Public Utility Model EMS

From their inception, public utility model (PUM) EMS systems have been a subject of controversy.

From their inception, public utility model (PUM) EMS systems have been a subject of controversy. Separating facts from hype can be challenging unless one has an understanding of how the PUM is designed, and more important, why certain features were incorporated into the system’s structure.

PUM: Patient’s Viewpoint

In 1972, researchers and scientists at the University of Oklahoma’s Center for Economic and Management Research (CEMR) met to study emergency medical services. Team member Jack Stout had directed the private ambulance EMS demonstration project for the federal government. The project had not performed as well as some of the others, and Stout wanted to know why.

Wanting to design an effective EMS system, the academics began by researching the ambulance industry and EMS. The group included members with “doctoral-level credentials in economics, organizational psychology, operations research, finance and accounting.”1 The interdisciplinary team conducted an extensive literature review, then conducted site visits to observe five systems that were operating well without federal or local tax subsidies and five that were subsidized.2

The federal government was leading an effort to upgrade EMS because of well-documented problems in ambulance service and emergency care. The research conducted by CEMR examined response time performance, levels of service and efficiency.

Once the research was completed, CEMR set about designing an ideal EMS system model, making patient care its highest priority, followed by financial stability and a professional work environment for field personnel. Many, then and now, assume that all EMS systems are designed with patient care as their highest priority, but this is not so.3 Following are the priorities that guided the team in designing the system:1

Patient Care

The model would deliver the highest levels of care and specifically avoid call screening (refusing service to telephone callers, which several large systems had tried with some well-publicized failures); transport refusals (crews refusing to transport patients from the scene to the hospital); and “hand-offs to BLS crews.” There are systems today that refuse service to certain patients. Rather than attempt to sort patients and run the risk of leaving seriously ill patients behind, the planners designed the PUM to transport all persons who asked for service.

Financial Stability

The model would create financial stability through efficiency and diversifying income sources to fund clinical care, regardless of changes in the economy.

Professional Environment

The model would provide a professional work environment for medics, EMTs, dispatchers and other support staff who are needed to deliver this level of care.

Restore Competition

The model would embrace the idea that no organization should be allowed to provide service without earning that right through competition.


The model would guarantee that rate-payers and taxpayers got full value for their money.

These priorities were not based upon science—they were value judgments. There is no way to prove that an EMS system should be designed with patient care as its highest priority any more than it is possible to prove that it should be designed for the comfort of its workers or the business interests of the organizations providing care. However, it is possible to look at an EMS system and determine whose interests are being served at the expense of others. Most EMS professionals believe patient care should be the highest priority of any system, but there seems to be a lot of disagreement about what exactly that means in terms of design features.

Economist’s Discovery

After studying the electric utility industry, an economist with the CEMR group noticed a number of similarities between the utility industry and EMS. Two characteristics were new and far-reaching in their implications:

Natural Monopoly

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