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How Do You Eat an Elephant?

A year ago, in the January 2015 issue of IAFC On Scene, then-IAFC President Keith Bryant reminded us in Fire Service Culture: The Good and the Bad of the five wicked problems identified at the IAFC strategic planning meeting in January 2013.

They included:

  • Cost efficiency
  • Data
  • Deployment/staffing
  • Culture
  • Political acumen

That’s not one but five elephants. Big elephants.

In his article, Chief Bryant summarized that not only is culture its own wicked problem, but also a major factor in all of our wicked problems and that the aspect of fire service culture that most needs to change is the resistance to change.

This issue is further amplified by the fire service’s rapidly changing environment, most evident, perhaps, in the field of EMS.

As we move forward into 2016 and beyond, fire departments will need to consider their current cultural climate as they address the changing needs of fire-based EMS in their communities.

With the variety of issues facing fire-based EMS, the fire service as a whole will be affected in one way or another, regardless of the community or type of system—transport, nontransport, volunteer, paid or combination—with respect to the some of the top issues and concerns facing fire-based EMS.

Passed in 2010, the Affordable Care Act (ACA) brought about the biggest healthcare reform in America’s history.

The primary purposes of the legislation—to require health insurance, to mandate minimum coverage and to reduce the cost of healthcare—provide unprecedented opportunities and challenges for fire-based EMS to find its place in the emerging healthcare system.

Already mandated by the ACA with hospitals and physicians, value-based purchasing will soon be a mandated for Part B providers, which includes EMS.

There will soon be performance indicators for clinical performance and patient satisfaction.

EMS-agency leaders will have to consider how their agencies will measure up when these aspects of patient care are taken into consideration.

Federally funded, the EMS Compass Initiative was created to establish performance indicators specifically for EMS. This has never been done before.

The grant was awarded to the National Association of State EMS Officials to create 10 domains for EMS measurement for the purpose of guiding an EMS system’s quality-improvement strategies and for community reporting and accountability.

For example, here are four measures currently under review:

  • Measuring the percentage of stroke patients who had a stroke-severity assessment performed by EMS
  • Measuring the percentage of suspected stroke identified by EMS that have a documented blood glucose
  • Measuring the percentage of EMS transported suspected stroke patients that have prenotified receiving hospital
  • Measuring the time from first positive-stroke score to advance notification of hospital for patients with suspected stroke

While many EMS systems may be measuring the above indicators, healthcare is certainly moving in the direction where the focus is quality of care and outcome versus the quantity of services, and the results of these indicators will impact payment, clinical accountability and patient satisfaction.

In 2011, it was recognized that federal legislation passed in 1981—the Disproportionate Hospital Share Program—applied to the fire service.

The program was passed to solve the problem of negative financial impact to hospitals that are required to care for Medicare/Medicaid patients.

The fire service, obligated to provide care to the same patients, are eligible for Ground Emergency Medical Transport Supplemental Reimbursement, which may provide public fire-based EMS agencies new avenues of funding.

Scheduled to take effect in 2018, the Cadillac Tax will require health-insurance companies, employers or self-insured plans to pay a 40% tax on the difference between the amount the government believes is an equitable price for health insurance and what insurance companies actually charge for a particular plan.

The purpose of the tax is to both assist in paying for ACA and to involve consumers in the purchase of their healthcare.

No longer should we be satisfied with whatever our health insurance coverage provides or pays.

The concept is that the physicians and other providers will be forced to innovate, reduce costs and improve service in response to increased competition, which should ultimately lower the costs. It’s anticipated that this tax will be passed on to the insured.

The issues above have ramifications in

  • Service delivery
  • Clinical care and outcome
  • Data collection and evaluation
  • Finance and budgets
  • Personnel

They’re interwoven into the defined wicked problems.

They’re going to challenge the fire service and we’re going to have to fight for a place in the changing environment of healthcare in the United States, similar to how successful corporations have had to change, adapt and be innovative to remain relevant and successful.

That’s a huge cultural transition for the fire service. Fire chiefs will be forced to consider their cultural climate as they address these issues and then decide on the best way to eat this elephant.

In the meantime, the EMS Section will continue to serve up to you the most up-to-date information on these issues and more moving into 2016, one bite at a time.

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