The Myth of the Perfect Model

The Myth of the Perfect Model

Article Aug 31, 2006

What defines a quality EMS system is rooted in local experience. Who provides the services and how they do so may vary from place to place, but each of us has our opinion of the ideal model, shaped by our own experiences and exposures. Truth be told, there is no one "ideal" system model, but rather a whole host of local factors that determine the right delivery method for a community. Understanding the good and bad of each model is important to appreciating what makes sense for your community.

     What follows are broad descriptions of several system models and the advantages and disadvantages of each. Students of EMS systems are all too aware of the limited published literature available about each model, and much of what you'll read here is drawn from the experiences of system review and design practitioners who have decades of background with EMS systems. At the conclusion, basic benchmarks are highlighted to help readers look at their own systems.

     For purposes of this discussion, six common system types are described: fire service, private for-profit, third service, not-for-profit, public-utility and hospital-based. Obviously, many subtypes exist.

The Fire Service Model
     In addition to its dedicated commitment to fire suppression, the fire service has a long history of providing emergency ambulance service. Many communities have known no other model of delivery. Over the last decade, several localities have transitioned their emergency ambulance services from other models to their fire departments. Reasons have included performance, finances and sustainability. Last year, fire-based EMS represented the largest provider of emergency ambulance service in large cities.1

     Within fire-based EMS services, it's important to distinguish between two submodels: dual- and single-role. In dual-role systems, personnel are trained as both firefighters and EMTs or paramedics. Single-role systems have an EMS division or section, but their personnel, and often their management, are kept separate from fire suppression.

     One other distinction of fire-based EMS is its focus on 9-1-1 patient populations, and not those requiring interfacility, critical-care or nonemergent medical transportation.

     Advantages-Firehouses have long been part of local neighborhoods. Citizens respect firefighters and perceive them as heroic. This provides a high degree of comfort to citizens and can often reduce public concern for the sustainability of emergency ambulance service.

     Fire-based service can be a benefit to public officials responsible for ensuring continued quality care. As part of local government, fire department management is directly responsible to city or county managers and elected officials. This allows oversight of the department's ability to accomplish key performance goals.

     Adding EMS into the fire department organizational structure may also provide advantages in the day-to-day management of both services. With fire suppression and prehospital emergency care operations under one roof, the need for parallel or separate management and administration is eliminated.

     Finally, training personnel as both EMS providers and firefighters enhances the versatility of the workforce, offers people variety in their duties and provides flexibility for management. Cross-trained personnel have the lowest attrition rate in the industry.2

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     Disadvantages-While fire-based EMS offers many advantages, it is not without disadvantages. It is important to note that many of these are rooted more in tradition than any inherent limitation of the model. They can often be overcome.

     Fire-based EMS systems tend to be measured on their level of effort (LOE) rather than the results of their performance. When a system's performance is viewed solely in the context of LOE or successfully completing a process, it captures only a piece of the puzzle. Having performance expectations that are outcome-focused emphasizes achievement of results.

     EMS call demand acts differently than fire call demand. To adequately serve potential patients, EMS resources must be matched to meet demand. Fire departments have historically deployed ambulances using a fixed neighborhood station model, and many continue to use 24-hour shifts.1,2 This approach results in too many resources available during non-peak hours and not enough during peak periods. Twenty-four-hour shifts often require a static deployment model to allow providers recovery time, limiting efficiency in managing the system status.

     The fire service labor force has long been heavily organized. This has resulted in competitive compensation and retirement programs, making the fire service an attractive employer for many career EMS providers. Labor agreements, however, also add a degree of complexity for an organization's leadership, often limiting their ability to manage the system. In addition, labor costs are higher than other system models.2

     Finally, fire service-based emergency ambulance services, as with most government-based models, only serve patients who request care through 9-1-1 systems. Nonemergent patient transport needs are delegated to local private providers.

Fire Service EMS: Performance-Based Contracting
     Where should communities be looking for best practices in fire service-based EMS delivery? How about Muscatine, IA?

     With just two stations providing EMS and fire suppression to a service area of 145 square miles, this small department, which runs more than 3,100 calls annually, might easily be overlooked. But in 1999-2000, the city and county of Muscatine commissioned an independent review of their local EMS system. Recognizing that a higher level of service was needed, leaders put their emergency ambulance service contract out to bid. Bidders included both private-sector entities and the Muscatine Fire Department (MFD). To ensure an objective comparison with private providers, the bid process quantified costs that are frequently not considered when EMS is operated by a public entity. MFD scored the highest in the bid review process, with 94% of possible points, and was awarded the contract.

     Since MFD began providing EMS, the department has been recognized by the Iowa EMS Association as its 2002 EMS Service of the Year, and an MFD member was awarded Paramedic of the Year. Sights are now set on accreditation. MFD shows that large or small, focusing on a high level of service is the right answer for any community.

The Private For-Profit Model
     Another dominant model in EMS delivery is the private for-profit company. In this model, emergency ambulance service is provided through contracts between private providers and local government. Nonemergency services may be included. As with the fire service, these contracts may be LOE- or performance-based, with a focus on results. Management and oversight of clinical care, day-to-day operations, assets and capitalization are all accomplished in the private sector, and the level of involvement and financial support of local government is completely negotiated.

     Advantages-For local governments, completely outsourcing emergency ambulance service has many advantages. The greatest is the ability to not have to be directly tied to the day-to-day operations of the service. Through solid contracting and established performance reporting and quality assurance, local officials can rely on the provider to manage operations and focus solely on whether expected results are realized.

     In addition to managing the organization, the company also owns all the assets. This means local government does not have to invest in ambulances, buildings, equipment or staff; nor does it have to pay for maintenance or replacement.

     With performance-based contracting, communities have clear scorecards with which to assess the performance of their contractors. This also facilitates benchmarking against similar communities. If a contractor doesn't meet performance expectations, local officials can hold it accountable or replace it.

     Being motivated by satisfying customers and making profit, private for-profit companies focus on practices that increase efficiency and keep costs down. In most cases, they will be heavily engaged in the nonemergency market as well, to help offset the costs of serving the emergency market.

     Disadvantages-The private for-profit ambulance model can have some disadvantages, but when smart communities and reputable companies work together, these can be reduced or eliminated. In many cases, proactive contracting and relationship establishment can be the key to success.

     A common complaint with private for-profit models is a lack of accountability and transparency. Performance data may not be accessible, followup on complaints and inquiries may be inconsistent, and financial oversight is often limited. This can result from community leaders not having a clear appreciation of EMS or what's needed for their community. It can be corrected through expert procurement and performance contracting.

     Another challenge is unregulated competition. This is especially true within the nonemergency transport market, where the payer mix is more lucrative than in the emergency environment. Clear local regulation and contracting can curtail problems.

     Sudden withdrawal of the provider from the market is also a potential concern. This can happen if the provider decides the market doesn't provide enough revenue to support its service, or it can be due to internal financial issues that force downsizing. Either way, a community needs to clearly address this in its contract and remain alert to the potential need for another contractor to provide service on short notice.

     Lastly, private for-profit companies can be less attractive for field providers. Lower wages, less opportunity for advancement and higher expectations for productivity are all factors that may contribute to turnover.2

Private Ambulance: Meeting the Call
     As EMS EXPO attendees said hurried good-byes to colleagues and friends in an effort to evacuate New Orleans before Hurricane Katrina ravaged the city last August, a longtime Louisiana private ambulance provider was making plans for responding to what would become the greatest natural and social disaster of our time.

     Acadian Ambulance, one of the largest privately held ambulance companies in the nation, serves a sizable portion of the region impacted by the storm. With disaster response plans in place, management focused on serving their stricken communities. Dedicated field providers put the needs of patients before their own. Acadian's effort illustrates why it has grown to become an industry leader.

The Third-Service model
     The third-service model is one of the least prominent models of emergency ambulance service, but it's often referred to as the "holy grail." It involves a stand-alone department within a city or county government, like the fire and police departments, that is dedicated to emergency ambulance service. It is traditionally staffed with civilian employees and, like its public-safety counterparts, is completely owned, financed and operated within the local government structure. This model is often perceived by providers as favorable because it's dedicated to emergency ambulance service and appears to provide parity between EMS and its public-safety peers.

     Advantages-A key advantage to the third-service model is public ownership of the emergency ambulance component of the EMS system. While this is also true of the fire-based model, in this model there is also a single service-delivery focus. Everyone in an EMS organization is charged with and working on the delivery of emergency ambulance service, and management is directly responsible to local officials. This allows local government to have direct control over the day-to-day operations of the service.

     Another advantage of this model is that it uses a civilian workforce. This lets a department offer wages that are competitive to the market, but still reasonable. It also offers some flexibility in developing schedules that match resources to the demands of call volume.

     Disadvantages-As with fire service models, it is common for third-service organizations to be evaluated by a level-of-effort approach instead of performance outcomes. This means no repercussions exist if the service underperforms. Poor performance is often addressed by simply adding resources.

     Another challenge is cost containment. In a third-service department, control of expenditures is dependent on local government's own budgetary and managerial processes. Without other motivations, like competitive bidding, to ensure competitive pricing, there is less of a drive to keep costs down.

     While many providers believe, or at least hope, a separate department would provide them the same attention, support and place at the table given to police and fire departments, in most communities that's not the case. Third services are frequently assigned less value than their public-safety peers, and their leadership shares many of the same struggles for recognition as other models.

     Lastly, third services are often targeted only at the emergency market and do not serve the nonemergency patient population.

Putting the Third Service First: Data-Driven Management
     As any EMS leader knows, quality information is critical. For a department to have what it needs, it has to be able to measure its results, show how its performance can be enhanced and make a sound business case for doing so.

     Montgomery County Hospital District EMS (MCHD) is a department within a political subdivision of the state of Texas. Believing data could assist in managing their organization, enhancing the quality of their care and maximizing their revenue recovery, MCHD leaders invested in a suite of software that allowed for the integration of all data from receipt of the call through the patient encounter and all the way into billing. Now managers can query performance, justify billing claims and compare the results of published clinical research with local system data at the click of a button.

     With this integrated technology, MCHD operates on real-time information. Harnessing this data allows it to improve processes and prove its performance is worth the investment. MCHD is proactively carving its path and ensuring it's capable of meeting the needs of its patients and staff for tomorrow and beyond.

The Not-for-Profit Model
     Not-for-profit (NFP) organizations provide an interesting ambulance model that can be found across the country. They vary greatly, encompassing all-volunteer, combination volunteer/paid and fully paid/career staffing models. Some evolved out of volunteer roots into full-time services to meet growing demand, while others were formed by hospitals or other community leaders to meet local needs. Service may be full or strictly emergency, and independent governance often involves a board of community leaders and stakeholders. As with for-profit companies, assets are owned and controlled by the board. The NFPs' independent structure may result in their being lumped in with private for-profit companies, but here, all revenue generated is directed back into the service.

     Advantages-Like private for-profit contractors, NFPs can free local officials from involvement in day-to-day operations. The organization's own leadership manages operations and answers directly to a board of key stakeholders. Any questions or issues with service can be directed to and managed at the board level.

     NFPs are often self-sufficient or minimally subsidized. Those with volunteer roots may be partially supported through donations. Career and mixed organizations will attempt to maximize user and membership fees to support themselves. This results in a lower cost structure. In addition, since they are nonprofit, any revenue above their direct costs is directed back into the service.

     Depending on the agency's mission, another advantage of an NFP is that it can provide both emergency and nonemergency services and benefit from a more diverse payer mix. In addition, NFPs can extend beyond geographical boundaries and increase their market share and resource utilization, which may allow for improvements in efficiency.

     Disadvantages-Leadership and the development of NFPs may vary over time. Some lean toward a competitive business model and grow into professional, well-managed and sustainable organizations. Others, especially those with volunteer roots, may hold on to the more informal and service-minded model of the past.

     Accountability and transparency can be an issue for NFPs. Having a diverse and professional board of stakeholders and business leaders can be an effective solution. In addition, local government should consider performance-based contracting to ensure results are being attained.

     Finally, NFPs with a career and volunteer mix may experience turf issues over expectations and authority. In some cases these providers may fall under different rules and management, adding to the conflict. Addressing the structural and policy issues head on can eliminate the root problem, but historical factors may take longer to overcome.

Not-for-Profit: A Perfect Score
     With almost 15 years of service, Advanced Medical Transport (AMT) of Central Illinois has grown from humble beginnings serving just three communities to become the largest high-performance ambulance provider in central and southern Illinois. Started by three local hospitals and community leaders, AMT is board-governed and operates without any local tax subsidies.

     Since AMT's inception, its staff and board have focused on ensuring sustainable, quality emergency and nonemergency ambulance service. In 2001, those efforts were recognized when the Commission on Accreditation of Ambulance Services (CAAS) awarded AMT a perfect score. This honor was bestowed again during AMT's reaccreditation this year.

     AMT is an example of community focus, quality care and high performance coming together to provide stellar service. Its continued growth only increases its ability to share its service with a greater number of communities.

The Public-Utility Model
     The public-utility model (PUM) of EMS remains one of the most controversial and least understood system designs. Developed out of research led by EMS consultant and system designer Jack Stout, the PUM was designed based on principles discovered while comparing systems that functioned sufficiently with lots of external funding to those that functioned without.

     A PUM is a strictly defined business structure with a public agency providing oversight but day-to-day services and management contracted to an ambulance provider through a competitive, performance-based bid process. The provider tends to be a for-profit company, but doesn't have to be. In most cases, system infrastructure is owned by the public agency, which also manages the billing operations; operational management services and employees are left to the contractor. The contractor is held to clear expectations and rewarded or penalized for their performance. Poor performers can be replaced in a scheduled bid process.

     Advantages-The PUM probably offers local officials the most advantages over any other model. Public ownership of essential assets allows the community the security of owning the system-no matter what happens with the contractor, the community can maintain seamless service. Management of the billing process ensures that the public agency can focus on maximizing its revenue from user fees and have direct control over monies generated by the service. The contractor is left alone to deal with operational performance.

     A key aspect of the PUM system is performance-based contracting. Included in the contract are provisions to ensure transparency and accountability and clear performance expectations that include frequent reporting. This process allows an understanding between the community and the contractor as to what results are expected. The contractor knows the governmental agency will be monitoring for them. Contractors are motivated by knowing that failure to produce can result in fines and even termination of the contract.

     PUM systems also subscribe to a system approach that is not uniformly accepted by the industry, but has some support in the clinical literature (see Table 1). The PUM is an all-ALS service, with every ambulance deployed at the paramedic level, and functions as a single full-service provider able to respond to both emergency and nonemergency requests. This allows it to be effective at meeting call demands, while ensuring that no patient is missed or undertriaged.

     All told, the PUM structure combines the stability and accountability often expected by citizens with the efficiencies and innovations of a private-sector company working to meet a high standard of service.

     Disadvantages-If the PUM offers so many advantages, why isn't every community doing it? There are several reasons. Probably the simplest is that the model is complex and requires several key components to be aligned with clear direction in order to function effectively and provide the checks and balances necessary. It also requires the creation of a separate oversight entity, which some elected officials may not embrace.

     A key component of the model's success is the ability to place the ambulance contract out to bid. One issue facing PUM systems today is a lack of qualified bidders. At the time of this writing, Kansas City, Fort Worth and Richmond are all in search of qualified bidders. Kansas City and Fort Worth currently do not have contractors. A lack of qualified bidders is a major obstacle to the system's success.

     Finally, while the PUM system is designed for the benefit of patients and community needs, field providers may feel they are low on the system's priority list. While salaries are competitive for the industry, employees are also expected to function at higher production levels, do fully deployed system status management and deal with changing employers every time there's a new contractor. This may contribute to the higher attrition rates seen in PUM systems.2

The Hospital-Based Model
     If you asked members of the lay public whom they think would be the ideal entity to provide ambulance service, it wouldn't be a surprise to hear them say the local hospital. It makes sense: The M in EMS stands for medical, we transport patients to the hospital, and we work hand-in-hand with other medical professionals. Even our nonemergency work often involves hospitals and other healthcare facilities.

     In hospital-based EMS systems, service may be provided directly by the hospital, or a provider might be a stand-alone entity owned or controlled by the hospital. Clinical, administrative and billing resources are usually drawn from the parent entity. The full range of services may be offered, or just emergency or nonemergency services.

     Advantages-Hospitals usually play key roles in their communities and have the public's respect. That respect often carries over to their ambulance programs, providing a higher degree of public confidence. In addition, hospital-owned ambulance services are perceived as more stable because the parent organization usually provides the capital.

     Without a doubt, a key advantage of hospital-based programs relates to the continuum of care. Ideally, the clinical agendas of the ambulance service and the hospital are integrated to provide seamless care. With easy access to physicians and medical records, the opportunity for advanced quality efforts and study of outcomes is immense. Continuing-education programming can tap into the vast clinical expertise of the hospital, elevating the prehospital knowledge base.

     Being part of a hospital may also mean higher wages for providers and a host of choices for career development and advancement. This, coupled with a higher level of clinical practice, can be a recruiting advantage over other models.

     Disadvantages-Sadly, while the hospital model can offer so many advantages, it's not uncommon for hospital-based services to function in virtual isolation.

     A common challenge is placement of the EMS department within the structure of the hospital. In many cases, it is relegated to a low position in the hierarchy of priorities and finds itself under the director of nursing or the emergency department. Frequently, it is isolated from top leadership and unable to advocate for itself or be included in key hospital initiatives.

     Another disadvantage is in revenue recovery. Hospital billing services are often charged with processing ambulance bills along with other bills. Unless a billing-office staff member is dedicated to EMS, the intricacies of ambulance billing may not be appreciated, resulting in reduced recovery. In addition, large bills generated within the hospital are likely to overshadow the smaller bills of EMS, and EMS recovery may not be maximized.

     Finally, in communities with competing hospitals, providers may feel pressured to return patients to their parent hospitals. Hospital-based services have to ensure that local laws and hospital policies are followed in regard to patient destinations.

What Makes A Good System?
     After deconstructing the pros and cons of each system type, it should be clear that no single model is perfect. Each can be ideal in certain communities and under specific circumstances. The key is how each focuses on results and ensures quality performance to those it serves.

     The next question then becomes: What do we look at as attributes of an ideal system? There are many ways to answer this question. The American Ambulance Association publishes a Community Guide to Ensure High-Performance Emergency Ambulance Service. Intended as a reference for local government officials who wish to improve the quality of their services, it includes five "hallmarks" for ensuring high performance.

     Hallmark #1: Hold the service accountable. Every ambulance service should be evaluated on its ability to deliver results in the areas of clinical excellence, response-time reliability, economic efficiency and customer satisfaction. This can be accomplished through performance-based assessment.

     Hallmark #2:Establish an independent oversight entity. This is a body that has an arm's-length relationship with a provider organization and regularly monitors how it is performing. It periodically requires independent outside audits.

     Hallmark #3: Account for all service costs. This is especially true when attempting to benchmark system costs. Whereas for-profit and not-for-profit services may easily be able to account for their system costs, public and hospital-based services may share costs with components of their parent bodies, making it more difficult to gauge total system costs. In cases where user fees constitute revenue, accounting for the costs of uncompensated care is important.

     Hallmark #4: Require system features that ensure economic efficiency. Ambulance providers should match supply with demand. If possible, looking at multijurisdictional and full service (emergency and nonemergency) can optimize system efficiency and maximize economies of scale.

     Hallmark #5: Ensure long-term high-performance service. This includes requiring results-oriented performance standards to be met, and then either benchmarking the clinical and financial performance against other recognized high-performance services or engaging in competitive procurement.3

     At first, not all of these hallmarks may feel applicable to every system model. Careful study, however, will reveal that there is something to offer for all. If anything, they act as a benchmark to use when considering the effectiveness of your own system.

     The hallmarks are effective for use as broad benchmarks, but what do we know about more specific system components that are important to quality EMS? Unfortunately, as we're all aware, there are no significant, widely accepted industry benchmarks to use. Components that have some support in the trade and peer-reviewed literature are summarized in Table 1.

     Admittedly, the literature is limited, and some might not concur with the conclusions toward which it points us. Unfortunately, even in this time of enhanced focus on preparedness and the effectiveness of our emergency-response systems since 9/11 and Katrina, EMS system design and effectiveness remains absent from academic study. What's more, our perceptions and experiences have not been validated in the research that does exist. To say EMS system research is an opportunity for improvement is an understatement.

Conclusion
     Each of us has a desire for EMS to move beyond its extended infancy into the profession we know it can be. Part of that growth involves recognizing that there is no single answer and that it's OK to be different. The future of EMS systems will always have a patchwork of models, each with their own attributes and faults, but the more important issue to address is how we're meeting the needs of our patients and communities. Let's turn our attention there.

References

  1. Williams DM. 2004 JEMS 200-city survey: A snapshot of facts & trends to create benchmarks for your service. J Emerg Med Serv 30(2): 42-60, Feb 2005.
  2. Williams DM. 2005 JEMS salary & workplace survey: What you earn, where you work, & what it all means. J Emerg Med Serv 30(10): 36-55, Oct 2005.
  3. American Ambulance Association. Community Guide to Ensure High-Performance Emergency Ambulance Service. McLean, VA, 2004.
  4. Dean SF. A study of the political and economical obstacles to improvement of emergency medical service systems. Unpublished doctoral dissertation, University of Maryland Baltimore County, 2004.

David M. Williams, MS, is a senior associate with the international EMS/public-safety consulting firm Fitch & Associates, LLC (www.fitchassoc.com). His doctoral studies are focused on EMS systems. Reach him at dwilliams@fitchassoc.com.

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