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Future EMS Delivery Models

Executive leaders in the fire service sat down August 26, 2015, with leadership from American Medical Response (AMR) to discuss the future of EMS. The first-ever Collaboration Forum, which was held in conjunction with Fire-Rescue International in Atlanta, was a joint effort of AMR and the IAFC. AMR executives and IAFC officials spent several hours discussing EMS systems, healthcare financing and mobile integrated healthcare (MIH).

Ted Van Horne, CEO of AMR, opened the forum by welcoming attendees and talking on the importance of collaboration and cooperation at all levels of healthcare. Relationships among the fire service, EMS agencies, hospitals and other stakeholders will be key to meeting the Triple Aim by improving patient care and population health, while decreasing costs, he said. “The future of healthcare is unknown, but working together is important.”

Chief Rhoda Mae Kerr, was installed as IAFC president during the FRI, stressed the importance of focusing on the patients. “We have one goal in mind, which is to serve the community better. It’s not about us.”

Paying for EMS

Changes in delivery systems and associated reimbursement models for prehospital EMS dominated much of the conversation, with the fire chiefs and AMR executives agreeing that the system needs to change.

John Sinclair, IAFC first vice president, started the discussion by strongly arguing that the current model for paying for ambulance services—which reimburses for transports, but not patient care—was decades out of date. By paying only for transport, he said, payers only reinforced a system that takes every patient to the emergency department, whether they need it or not. “It’s time to force [healthcare payers] to the table. We have to get them to talk about it. We have to change the ways the incentives line up.”

An example of where the EMS community missed an opportunity to push for change occurs each time a hypoglycemic diabetic patient is treated and not transported, Van Horne said. In many EMS agencies, these patients receive an intravenous line and IV fluids and dextrose, yet unless they’re taken to the hospital—which research indicates isn’t necessary—the agency will not be paid for the services.

“We’ve been doing this for diabetics for decades,” Van Horne said. “We’ve been doing it great. We are just the craziest group that we didn’t go back to Medicare and ask for $80 for that. Shame on us, because that would’ve been the beginning” of a better reimbursement system.

Chief Bill Metcalf, EFO, CFO, IAFC president 2013-2014, expressed concern that many of the national conversations surrounding the future of EMS and reimbursement were occurring before common definitions had even been agreed upon. For example, he said, even the term payer means different things to different organizations. For many public EMS agencies, payers include not just insurance companies that reimburse for services but also the municipalities and taxpayers who fund the system.

“We throw out words like payer and we assume that is a common group with common goals and agendas, and they’re not,” Metcalf said. “Particularly when we deal with this issue of the intersection of public safety and healthcare.”

Mobile Integrated Healthcare

Naturally, the topic of reimbursement led to a wide-ranging discussion of MIH and community paramedicine programs. AMR executives discussed some of the different models that AMR and its sister companies, EmCare and Evolution Health, have been piloting.

Ed Racht, AMR’s chief medical officer, demonstrated some of the technologies being used when he used his phone to video conference with the medical command center in Dallas, who then patched him through to a pharmacist in Florida. Using this technology, healthcare providers visiting patients in their homes can access specialists and other partners in the healthcare system in real-time and have conversations with them and the patients. This could be especially useful for low-acuity 911 calls, where it may be in the patients’, the systems’ and the payers’ best interests to avoid a trip to the hospital.

“If you talk to the insurers, unplanned care is their death sentence,” Racht said. “It takes everybody out of the program, and it increases their costs.”

The key, he said, is information exchange—ensuring that anyone who sees a patient, including emergency responders, knows the patient’s current medical problems and how they’re being managed. So if a patient with a non-emergent condition is part of a specific program or medical home, every provider will know to contact the right person before treating or transporting the patient.

“Our dream environment,” Racht added, “would be where we provide mobile integrated healthcare, where everyone that could potentially go to that patient’s home knew that that was a different kind of patient.”

Several forum attendees stressed that no pot of gold sat waiting for EMS to claim by establishing MIH programs. In fact, they said, these programs may struggle to find hospitals willing to pay for readmission avoidance or frequent user programs, especially while the current fee-for-service model is largely intact for emergency services.

Some chiefs expressed concern that communities are footing the bill for the programs, which isn’t sustainable, and that payers and other healthcare entities aren’t all rushing to fund MIH programs. “The longer you pay nothing for something, the longer you begin to think that that’s the value something has,” Sinclair said. “We are doing a disservice, I think, by going at-risk and providing things because it’s the right thing to do.”

Culture Change

Just as much of a challenge will be the culture change needed for EMS to be a part of a new, collaborative healthcare model, several people argued. Jeff McCollom, AMR’s senior vice president for innovative practices and business development, said healthcare is undergoing a paradigm shift from a system-centered approach to a patient-centered model. That may mean using different types of healthcare providers in new roles in an EMS or MIH system.

In Las Vegas, for example, AMR is looking to have a psychiatrist medical director in addition to the traditional emergency medicine-trained operational medical director, because so many MIH programs involve patients with psychiatric needs. Considering who may be best to lead the programs may require EMS organizations to shift how they view their relationships with other specialties within the healthcare community.

“Emergency medical directors have not always been the best MIH directors,” Racht said. “The primary care physician could be the best medical director [for some MIH programs].”

The culture change would go well beyond which physicians and other healthcare providers interact with EMS, though. As Racht pointed out, EMS did a very good job of convincing patients to call 911 and expect a fast response and transport to a hospital. Changing both the public’s and the healthcare industry’s views of what EMS can—and should—do won’t be easy, everyone agreed.

“There’s a group advocating for every hypoglycemic patient to go to the hospital,” Racht said. “Culturally, it’s you call, we haul.”

Similarly, EMS providers themselves are not necessarily trained for or even interested in the types of services that are needed for many MIH programs. Racht told the story of an early AMR community paramedic program that selected paramedics who were some of the strongest within a 911 system—ACLS and PALS instructors and experts in resuscitation and other time-critical emergencies.

“It was the wrong person,” he admitted, stating that other skills would make paramedics thrive in the MIH environment, including collaboration and patient navigation—skills not currently emphasized by EMS education and training programs.

“The classes that are out there now are not teaching that,” said IAFC EMS Section Chair David Becker. “You’re talking about going back and changing the education standards.”


What all these changes will require, forum attendees, is collaboration. Collaboration among transport services and first responders, AMR and hospitals, public safety and public health, and more. Chief Jeff Carman, Contra Costa County (Calif.) Fire Protection District, spoke briefly about the unique partnership his agency recently formed with AMR, which has had a contract to provide EMS transport in the district’s area for decades.

This year, for the first time, the fire department submitted a proposal to provide EMS services for the district—with AMR as a subcontractor, still providing the transport. The county awarded the contract to this alliance between Contra Costa County FPD and AMR, which Carman said would create a more efficient, effective system.

“For me it’s about sending the right resource to the right call and adding capacity to our system. I don’t have any more money; I’m pretty well tapped out right now.”

By combining dispatch facilities and training resources, AMR and the fire department will eliminate some redundancy and enhance capacity. Previously, the department sent a fire engine or truck company to every EMS call, often because they had little way of knowing exactly where the ambulance was responding from. Now, Carman plans on using fire units—which are staffed with an ALS provider—for higher acuity EMS calls and fires, but not for calls where they’re not needed.

The alliance also made sense for both organizations financially, said Tom Wagner, CEO of AMR’s West Region. In California, only government entities are eligible to receive funds through the Medicaid Ground Emergency Medical Transport supplemental reimbursement program. “The district becomes the ambulance provider of record and has access to those federal dollars.”

Under the agreement, the fire district bills patients and their insurers for ambulance transport and AMR receives a set fee regardless of the number of transports or the recovery rate.

Both Carman and the AMR executives expressed optimism that the new alliance will open up new opportunities to collaborate with each other and with other organizations in the county, paving the way for future improvements to the service they provide the community.

The Collaboration Forum was just the first of several meetings to bring together voices from different EMS service types to talk about EMS system design, finance and other issues confronting EMS organizations

“This is a long process of engaging the fire and EMS leaders in a collaborative way,” said Mike Ragone, AMR’s national director of EMS design.

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