Iíve said this before, and Iíll continue to say it until I can do something about it: The Fee-For-Transport model has failed EMS. We have to change it and we have to change it soon.
In fact, I believe that the entire revenue model we use for our industry has failed. I think that the ďFee for TransportĒ model employed by the Emergency Medical Services industry is flawed, archaic, outdated, and is not conducive for the development of our profession. I think it stifles growth and development. I think that it is unfair to make this inequity up through local property taxes.
I think it has to change.
Donít know what Iím talking about? Letís hear what Medicare has to say on the subject:
ďThe Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.Ē (https://www.cms.gov/manuals/Downloads/bp102c10.pdf)
Yes, thatís what that means: Medicare sees EMS solely as a ďtransport provider.Ē
Basically Medicare is saying that all theyíre going to pay for is taxi service. Sure, theyíll reimburse some other expenses, but without the taxi component, theyíre not picking up the tab. Theyíre certainly not going to pay for you to provide medical care for one of their clients on a scene. Theyíre not going to pay you for sweetening up an unresponsive diabetic and leaving them at their house, theyíre not going to pay you for providing Community Paramedicine, and theyíre certainly not going to pay you for other home health or primary care services. To them, weíre a medical transport industry. They pay for transportation and thatís it. Sure, they make a differentiation between ďEmergencyĒ transportation and ďNon-Emergency TransportationĒ and use the term ďskilled medical treatmentĒ for some of the things done in the back of our rigs, but that whole ďtransportationĒ thing is always there. No transport, no payment. Itís as simple as that.
Not sure about that? Well, hereís more reading on what Medicare WILL and WILL NOT pay for in this informative booklet that I just printed out for every EMT at my service to read:
Thatís the link to the ďOfficial Government BookletĒ that explains:
- ďWhen Medicare Helps Cover Ambulance ServicesĒ
- ďWhat Medicare PaysĒ
- ďWhat You (the patient) PayĒ
- ďWhat to do if Medicare Doesnít Cover Your Ambulance ServiceĒ
Iíll admit, this is pretty light reading by government standards, but itís important for all of us in the profession to read, understand, and know this stuff. Sure, I know that some of you out there are going to fall back on our old standby statement that ďIím not in this for the money, I just want to help peopleĒ or some other platitude just like that, and I understand and appreciate your altruistic motivationsÖ but I will tell you that EMS needs money to operate. Whether youíre a volunteer or a full-time paid employee, your ambulance service needs money to function. Paid employees need to make a living, ambulances need fuel, stations need heat, equipment needs to be replaced, and communities need 24-hour ambulance coverage to meet both their emergency and non-emergency needs. Ambulance services are critical for any community, no matter their capacity, and all of that stuff takes money. Medicare, through the ďCenters for Medicare and Medicaid SerivicesĒ (CMS) sets the tone for the entire healthcare payment industry and by default they have become responsible for propping up a majority of ambulance services through providing the lionís share of their total revenue in some areas. Theyíre the big dogs in the healthcare payment arenaÖ and theyíre holding us back.
Not that Iím solely picking on Medicare hereÖ but letís read further into their definitions, shall we? (From the second document I linked to above):
ďEmergency ambulance transportation
Emergency ambulance transportation is provided after youíve had a sudden medical emergency, when your health is in serious danger, and when every second counts to prevent your health from getting worse. The following are examples of when Medicare might cover emergency ambulance transportation:
- Youíre in severe pain, bleeding, in shock, or unconscious.
- You need oxygen or other skilled medical treatment during transportation.
- You need to be restrained to keep you from hurting yourself or others.
These are only examples. Medicare coverage depends on the seriousness of your medical condition and whether you could have been safely transported by other means.Ē
Clearly, Medicare thinks that only ďSkilled Medical CareĒ provided whilst tires are rotating under a patient is valuable. They pay no attention to the fact that there are better and cheaper alternatives out there that our profession could offer them. I know that Medicare represents taxpayers and the payments they give out are tax dollars, and I appreciate and want them to be responsible with those tax dollarsÖ
I just donít think that they are.
Medicare has determined that the only way they can be responsible with our tax money is to deny as many payments as possible and to only pay for the bare minimum that they feel is important. Thatís why ambulance services are ďTransportation providersĒ in their eyes. However, this ignores so much potential in cost savings in my opinion. They pay no attention to the fact that while itís nice that they pay for ďWait-and-returnĒ ambulance transfers to and from nursing homes and clinics, those services could be provided in a lot of cases by paramedics who could take care of the patientís needs on site and save them a ton of money by offering the new service. They ignore the fact that if they provided a $250-$300 benefit for an ambulance to come, fully assess, treat an unresponsive hypoglycemic diabetic, and then release them safely without transport, they could avoid the (estimated) $500 transport bill and subsequent $1000 ER bill. The savings are potentially enormousÖ and there are a ton of ideas like that waiting to be explored.
We, as a profession, just have to convince them that these ideas are worth being explored.
The healthcare payment system shapes healthcare.† It certainly has shaped the way we operate in EMS. The pressure to do only what weíre going to get paid to do is so prevalent a force in the industry that it is almost the very foundation of what we do and how weíve evolved. The payment system didnít evolve to meet our potential; EMS has evolved to fit its limiting influence. This is why we do the BLS transfers that cost too much for too little benefit. This is why new products that canít be reimbursed arenít making their way into the hands of field providers. This is why treatment modalities arenít expanding as fast as in other areas of medicine. The CMS fee schedule dictates all of this.
And we as a profession have to change it.
Imagine what EMS would be today if we could bill for any service we thought provided benefit to our patients and our communities? To be sure, this would cause some ďwaste, fraud, and abuseĒ in the initial phasesÖ but that exists in todayís system. Could you imagine if Community Paramedicine was fully reimbursed? Can you imagine that if instead of providing a wait-and-return BLS transport for a nursing home patient needing a surgical wound re-check, you came, assessed, took some pictures on a cell phone camera and sent it to the physician wirelessly? Can you imagine if you could charge for responding, assessing a patient with a minor medical complaint, and then having the patient transported to an urgent care center that would continue your care? Can you imagine how different everything we do could be?
Well, at least I can start to imagine. I see additional revenue streams that would come into our industry and improve the profession, strengthen our patient care, and save the healthcare system a boatload of money while improving access to primary healthcare. I see paramedics and EMTs not being taxi drivers. I see a real career and a bigger impact upon the overall health of our communities. I see more fiscal responsibility. I see lots of great potential.
And I donít know how to do this yet, but maybe somewhere, someone reading this might have an idea.
Iíve written on this before, and maybe youíd be interested in reading some of those ideas:
And to look at a real-life example of how our British brethren are handling this issue and are having success across the pond: