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The recent news coverage of Chicago Fire Department losing big bucks to unreimbursed refusal of transport calls is not a problem unique to Chicago.  Sure, asthmatics will call for an albuterol treatment when caught without their own medications and some hypoglycemic patients will invariably need an emergency sugar boost.  The sophistication of modern day EMS delivers definitive solutions to many medical problems like these right on the street (in many systems at the BLS level).  Very often, no further care is needed.  Patients know they don't need to go to a hospital.  Many have experience of having been talked into transport only to waste hours sitting in a busy Emergency Department with no benefit whatsoever.  Firefighters know this too.  So why do we persist?


The answer lies in dollars: no transport, no money.  Not only for the fire department, but also no payment to the hospital or the physician(s) who see the patients we needlessly convince to accept transport.  It's time we smarten up.  Our patients aren't stupid; many know precisely what they need to get well and stay that way.  That's why they call us.  EMS needs to stand up and demand reimbursement for the care we provide - with transport or without.  There have been several common sense demonstration projects where insurers have agreed to reimburse EMS for responses without transport.  Every one of these have died.  Why?  In my opinion, it comes down to politics and money.  Physicians (yes, the people who write our treatment and transport protocols) and hospitals (yes, the places that provide medical control) want money.  And money requires patients.  So we keep bringing them in.


You'd think insurers would find appeal in the lower costs of paying EMS to solve problems on the street without transporting patients to another, more expensive level of care.  It sounds like a good idea and indeed, probably serves as impetus for demonstration projects every so often.  But ultimately, insurers need to stay on the good side of hospitals, and EMS represents a very small pimple on the face of total health insurance dollars.  So, while demonstration projects produce cost savings, they ultimately shift money from hospitals and physicians to EMS.  That's where they end.  It's time for EMS to get a spine.  If cities like Chicago are running $50 million dollar a year deficits, partly attributed to EMS no-transports, then why are not our advocacy organizations putting their collective feet down on getting paid for what EMS does?  Partly because EMS lives in a vacuum.


The place where decisions about healthcare dollars are made is the Department of Health and Human Services (HHS). But EMS is not sitting at the HHS table and it often seems like they don't even know they should be.  The Department of Transportation is not a healthcare entity.  Neither is the Department of Homeland Security. If EMS ever wants to improve their reimbursement position, they will need to take a seat at the table where the game is played.


Mike McEvoy

EMS Editor

Fire Engineering magazine

Views: 1258


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Comment by Harold C. Cohen on October 28, 2011 at 9:25am

Dr. McEvoy is absolutely correct about the current EMS reimbursement policies of federal and private payor being counterintuitive by providing reimbursement only for taking patients to the most expensive care available. Many look to demonstration projects involved expanded scope of service that show promise, but lose steam because they we have been unable to tie in the payor.

I believe that Dr. McEvoy may have uncovered the direction needed. While I usually support initiating programs such as expanded scope of service from local demonstration to national implementation, perhaps we must put more emphasis on a top down approach?? Timing may be right because a new EMS scope of practice and a  national certification plan being introduced are complementary to a new reimbursement philosophy and plan. New federal representative groups such as FICEMS must begin to reverse the recent so called CMS negotiated rule making process that left EMS with an enhanced plan to fail.

Our new course must also acknowledge and leave behind those examples of self-sabotage. Municipal EMS systems under the mistaken belief that fee for service is a double tax, or the minority of commercial services taking advantage of the reimbursement system must be shown the exit door. It only takes a few ethical breaches, or one significant signn of disunity among EMS professional organizations to allow those wanting to keep EMS outside of the healthcare community.

Dr. McEvoy has inferred that not only is a federal EMS agency needed, but HHS is the most appropriate place. Frankly, I'm not sure where the federal leadership for EMS should be housed. While fighting for control of EMS may be unhealthy, I'm glad to see that federal agencies are fighting for us, instead of seeing EMS as a hot potato that landed in DOT. Perhaps that is our healthy indicator that EMS really does influence healthcare.

Regardless of what delivery model is used or how reimbursement is secured, a few standing principles must apply.

1. Who should be the community EMS provider - the provider(s) who will do what it takes to do it well (regardless of which type of agency).

2. Agreement not to resist the emerging standards of practice, quality management mechanisms, and accreditation of services and educational programs.

3. Demonstrations of how EMS can positively impact healthcare economics for patients and payors.

I know, easy for me to say.

Thanks Mike for stimulating our thoughts.


Harold C. Cohen, Ph.D., FACHE, NREMT-P

Division Chief (Retired)

Baltimore County Fire Department

Catonsville, MD

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