Examining the 2020 Vision of EMS

The NHTSA Office of EMS released a significant document last year called the EMS Agenda 2050 that was carefully crafted to set a bold vision for the next 30 years of paramedicine by clearly differentiating the focus of care from its original definition in the 1996 EMS Agenda for the Future. Now, after just a few months of a COVID-19 pandemic, we have seen these modern precepts being challenged. As with any such vision of the future, a bit more perspective then just the immediate quarter is required. Before stepping toward the future, it is important to know exactly where we are today. To provide that update, NASEMSO released a new National EMS Assessment this past April to provide a measure of emergency medical response personnel and their agencies in this pivotal year of 2020. Although the latest survey is only updating the original work of a decade ago, there have been such dramatic changes that direct comparisons, even over this relatively short time frame, are difficult. To help bridge that gap for comparison, the folks over at ZOLL did a quick blog to reflect on the evolution of the EMS industry since 2011. Still for many, a little more context on how we got this far may be helpful before we can truly understand the significance of these most recent discussions regarding the future of EMS.

It was only back in 1960, that President John F. Kennedy made the statement that “traffic accidents constitute one of the greatest, perhaps the greatest, of the nation�s public health problems.” The automobile was well entrenched in the new American dream by this point as ribbons of smooth highway were unrolling across the country that facilitated speeds of travel much greater than the safety aspects of the car would afford. Yet it wasn’t until 1966 that the National Academy of Sciences ‘white paper,’ officially titled “Accidental Death and Disability: The Neglected Disease of Modern Society,” that ambulances began to transform from a side business at funeral homes into our modern Emergency Medical Systems of today. This initial milestone report, delivered during the Vietnam War, stated that �if seriously wounded � chances of survival would be better in the zone of combat than on the average city street.� So, the signature of President Lyndon Johnson provided federal funding through the National Highway Safety Act of 1966 that not only provided for the establishment of EMS programs, but thoughtfully placed the system within the federal Department of Transportation. Although the Omnibus Budget Reconciliation Acts of the 1980’s under President Ronald Reagan transformed direct federal EMS funding into state preventive health and health services block grants, federal guidance remained within the National Highway Transportation Safety Administration.

The numbers 9-1-1 were added to the American experience by AT&T in 1968 and it grew slowly across the nation as more communities demanded Emergency Medical Services. The most effective recognition of out-of-hospital care throughout the 1970’s came as the result of a television show simply called “Emergency!” This drama highlighted the results of efforts by early cardiologists like Drs. Lown, Zoll and Pantridge in having developed portable devices capable of disrupting the lethal dysrhythmias of v-fib effectively parlaying paramedicine from a focus primarily on trauma to include chronic medical conditions within the home as well. Pediatric trauma would not be officially recognized until 1984 with an Emergency Medical Services for Children study leading to a report finally published in 1993. The patchwork quilt of EMS continued to grow with increasing interest and even more piecemeal funding. Economist Jack Stout led a revolution in economic modeling of EMS systems during the 80’s and 90’s in response to the imbalance of demand and financing that had already fractured EMS into a kaleidoscope of models from fire-based, public safety to “third-service” public utility models to for-profit integrated healthcare businesses. 

It is certainly no accident that our industry has ended up in the position we are today. As W.E. Deming has taught the world, “every system is perfectly designed to get the results it gets.” And we proudly embrace the philosophy that states “when you’ve seen one EMS, you’ve seen one EMS” because we still believe that each service knows the particular unique expectations of their individual community while allowing insurance companies to dictate reimbursement rates. As a result, there is little federal standardization beyond a minimum national level of competency and few local agencies that are funded as “essential services”  even though the NAEMT has advocated this position for years. 

Today, it is heart disease that has overtaken the American consciousness as waistbands expand across the countryside demanding more from our organs than the body was designed to provide. In addition, we face new biological and socio-economic challenges for delivering healthcare in the field. We’ve needed a new road map like the EMS Agenda 2050, but we can’t just sit back and wait for it to happen. As professionals, we all need to educate ourselves on topics like Emergency Triage, Treatment, and Transport (ET3) and health information exchanges that are being piloted at select services. We must be the change we want to promote. 

 

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How "New" Will "Normal" Actually Be?

Be careful what you wish for. Just a few months ago, before the words “COVID-19” and “social-distancing” became a regular part of our conversations, I was speaking with the Operations Chief of an EMS service about the difficulty in hiring and retaining paramedics. He said it would take “a downturn in the economy before we could hire enough medics” since candidates typically gravitate toward stable jobs in public service when the market is in a recession. Well, its technically not a recession, but the current pandemic is clearly stressing the world economy and even altering patterns of use for many EMS agencies. In some areas of the country, call volume is now out-stripping capacity while others find themselves in a very different place with far fewer calls than normal. So, as we even consider whether we still need the paramedics we had planned, the immediate questions become “what is ‘normal’,” and “what could be so ‘new’ about it?”

The past can often be a good guide. My primary job in consulting is helping agencies with the optimization of their resources. Doing this successfully requires that I can discover patterns from history to guide forecasts of the immediate future. This is a difficult position when the world is no longer behaving according to the regular fluctuations of the past. Yet, as an undeterred student of history, I continue to search for models that can illuminate the path before us as I did regarding demand in my previous post. There is no shortage of significant anecdotes from history to review, but each has its limitations when applied to today.

My first study was the so-called “Spanish Flu” of 1918-19. It was the deadliest pandemic in history that infected nearly a third of the human population and killed well over 20 million (or by some estimates more than 50 million) victims, including some 675,000 Americans. This historic pandemic had a similar effect to today by shutting down world economies and hiding its population behind face masks. The scariest consideration of a modern parallel to this period would be the idea of an even more devastating second (or even third) wave of infections yet to come. This historic flu, however, was still not able to destroy the world order as some feared. In fact, it preceded one of the greatest economic expansions of industry leading to a period that would be known as the “Roaring Twenties.” The score of our current pandemic is merely a shadow of its predecessor with less than 5 million worldwide infections known and slightly more than 300 thousand total deaths around the globe. So, could we also expect a similar economic boom following our current crisis? That is highly doubtful as the economic conditions preceding this shutdown were entirely different than a century ago. And I’m also not sure we would necessarily want that same exuberance that stemmed from a generation that developed an attitude of “nihilistic hedonism” born from a season of austerity and fear caused by the disease. The age group primarily affected at that time developed a laissez-faire attitude toward life fueled by a rapid rise in prosperity induced by sweeping changes in technology, society, and economy. It was literally the beginning of the modern age – and then came the worst economic depression ever.

Fortunately, the current death toll is still far too low to engender a similar sociological backlash even in a time of modern polarized politics echoing the protests of the last century. With a presidential election less than six months away, many states have entered some form of “Phase 1” of a controlled economic reopening of society. There are probably as many anecdotes as opinions with states like Texas going big on economics over epidemiology compared to the more cautious moves of hard-hit states like New York and New Jersey only ‘cracking open’ slowly. While scientific advances are promising, we still do not have a vaccine, effective treatment, or even reliable tests. Yet we seem reliant on the promise of “contact-tracing” in an environment of community-spread rather than recognized efforts elsewhere at “contact-isolation.” So we can likely plan on seeing more cases of COVID-19 in the coming months and political reactions will likely vary with an increased influence of politics.

What is likely to be lasting from our current experience are new “telemedicine practices” being implemented by physicians and widely accepted by a public that fears even going to the hospital at the moment. If EMS will ever be able to justify the continuation of Community Paramedicine practices or possibly even extending them through their own Mobile-Integrated Healthcare outreach (or as a home-provider within the telemedicine practice of doctors) it will be right now. If the opportunity of the current crisis passes without making political gains to extend the reach of EMS, it will only be more difficult to accomplish in the future. We have also seen traditional conferences gone virtual to eliminate travel and large physical gatherings. Although the experience lacks some of the traditional perks, it has huge cost and time savings. Similarly, professional-referred journals are quickly giving way to a faster social exchange of information and ideas online that bypasses traditional peer-review being replaced by a new social review creating “healthcare influencers” online. To continue this trend, we must figure out how to “qualify” these social icons in the long-term and socially circumscribe their power.

There are also examples we could study of pre-hospital responses to HIV/AIDS, MERS, and SARS. Even though each occurrence caused a significant public panic and subsequent EMS response, their lasting influence quickly waned and the lessons they taught for preparedness were not applied nationally to help us respond to a pandemic. Consequently, the real strategic question we must consider in planning for the future is fortunately not how society will react or estimate how many cases of COVID-19 we will experience, but what effective change will be wrought related to how EMS functions or is financed going forward. As we contemplate moving out from the Department of Transportation  where we are paid only for moving patients, we could consider the terrorist attacks of September 11, 2001, as another example of a precedent model. However, that initiating event concluded within hours and its perpetrators targeted an ideology rather than a lack of immunology. Both passions and fears were inflamed worldwide by these coordinated attacks, but the only lasting results have been legislation expanding government surveillance in the Patriot Act (reauthorized yet again nearly two decades after the event), the creation of a new government bureaucracy over the traveling public in the Transportation Security Administration (which remains focused largely on airline travel which was the target of the terrorists at that time), and the longest on-going war of American history.

Today, the enemy has no flag and the world (or even our industry) also has no unified leader to coalesce a response tactic. Even in the field, the providers of EMS services cannot agree on whether we represent public safety (which justifies an essential funding stream for the public good) or that we provide bona fide healthcare services as a part of an integrated service stream offering appropriate care anywhere from the home to a hospital (that is worth reimbursement independent of driving someone to the hospital.) What history teaches us are several lessons. First, government responds to situations that expand its own interests and that are simultaneously supported by the affections and desires of the public. Even during this EMS Week, it is doctors and nurses who are seen on the front lines of the pandemic war even though the tip of the spear is made up of Emergency Medical Services professionals who go into the homes of the sick and reach through the wrecked vehicles of the injured to risk themselves in the preservation of others. We will continue to be the ‘invisible third service’ as long as we struggle with our identity and lack the statement of a value proposition for a suitable underlying financial mechanism. Second, government consistently responds along an evolutionary path to the last threat rather than a forward-thinking approach. Until we can justify the payment for necessary treatment on scene in addition to any transport to definitive alternative destinations, we will not see revolutionary change. Even wars can be waged indefinitely as long as no one notices they continue. 

We may see some fluctuation in demand for a while, but in the long-run we will return to a familiar normal fare of heart attacks, strokes, and falls once again. It may not be the exact same place we left months ago, but it will not be an entirely new place either. The struggles we fought before will continue to be our struggles again. Hiring and retaining paramedics will again become a topic of discussion as we continue to fight for budgets to maintain our response metrics. That is unless we can learn from one other historical example that comes from back in 1843.  That is the year that Charles Dickens published his famous work known as, A Christmas Carol, where the the Ghost of Christmas Yet to Come prophesies, “If these shadows remain unaltered by the Future, the child will die.”

What Higher EMS Pay Requires

I know that the debate on EMS wages did not begin last week with Sean Eddy’s post “5 Reasons Why EMS Doesn’t Deserve Higher Pay.” For instance, Caitlyn Armistead did a great article last October entitled “Burger Flippers Vs. Ambulance Drivers” long before her recent rebuttal in “5 Reasons EMS DOES Deserve Higher Pay“. The extremes of passions also came out in another post at this site that has helped propel the debate if even in a less than civil manner. Catherine Counts also recently added her voice, and unique perspective in the “EMS Pay Debate.” Recently, EMS World also ran an article written by Gary Ludwig. In addition, there has also been a mixture of passions and reasoning on many Facebook pages and I am sure several other places I haven’t even discovered yet. The common thread between most of these is that they focused on who we are as the health care providers in the field. While I am a relative newcomer on the ambulance, the vast majority of my career has been in consulting on business process improvement and I would like to share what I have discovered in my journey to a job in EMS.

While I wholeheartedly agree with improving our educational requirements, it is not because of any direct causal relationship between scholastic degrees and financial compensation within our field. After all, the core design of the EMS industry is based on provider certifications rather than personal knowledge. By definition, we provide circumscribed care to the sick and injured based on protocols and guidelines, not based solely on our own intuition, beliefs, or even “ninja-like” skills. The services we work for are reimbursed for the production of “transportation units,” not compassionate care. The fundamental truth we must recognize is that our agencies have historically been paid for the number of patients delivered to a hospital. Period. Even though most field providers are concerned about “doing the right thing” for our patients; we are simply not compensated, at least in any large measure, for the level of “care” we deliver. Diagnostic technology has advanced, training has improved, even our knowledge of human pathophysiology has grown tremendously. But the financial model that drives our employers is fundamentally unchanged from the days when funeral homes scooped the dead and dying off the streets. The Centers for Medicare & Medicaid Services (CMS) and insurance agencies simply “reimburse” agencies based on formulas of care. Quality beyond basic competence, at least prior to the Affordable Care Act (ACA), has not been a criteria.

Our skilled care, compassion, and like it or not; our response times, rhythm analysis times, 12 lead performance rate, mileage reports, patient satisfaction scores and all of the other graphs posted on the bulletin board at your base are important in allowing our employers to keep a contract. It doesn’t matter fundamentally whether you are employed in a local government “3rd service”, private contractor, volunteer service, or whatever. Your employer has a “contract” to provide services that can be lost and replaced with another service model. This contract, often as a sole provider, eliminates significant competition at the patient level. They have an emergency, they call 9-1-1 and accept the level of care provided while en route to the hospital for that occurrence. If cumulative expectations are not met by the public, a change in the service is demanded. This arrangement far from absolves us of personal responsibility for the quality of service, but should actually drive us to improve in all measures (especially those that impact the continuity of our employment.) EMS Compass is a new initiative to help map out the measurement of performance in EMS services. If we care about the future of our agencies and the conditions we will work under, we should become actively engaged in this program. But it doesn’t end here. The whole employee/employer relationship must be born of a mutual respect and understanding.

To say that “corporations make huge profits and can therefore afford to pay living wages” or “our work is so risky to our personal mental health that we deserve more” are not only simplistic ideas, but they set up an adversarial relationship with employers in place of a cooperative one. We must work together throughout all levels of the organization to show value (or need) in order to justify the allocation of additional funds for whatever purpose.

Similarly, we must also refrain from dividing ourselves from each other. I have heard several complaints that volunteerism in EMS holds wages down. This is a spurious argument in my opinion for two basic facts. First, in many areas, a lack of volunteer EMS services would simply mean a lack in any professional prehospital emergency services there. In rural areas where population density is low, demand is also typically low along with the financial resources to sustain a paid service. Extreme rural lifestyles have a different balance of costs and benefits that cannot be compared with extreme urban choices. It is unfair (and burdensome) to demand equality of services in either case – even if it were possible to achieve. Law enforcement and fire protection services are also routinely provided differently at either end of that spectrum and accepted as a part of the lifestyle in that area. Secondly, wages are only a portion of employer expenses. For any “business” to succeed (and yes, you work for a “business” if only in a broad sense of the term) you need to constrain debits (operating expenses) relative to credits (budget allocations, fees or other reimbursements.) In some cases, services can operate at a deficit if they are recognized as providing an intangible service greater than their expense. Reedy Creek Fire and Rescue, for instance, provides all services to the visitors of Walt Disney World at no charge because Disney sees a value that outweighs the cost and is consequently willing to pick up the entire tab. The majority of the world, however, must show “tangible values” that exceed their costs of operation in order to collect any fees from whatever payers. The fact that a volunteer is willing to drop everything at a moment’s notice to attend to the injury of another human being has never taken food from the mouth of an EMT somewhere else. We may not all be equal, but we are the same nonetheless.

If the intention of increasing educational requirements and eliminating volunteers is to reduce the available workforce in order to improve competition for positions and by extension improve our wages, then it will be a failure. If we raise the knowledge level of providers and therefore allow them to perform different roles such as Community Paramedicine (or Mobile Integrated Healthcare if you prefer), then we have a basis for providing new value. The next step is to find someone who is willing to pay the costs to support that improved value. This is where the ACA has brought quality of care into the picture. If a patient requires re-admittance to the hospital for the same condition too quickly, the costs that the hospital has incurred in the treatment of that patient will not be reimbursed. We currently operate at the gateway to that readmission process and potentially stand to save hospitals significant sums of reimbursement payments if we can form successful financial partnerships that ensure proper care at the lowest cost. We already work in the home environment and should have the necessary skills to ensure that a high quality of care is maintained through the “convalescence” period following a hospital discharge as well as transport critical patients for treatment. We need to accept, however, that we are not simply “public safety” agents, but agents of “healthcare reform.” This alignment can pit us against aspects of the nursing field, but we can be relevant here as we are a significant, educated local workforce that already possesses the unique skills and patient familiarity required to perform the job.

Attempts to address our personal pay by reducing workforce potential (by setting higher educational standards for providers or eliminating volunteers) is actually counterproductive because it forces agencies to streamline the production process actually making working conditions worse. We are better off expanding our scope of practice and providing extended value to patients and other health care partners. We cannot blame wages on the workforce just as we cannot presume our employers are greedy bastards. This infighting and misplaced aggression only confuses the issue. The agency compensation model must change by altering the basic business paradigm in order to see meaningful change in wages. Further, choice must be introduced in patient endpoints for service as well as seeking compensation for services based on the provision of a “level of care” as defined by medical outcomes or patient satisfaction.

Mobile Integrated Healthcare is our greatest promise for changing the model. In many cases, laws (and even service charters) must be changed to allow the field of paramedicine to grow. The Field EMS Bill is attempting to make basic changes and is our best hope in that regard. Making ourselves better providers may make patients, or our employers, happy by providing better “9oth percentile statistics,�? but that in itself doesn’t change the underlying business model to generate the revenues required to pay employees more.

We need to mimic nursing professionals, or even doctors, as our political role models; not compare ourselves to fast food service workers. Each of us must become politically engaged in the changes that are being discussed within our industry and work to affect change that is in our best collective interest. Communicate and project professionalism to the community we serve in order to gain their respect and elicit their support as a valuable partner in the health care of our community. We must work cooperatively to seek new opportunities to increase and provide economic value. Seek creative partnerships that tap new revenue sources instead of increasing the competition for diminishing grant opportunities. Wages will change when we decide to work for them.

Late for the Future

My friend Mike Ward, who I met as “FossilMedic“, asked a question in a blog post back on September 10 wondering aloud “What will the fire service look like by September 11, 2021?�? Well, a few of my fellow EMS bloggers took the challenge of answering that question. In his blog post on the subject, Greg Friese presented a mixed bag of specific predictions as he also extended the question to include EMS as well as Fire in the query. The gadget geek known as “UnwiredMedic“, or just Christopher Matthews to some, also quickly took up the challenge focusing on the advances in technology as he usually does in his post on “the closure of another anniversary“. Finally, Bob Sullivan focused on his trademark patient perspective in discussing provider skills and training that will be common in his view of “EMS on 9/11/2021“. I am quite late to the fray, but hope to join these friends in making my own prognostications from my own unique vantage point on improving the efficiency of EMS.

The way I see it, in another ten years we will be past most of the in-fighting we currently experience between firefighters and paramedics about who does what more effectively or efficiently. I hope that by the 20th anniversary of the terrorist attacks we will finally recognize that the public is both the focus and financier of our efforts outstripping our desires for shiny equipment or promoting blind union allegiance. We face the pressures today of a changing environment where a lack of volunteers is necessarily being replaced by paid staff increasing provider costs and an aging and increasingly unhealthy population is placing more demands on emergency resources. All while, the very foundation of the heath care system is continually being overhauled with changes to well-established financial reimbursement incentives. The fundamental change we will witness regarding the structure of provider agencies in coming years will not be a linear progression from today, but the enhanced variation of a “punctuated equilibrium�? driven predominately by rising costs and demand that are clearly out of line with our commitment of resources.

The first ten years since 9/11/2001 saw unprecedented spending in public safety at every level raising debts nationally and locally. Now we face an economy that cannot sustain current spending patterns and will demand increased efficiency along with the increasing efficacy of evidence-based treatments. To get more from less, we must do better. I believe we will see the advances in technology and education that others have predicted because it will prove to improve service, but we will also see consolidation of agencies along with increased specialization. Medically focused professionals will handle the majority of medical calls. Savings will be realized by integrating these medical responses with advanced medical providers given incentives to improve long-term health outcomes.

A future we need and can live with. What do you see?