There are two components to this question. First, should the fire department be providing FIRST-RESPONDER medical services? Second, should the fire department be providing TRANSPORT medical services?
The heart of the policy issue for fire-based EMS is threefold and based on desire: What level of pre-hospital medical care does the community desire? Does the community desire to have the fire department provide some component of its pre-hospital medical care? And, does the community desire to pay for some form of government-provided pre-hospital medical care?
The issue is best addressed by assessing the current system. What is working? What is broken? Across the country, the pre-hospital delivery of health care is shifting toward cost efficiency in today’s economic climate; cities may be unwilling to pay more for services that are currently provided by a private entity. Financial investment comparisons, conducted through efficiency studies, reveal economies of scale associated with employee cost and utilization, vehicle purchasing, medical equipment, supplies and communications.
If we look at how private-sector businesses operate – i.e., remain competitive in the market – we find that reductions in goods and services often result in the private side examining its business model and finding more efficient ways to compete for customers. This may be by reducing payrolls, eliminating staff, changing product lines and collaborating with fellow businesses.
Scrutinizing budgets
Difficult economic times are driving local governments to re-examine services offered and to what degree those services are provided. As stated previously in this series, our customers are very conscious of government spending and often critical of new endeavors. This is not to say that progressive organizations should not examine their business to reveal efficiencies and perhaps take on new programs. That progressiveness, however, must be balanced with the reality of the “new normal.” Is the timing right for new initiatives when the taxpayer is looking for less government?
Are there opportunities for improvement? The evaluation of an EMS system’s efficiency and effectiveness may best be conducted by an independent third-party. (Note: The authors are not seeking business opportunities with this recommendation, as they do not conduct such EMS system evaluations). City leaders should carefully assess the data collected in any study of efficiency and effectiveness. Most cities are interested in curbing future expenditures. The bottom line may be based on cost and not who is best to treat the patient; it is about conserving money and capitalizing on efficiencies of service.
An independent evaluation by a reputable firm ensures that no special interest influences the findings. Before embarking on an endeavor that can result in the creation of an EMS system that is worse than the one currently in place, it makes sense to determine whether anything is wrong with the current system. No system is perfect; there are always opportunities for improvement. Even if the evaluation determines the current system is functional, it is likely to also reveal opportunities to make changes.
Discussion points
There are distinct advantages and disadvantages for fire-based EMS systems, whether at the first-responder or transport level of service. Arguments can be made for and against the fire department providing medical services. Here are some items for consideration, with full acknowledgment that determining whether some of them can be viewed as assets or liabilities will depend on local circumstances and which side of the fire-based EMS issue a person lines up on:
• Management. A true business model and plan are required to successfully manage an EMS-delivery system. Most fire departments lack this business model background and experience. It is essential that senior leadership acknowledge the need for a “business mind” and select a leader to manage that aspect of the department.
• Control. Where EMS are provided by a government agency, elected officials have greater control over how the services are provided. Where EMS is provided by a private entity, elected officials may have less control over how services are provided.
• Financial. There is a cost to providing EMS. Personnel, apparatus, equipment, supplies and training are the most significant expenses incurred when providing EMS. There are also opportunity costs – the costs associated with other duties responders could otherwise be doing if they were not providing EMS. These may include prevention, inspections, training and even responding to other non-EMS emergency calls for service.
There can also be a revenue-generation component to EMS. Many fire-based EMS services, like their private EMS counterparts, charge for services. Changes in reimbursement rules have made collecting fees more challenging and limitations in reimbursements from Medicare and Medicaid limits also impact revenue recovery. However, as long as local officials are willing to charge for EMS, the full cost of the program does not have to be paid by taxpayers. Some opponents to charging for fire-based EMS services may argue that a fee for service is the same as a tax. That is a discussion to be held in local council chambers.
Where fire-based EMS agencies currently do not charge for services, the discussion should be held on the benefit and detriment of billing. Some may argue that charging a fee for a service that previously was free will deter the sick and injured from calling EMS when they really need it. The argument seems plausible, but where agencies have billed for services that has not been their experience. That discussion should compare possibility to probability. Is it possible that a person having a heart attack would not call an ambulance because of the cost? Yes. Is the probability of it happening high? Not likely.
• Competition. Some may argue that public entities should not provide services that could otherwise be provided by private entities. Again, this is a discussion to be held in local council chambers. However, as a city council looks to the services that could be provided by private entities, it should look fairly at ALL city services through the same lens. There are private entities that can remove snow, mow grass in parks, maintain roadways, fix broken traffic signs and provide recreation programs. There are also private-contract agencies that can provide administration services, finance services and city management services. The slope can be a slippery one.
• Quality of services. Some may argue that the services provided by a fire-based EMS service are of higher quality than those delivered by a private EMS provider. This may be true. It may be false. An independent evaluation of the services can help make that determination. The delivery of public safety should be viewed from a global perspective, a systems approach with interrelated parts. Who is positioned best to provide a service and for what cost? Cost may be viewed not only in the fiscal nature, but also from staffing, time saved or spent, other opportunities created and improved coverage.
We have discussed the importance of defining outcomes when evaluating service delivery. When looking at quality of service, having a desired outcome – i.e. response time, patient to hospital time, patient outcome and system redundancy – is a key ingredient in determining the appropriate provider. Some within the fire department may argue that responders who work for the city are local residents who will show greater compassion for their neighbors than those working for a profit-driven company. Again, the quality can vary widely. There are fire-based EMS systems that are wonderful providers. There are some that are terrible. The same can be said for private systems.
• EMS system abuse. The 900-pound elephant in the room is this – the healthcare system in the United States is broken. Notwithstanding efforts to pass various pieces of legislation to fix the problem, the system is a problem and, at least for the pre-hospital care component, current laws will not provide the fix. For many Americans their first (and only) access to medical care is the hospital emergency room (ER). Thus, the EMS system is being abused. First responders are routinely summoned to take people to the hospital for a wide variety of non-emergency injuries and medical conditions. Some of the system abusers simply do not know any better. Some know EMS to be their only way to get access to medical care. Some know they are abusing the system, but they see it as their right to have an ambulance at their beckon call to take them to the emergency room any time they want for whatever reason they want.
Some system abusers are clever. They have learned what “trigger words” score them the automatic ride – “chest pain” being one. For some, they are simply seeking a ride downtown and the ambulance provides it. Once their care is turned over to hospital staff, patients sign themselves out of the ER or simply get up and walk out. There is no law that compels them to stay. In fact, there is no law that can compel the hospital staff to make them stay. And the next time they want a ride downtown, EMS will be there again to provide it.
Clearly, the system is broken and it must be fixed on a broad scale. Some EMS agencies have actually gone as far as providing taxicab tokens so system abusers can simply take a taxi to their desired destination instead of abusing the EMS system. Those with legitimate injuries or illnesses that are minor are also provided with taxicab tokens for rides to the emergency room. The real system abusers do not like this, however, because they do not get the express entry into the ER as they otherwise would when they arrive by ambulance. If they come by taxi, the wait in the ER can be hours.
• Response times. Some argue that response times are critical in medical emergencies. Indeed, for some emergencies every second counts. However, in some cases, time is not critical. One only need to take a trip to an ER for a minor emergency (e.g., suturing a lacerated finger) and see the people waiting for hours. While the ER waiting room is full, most of what is there are not emergencies. The same it true in the pre-hospital environment. Many, if not most, calls for EMS are not true, life-threatening emergencies. The caller may require medical care, just not EMERGENCY medical care.
However, for those with an emergency illness or injury, response times are critical and truly every second does count. Part of the problem is that first responders often do not really know what is an emergency until they arrive and assess the patient. Even in systems where dispatchers are trained to ask the right questions and provide pre-arrival medical instructions, the system is not perfect. An accurate patient assessment cannot be conducted over the telephone. Only a trained responder assessing a patient’s condition can truly determine the emergency need for medical care. In a litigious society, the risk is too great, so many systems default to treating every EMS call for service as an emergency.
• System demand. When assessing the impact on a fire-based response system, it is not abnormal to see EMS accounting for 70% to 85% of calls for service. Clearly, in some systems it is the vast majority of the services provided by the fire department. Some may contend that reducing or eliminating fire-based EMS would let a city significantly reduce the number of firefighters on the payroll. This conclusion may be premature if elected officials lose sight of the core mission of the fire department – to protect the lives and property of residents, businesses and visitors from the ravages of fire. In most systems, on-duty EMS responders are also cross-trained firefighters and when there is a fire, it is an extremely labor intensive activity. For example, a working fire in a single-family home could easily require 15 to 30 personnel, depending on the size of the structure and the complexity of the incident (i.e., the size and construction of the building, contents, extent of fire involvement, rescue of occupants and water supply). As staffing is reduced, so is the number of responders available for labor-intensive fires and complex rescues. While those happen far less frequently than medical calls, the consequences in relation to the loss of life and property is often exponentially greater.
• Exit strategy. The determination to outsource or privatize a function that historically the fire service has provided is an extremely difficult and often emotional decision. Often, the decision to eliminate a service is predicated on sound and rational findings, the efficiency and effectiveness study discussed earlier. Right-sizing and restructuring of fire department resources has become the norm. Fire departments are sometimes forced to decide what services they can adequately provide. This may result in discontinuing a prized service.
• Opportunity cost or opportunities lost. While it was mentioned briefly earlier, the opportunity for responders to be doing something else in lieu of responding to medical calls warrants additional discussion.
Further the mission
Notwithstanding the previously noted system abuse issues, if responders were to benefit from fewer calls for EMS, what else could they be doing? This is a question fire department administrators should be prepared to answer. Perhaps stated another way, what could the fire department do more of, or start doing that it does not currently do, that would advance the core mission of saving lives and property from the ravages of fire? What other proactive prevention-oriented activities could the fire department be involved in to help reduce calls for service or enhance the quality of life for citizens. A few examples come to mind:
? Home fire-safety inspections
? Safe-cooking awareness classes for seniors
? Assisting in child-proofing homes to prevent injuries and poisonings
? Swimming pool safety classes
? Child-restraint seat installations
? Slip-and-fall prevention programs
? Teaching non-English-speaking populations about fire safety and the EMS system
? Rental-housing inspection
The list for each community would be customized based on local need. However, there are likely a list of prevention-oriented activities that could fill the void and serve a valuable purpose.
The initial question was whether the fire department should provide medical services and, if so, at the first-responder or transport level. The answer lies in having a meaningful discussion with elected and appointed officials about control, finances, competition, quality of services, EMS system abuse, response times, system demand, opportunity costs and opportunities lost.
Richard Gasaway will present “Fireground Command Decision Making and Situational Awareness” at Firehouse Expo 2013, July 23-27 in Baltimore, MD.
