In Case of Emergency, Consider Quality Improvement

By Scott Harris

If quality improvement measures are good for the hospital or the doctor’s office, why not also for emergency medical services (EMS)?

Reimbursing for a few more EMS options could prevent hospital admissions and increase care efficiency. So says an analysis from two emergency physicians published in the February 20 edition of the Journal of the American Medical Association. The analysis estimated that 7 to 34 percent of Medicare patients transported by ambulance to an emergency department could have been successfully treated before reaching the emergency room.

“While we are starting to recognize that fee-for-service reimbursement has led to suboptimal health care delivery systems in hospitals and among ambulatory care networks, little attention has yet been paid to how the same fee-for-service reimbursement system affects out-of-hospital care systems,” said article co-author Kevin Munjal, M.D., M.P.H., assistant professor of emergency medicine at Mount Sinai Medical Center in New York.

As an example, the authors used the hypothetical case of an asthma patient who calls an ambulance after experiencing shortness of breath. Under current reimbursement rules, EMS personnel would bring the patient to the emergency department for a visit that would cost an average of about $970 and result in $464 in EMS-related reimbursement.

But it doesn’t necessarily need to be that way, the authors assert. Nebulized albuterol treatments and some primary care coordination could provide an equally effective, less-expensive outcome.

To prevent unnecessary downstream costs, EMS could be empowered to coordinate treatment with a patient’s usual source of care. If transportation is necessary, non-hospital destinations including the physician’s office, community health centers, or even a relative’s house could become new menu options. EMS providers could also have more choices at the initial point of contact, including a delayed response, transporting more than one patient at the same time, or even not responding altogether in cases where telephone consultations or similar measures can safely solve the problem.

“EMS can coordinate with hospitals and ambulatory care physicians to safely address unscheduled care needs in a patient-centered way,” Munjal said. “Transporting all patients to the emergency department may not be the most cost-effective way to allocate resources.”

Given their broad clinical and administrative reach, academic health systems could be incubators for this kind of innovation, just as they are for innovations inside hospital walls.

“Academic medical centers provide medical oversight and online medical control to EMS systems,” Munjal said. “They are thus uniquely positioned to pilot innovative models of care in the out-of-hospital setting by connecting the EMS system to both primary and specialty physicians…finding better ways to meet unscheduled care needs, and coordinating care to improve the transitions of care and reduce readmissions.”