Chasing the costs of ambulances

On a given day in Michigan, anyone with a scanner listening for 911 medical calls might hear something like this: "trouble breathing," "pain in abdomen," "swallowed something."

Some are emergencies. Others are not.

In most municipalities, there is a good chance first on the scene will be a crew of medically-trained responders from the nearest fire station. The patient is most often whisked by ambulance to the emergency room.

The ambulance bill is typically at least $500. The emergency room visit will rack up hundreds of dollars more.

But for true emergencies, few would quibble about cost. After all, who puts a price on the loved one with a heart attack who pulls through?

And in that sense, in most jurisdictions,Michigan's Emergency Medical Services system works. It saves lives.

But for all that, experts and some EMS providers question its efficiency. Is sending a fire truck loaded with paramedics to an unknown medical situation a smart use of resources? Could some patients be safely diverted from the emergency room?

"You get a call and someone says, 'My dad has collapsed,' said Brian Walker, general manager of Universal-Macomb Ambulance Service in Sterling Heights. He has been in the ambulance business for 40 years. "You don't really know what is happening until somebody is there. Does that somebody have to be eight guys and a fire truck? You are subsidizing a very expensive piece of equipment going out on medical runs.

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"Nobody goes out in front of a city council and admits that what you do is not an emergency. That does not get you millage. Crisis gets you tax dollars."

Response crisis in Detroit

Walker's firm has been helping Detroit with a bona fide EMS crisis, as it sends ambulances under a mutual aid pact into that city while Detroit grapples with reports of delayed response and broken-down ambulances. Unlike many large cities, Detroit does not use fire-based medical responders and relies instead on a separate ambulance fleet paid from the Fire Department budget.

Almost no one believes it functions as it should.

 In 2010, then-Detroit Fire Commissioner James Mack, Jr. conceded: "There are times during the day that we may not have units available, period."

Making matters worse, Mack asserted, just 10 percent of its 130,000 EMS calls a year were true medical emergencies. In 2011, the city rolled out a response policy intended to weed out low-priority 911 calls for concerns like toothaches and boils.

Experts say it is vital dispatch centers discern medical emergencies from issues that can wait, much like the triage protocol that governs emergency room treatment.

"It is critical," said Mike Thompson, medical consultant for Utah-based National Academies of Emergency Dispatch. The nonprofit organization sets certification standards for individual dispatchers and accreditation standards for dispatch centers.

Thompson believes dispatch centers around the country, including Michigan, are guilty of EMS overkill out of fear of facing lawsuits.

"Virtually everywhere we have these EMS centers out there and when you call 911 with a complaint, virtually everyone in the country will send you an ambulance. We over-treat, we over-provide because we are afraid of being sued."

From 'patchwork' to authorities

Michigan is divided into 65 medical control authorities, charged with overseeing EMS response within each jurisdiction. Put in place in 1978, the system replaced a patchwork of private and public responders that lacked unified performance standards and strong oversight. In the decades since then, most of Michigan's 1,062 fire departments have added EMS to their firefighting duties.

Still, there is widespread variation within these authorities in how EMS is rendered.

Most communities send medically trained firefighters as first responders, backed by advance life support. Some -- like Lansing -- staff and maintain their own ambulance fleet. Others -- like Grand Rapids -- contract that service to private providers.

For urban areas, the gold standard set by the National Fire Protection Association is to get a first responder on the scene within four minutes 90 percent of the time and advanced life support within eight minutes.

But as EMS consultant Thompson indicated, there is ongoing debate about the need for such aggressive responses for all 911 calls.

One national study identified seven clinical conditions that account for 66 percent of all adultEMS transports and seven that account for 86 percent of pediatric transports. Of these conditions, only cardiac arrest -- the second least frequent of all the conditions -- appeared to require rapidEMS response.

In the days leading up to the 2011 Super Bowl inTexas, Forth Worth-based MedStar EMS encountered a freak snow-and-ice storm that prompted it to suspend use of lights and sirens for 48 hours. That slowed response times.

MedStar found no difference in patient outcomes during that period.

EMS touted as 'perfect fit'

In the St. Joseph County community of Three Rivers, Fire Chief Dan Tomlinson would rather not take that chance.

Tomlinson calls its EMS system the "perfect fit" for those it serves. Established in 1982, its fire-based system deploys medically trained firefighters for basic life support, advanced life support and transport to the hospital.

"When you look at the traditional primary mission of the fire service and that's to save lives and protect property, statistically we can save more lives more often than not on the EMS side than on the fire side."

Tomlinson concedes that not all EMS calls turn out to be emergencies. But he would rather err on the side of caution, noting that 72 percent of the more than 1,500 EMS calls a year triggered advanced life support.

"From my standpoint, if it were up to me, every call would be an emergency until we have a professional on the scene."

Kentucky diversion program shows promise

But in Kentucky, medical officials are taking an alternative approach.

Concerned that too many 911 calls were needlessly transported to the hospital, Louisville EMS launched a program two years ago to screen low-priority calls and divert appropriate patients from the emergency room. Officials there know of no other program like it in country.

Kristen Miller, chief of staff for Louisville EMS, said it has exceeded expectations.

"I am 100 percent (sold) on this program. When we first started working on it, we were all a little skeptical about how it would work."

Miller said dispatch phone operators are trained using a carefully-scripted protocol to identify 911 callers who may not need an ambulance. They are routed immediately to a nurse for further consultation. In many cases, they are sent instead to an intermediate care center, physician or clinic.

Instead of by ambulance, they arrive by a contracted ride service that charges $26 a trip. The majority of these patients would have landed in the emergency room under previous practice, Miller said.

"I tell people, 'I can have you picked up within 30 minutes and get you seen within 90 minutes or you can go to the emergency room and wait eight hours," Miller said.

Among the calls re-routed from emergency transport: sore wrist or back from a fall, pink eye and leg pain.

Miller said patient satisfaction with the system is "above 90 percent" as Louisville EMS recently decided to expand it by adding a second nurse. While Louisville could not provide exact figures, it reported cost savings from the diverson program, too.

Miller said the biggest hurdle to overcome is fear.

"People are generally risk-averse. Once we put away all the unfounded anxiety, we figured out what we were doing was immensely helpful."

Ted Roelofs worked for the Grand Rapids Press for 30 years, where he covered everything from politics to social services to military affairs. He has earned numerous awards, including for work in Albania during the 1999 Kosovo refugee crisis.

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David Micallef
Thu, 06/28/2012 - 9:05am
FIrst, let me say I am a big fan of The Bridge. For as much as I am a civil liberal, I am undoubtably a fiscal conservative, and I appreciate that fiscally conservative approach provided by this news letter. I will be speaking on this article from the position of a guy who worked as a paramedic for private EMS companies like Mr. Walkers Universal Ambulance, from the position of a guy who has worked as a paramedic in a Level II Trauma Center Emergency Department, from the position of a guy who has worked on a high call volume Fire/EMS Department, and now, as a guy who works as a RN in that same Level II Trauma Center. I'm going to take the opportunity to be critical of some quotations in this article because I know first hand them to be a fallacy. Mr. Walker from Universal Ambulance stated: "does that somebody have to be 8 guys in a fire truck?". That is 100% false and and overinflated number. The responding man power from the municipality Fire Departments that his private company does business for is no more than four men, and in most cases is down to three firefighter-paramedic initially responding in a fire engine. Eight would be absolutely absurd, and which is why it is indeed false. That does not happen. Also, in regards to what Ms. Miller stated; “I tell people, ‘I can have you picked up within 30 minutes and get you seen within 90 minutes or you can go to the emergency room and wait eight hours,” I can't speak to the hospitals in Louisville, but, I can speak to my hospital, and it is the only Level II trauma center on the upper eastside of the DET. No patient of ours waits eight hours to be seen, EVER. Thats absolutely ridiculous. Our patients are seen in triage upon arrival by a RN, and most are scene by a Doctor, in a room, within 60 minutes, and I'm being very liberal with that time because I can rarely think when its taken less than 30-45 minutes for someone to see a doctor. I'd questions that throughput procedures that are evidently in place in area hospitals in Louisville, or, I'd ask Ms. Miller to clarify her statement for accuracy. To the notion of having someone who is answering the 911 call decipher what type of response, if any, the caller should receive; i'm very skeptical, but i'm not saying its impossible. For example, I can remember my first 911 call as a paramedic for a private company up north. We received the call from dispatch as "chest pain". We arrived on scene, just my partner and I, and the gentleman was in fact having chest pain. That chest pain, however, was not cardiac in nature, it was because he has been shot in the chest. My point? When people call 911, they are more often than not panicked. I think it is a dangerous game to let anyone other than someone on scene make the decision as the the acuity of the patient. Yes, its dangerous in a sense of legality, sure, but I'm sorry, my primary concern is the level of care to be received. I appreciate this news letters consistently watchful eye on fiscal responsibility, but, municipal based fire department provide a service first, not a business. Whether those fire department provide transport of their own to generate considerable revenue for their municipalities like the City I live in, or they just provide initial ACLS (Paramedic) care and stabilize the patient until a private ambulance arrives, it is a service to the residents that they receive with their tax dollars, not a business. That is what are taxes are there to provide us with, a SERVICE. Does 911 get abused? Yes, it does. But so do area Emergency Departments as well. The answer is education. When I was on the FD, I brought forward the idea to our Chief of launching an education program for our residents. It is much of the same as to how at the hospital we try to educate patients. The goal of this was not to try to drive down our calls for service, or drive down the Emergency Departments volume, but to show residents how their chain of care should go, and how they can get the best care. Residents/patients, need to find a primary care physician, develop a rapport with him or her, and retain that physician. Its education, the hospital, the Fire Departments, and the staff at the primary physicians office can educate people as to what an emergency is. That way, when a resident has chest pain after having a cough for 5 days, they know to contact their primary doctor to make an appointment to be seen, because the chest pain is likely due to the stress on the muscles of the chest from coughing for 5 days. Also, it costs considerably less to see your primary doctor than it does to be seen in an Emergency Department. In most EDs, it costs you nearly a $100 just to sign your name for consent of treatment. That is not the case at a doctors office. If people make their doctor their first point of contact, then people will not only have a physician that knows the ins and outs of their medical conditions, but also save themselves money.
Charles Richards
Thu, 06/28/2012 - 12:26pm
This is generally excellent, but I disagree with the author when it comes to the question of taxes and services. It is true that taxpayers expect to receive a service in return for their tax dollars, and that that service is not a business, but that does not negate the necessity of using tax dollars efficiently. After all, the more efficiently dollars are used, the more value that is obtained for each dollar, the more services that can be provided.
Charles Richards
Thu, 06/28/2012 - 1:18pm
This is a very good article, but it is not sufficiently incisive, it does not frame the question in a significant, decidable way. Yes, a high proportion of calls are not true emergencies and can be handled far less expensively than real emergncies. But no screening system is perfect, and there will inevitably be errors. The screener can decide that a given call is a true emergency, and if it is not, then the screener has made a false positive error. On the other hand, if the screener decides the call is not an emergeny when in fact it is, then the screener has made a false negative error. Even a well designed ystem with experienced, highly qualified screeners is going to have errors.The crucial question then is what ratio of false positives to false negatives is acceptable. Horrifically, it is ultimately a question of balancing costs against lives. The difficulty is that the overwhelming majority of people cannot bring themselves to explicitly put a price on human life.
Dan Tomlinson
Thu, 06/28/2012 - 2:21pm
I want to compliment Mr Richards for his observation. He is absolutely right about the potential for a false negative error. This is where the wrong patient receives the wrong response, and the system failed the deceased instead of the over-treated. But I think it is important to consider that it is not necessarily an error by the 'screener' or the 911 dispatcher. Telecommunicators depend on information from un-trained citizens who may be under a tremendous amount of stress. The stressed caller can be easily elevated to a state of duress when faced with numerous patient assessment questions they are not qualified to answer. They give answers, right or wrong, to expedite the request for help. We simply cannot expect trained dispatchers to provide accurate information to trained responders with information from un-trained callers. The Kentucky diversion program is worth tracking, but I think you will find that areas with flexible public transportation are already experiencing relief in terms of unnecessary ambulance transports.
Thu, 06/28/2012 - 6:10pm
From what I have experienced in at least two cities in Michigan, ambulance runs are charged back to the patients insurance like any other medical expense. If not insurance, then Medicare or Medicaid. The taxpayer is not expected to incur the cost of Fire Department EMS runs.