life-threatening emergencies. These delays are further prolonged by lengthy hospital “turnaround” times, averaging 30-45 minutes, before an ambulance can return to the streets for the next call.

Our success as an emergency healthcare system coupled with our nation’s lack of success in providing primary care alternatives has created this misplaced demand. Healthcare reform at both the federal and state level has encouraged the development of more robust treatment options that could be utilized for emergent but non-life threatening conditions.

EMS systems, however, remain constrained by antiquated Medicare regulations, followed in lock-step by Medicaid and many health insurance carriers that classify EMS as a transportation service with reimbursement only occurring when the patient is transported to a hospital’s emergency department, regardless of need.

This financial disincentive needs to change, and hope may finally be here.

The federal Medicare program has agreed to begin adopting changes, and Medicaid and private health insurers will need to follow. Reimbursing EMS following any 911 system response, even those that do not result in transport and those tat result in transport to destinations other than overcrowded emergency departments, would unleash innovation, allowing EMS to partner with community-based healthcare providers that can provide acute care for non-life threatening injuries/illnesses followed by seamless transition to outpatient follow-up care for existing underlying chronic diseases.

This would improve patient health outcomes, both immediate and long-term, while reducing the far-higher downstream costs that result from emergency department visits and hospital admissions. This would incentivize, rather than penalize, EMS providers for offering the most medically appropriate patient-centric care.

If only 20% of EMS call volume no longer resulted in transport to an emergency department, ambulance availability would dramatically increase, thereby allowing EMS resources to respond faster to time-sensitive, life-threatening emergencies.

This will also require modifications in EMS operating regulations by state and local medical and regulatory authorities.

Much work would need to be done to form new partnerships between EMS and community-based healthcare options other than emergency departments. And we will need to be innovative in creating new ways of operating, similar to our Fly Car pilot in the Bronx, where paramedic units respond to treat life-threatening emergencies, but when stabilized allow other units to transport — thereby returning more quickly to the field and being available to “fly” immediately to the next potentially life-threatening emergency.

Ultimately, changing reimbursement regulations would kick-start greater investment in community-based healthcare for patients with chronic conditions and increase availability of EMS and emergency department resources for those with acute life-threatening conditions. Breaking the current unsustainable cycle would begin to improve healthcare for all patients and is a critical step in restoring the health and viability of this city’s and this nation’s 911 emergency medical system.

Prezant is chief medical officer for the Fire Department of the City of New York.

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