EMS is a vital component of healthcare, public health and public safety. On any given day, in almost every community in our nation, EMS response to calls for help, 24/7.
EMS saves lives from heart attacks, strokes and drowning; treat injuries due to motor vehicle collision, shootings, stabbings, and other violence; and provide care for the myriad other illnesses and injuries that occurred daily in United States. When the big incidents hit – weather natural (tornadoes, floods, hurricanes, pandemics) or man-made (terrorist attacks, explosions, active shooters) – EMS provides medical care and helps communities pick up the pieces.
The public counts on EMS to help them in their worst, most harrowing moments. Yet few understand exactly what medical services EMS provides, how EMS fits into the wider healthcare system, or how EMS is staffed, funded and delivered.
The national Association of Emergency Technicians (NAEMT) is pleased to present this brief introduction to EMS. The goal is to help elected officials, their staff and key stakeholders better understand EMS and how it functions throughout the United States to inform legislative and policy decision-making.
81,295 Number of EMS vehicles, including ambulances, helicopters and other aircraft, quick response vehicles, rescue vehicles, firetrucks and all-terrain vehicles
37 million Number of calls EMS response to annually
826,000 Number of EMTs and paramedics nationwide
8,459 Number of EMS medical directors (physicians who provide oversight to EMS agencies)
1 National EMS Assessment, 2011. The National EMS Assessment,led by researchers at University of North Carolina at Chapel Hill, incorporates data from the National Association of State EMS Officials 2011 EMS Industry Snapshot; Emergency Medical Services for Children program 2010-2011 report; the 2007 Indian Health Services Tribal EMS Pediatric Assessment; and the National EMS Database.
SERVICE DELIVERY
WHAT IS AN EMS SYSTEM?
EMS systems are highly complex, integrated structures with multiple components, each with their own mission, working together to collectively benefit patients in need. EMS systems include dispatch, first responders, fire departments, ambulance agencies, hospital emergency departments, and state EMS offices. Yet, while the makeup of EMS systems varies from one locale to another, one priority that remains constant is the need for all of the components within a system to function cohesively for the patient throughout the continuum of emergency care.
Each state and territory in the United States has a lead EMS agency. These agencies are usually a part of the state health department, but in some states they are part of a multidisciplinary state public safety department, or are an independent state agency. State EMS agencies are responsible for the overall planning coordination, and regulation of the EMS system within the state as well as licensing local EMS agencies and personnel.
WHAT TYPES OF AGENCIES PROVIDE EMS?
EMS can be provided by public agencies or private companies. Public EMS agencies include fire departments, or city or county EMS departments. There are also many private ambulance services, both for-profit and nonprofit. EMS agencies can be paid services, or staffed by volunteers. Some ambulance services combine both volunteer and paid staff to meet community need.
Private ambulance companies are often contracted by a city or county government to provide EMS. Hospitals also operate ambulance services, and may also be contracted by local governmentto provide services in a particular region. There is also an additional model called a public utility— a hybrid arrangement involving both a public entity and a private company.
There are many types of arrangements in which public and private entities collaborate on providing EMS. One common example is for a fire department to serve as first responders, meaningfirefighter-EMTs or firefighter-paramedics arrive on scene first, often in afire truck. Then, if the patient needstransportto a hospital, a private company’s ambulance, staffed by its EMTs or paramedics, arrives.
WHY ARE THERE SO MANY TYPES OF DELIVERY MODELS FOR EMS?
How a community provides EMS is decided at the local level, based on resources (such as the tax base) and needs. Ifs up to a local community if they want to support a paid service, volunteer or a hybrid paid/volunteer service; or if they want to contract with a private ambulance service to augment public services.
FINANCES
HOW IS EMS PAID FOR?
EMS is paid for through local taxes/municipal budgets and by billing insurance companies, Medicare and Medicaid for transportingpatients. Public EMS agencies typically receive taxpayer supportto fund operations and pay staff. Volunteer organizations may also receive some tax support. Private ambulance companies typically receive no or minimal taxpayer support. Instead, private companies mostly rely on billing insurance, Medicare, and Medicaid for transports.
WHAT CAN EMS BILL FOR?
This may come as a surprise. EMS may only bill for transporting patients, not providing patient care.
On any gven day, EMS personnel may restart a heart due to cardiac arrest; resuscitate a person after a near-drowning or stop severe bleedingto save a life. EMS may administer medications to relieve pain, halt a drug overdose or stop an asthma attack; dear an airway to allow a person with severe injuries to breathe; splint a compound fracture or revive a diabetic with hypoglycemia.
Yet EMS is not reimbursed for providing patient care. EMS is considered a transportation provider, not a healthcare provider, by the Centers fo r Medicare and Medicaid (CMSL and private insurers,which often follow the lead of CMS. EMS is reimbursed only for transporting a patient and mileage. If EMS provides medical care on scene but does not transport a patient, they are not reimbursed forthe response.
EMS Stands for Emergency Medical Services –
Yet EMS Does So Much More
Responding to emergencies is a very important part of what EMS does for communities. But EMS does more than respond to emergencies.
When a member of the public calls 911 for help, laws in every state require EMS to respond. EMS is also obligated to take that person to an emergency department if the person wishes to go.
People call 911 for all sorts of reasons – though many calls aren’t for medical emergencies. Common situations encountered by EMS professionals include responding to calls from homeless or indigent people, or those having a mental health or substance abuse crisis. EMS often responds to calls for help from elderly people who are struggling to care for themselves, or who have fallen and need help getting back into a chair or bed.
Every region has a few people who knowingly misuse EMS services, calling again and again for reasons that are clearly not medical emergencies. But many others call EMS because they don’t know where else to turn. They’re having trouble managing chronic diseases such as diabetes, hypertension or congestive heart failure and are both sick and scared; they’ve been recently discharged from the hospital and are experiencing an exacerbation of their condition; or they don’t know how to access more appropriate healthcare.
While much of health reform emphasizes avoiding emergency department visits, EMS remains paradoxically incentivized to transport any and all patients who call 911 to the emergency department. Despite several previous pilot projects that were found to be either cost effective or cost saving, innovative out-of-hospital care models will not become widespread without EMS reimbursement policy reform.
- EMTs, paramedics or community paramedics visiting patients in their home to help with chronic disease management and education, or post-hospital discharge follow-up, to prevent hospital admissions or readmissions, and to improve patients’ experience of care
- Navigating patients to destinations such as primary care, urgent care, mental health or substance abuse treatment centers instead of emergency departments to avoid costly, unnecessary hospital visits
- Providing telephone advice or other assistance to non-urgent 911 callers instead of sending an ambulance crew.
Mobile integrated health care and community paramedicine programs aim to address critical problems in local delivery systems, such as insufficient primary and chronic care resources, overburdened EDs, and costly, fragmented emergency and urgent care networks.
BARRIERS TO MOBILE INTEGRATED HEALTHCARE AND COMMUNITY PARAMEDICINE
There are many hurdles to implementing these programs, induding state laws that prohibit EMS from engaging in activities other than strictly emergency response. Another major barrier is funding.
As stated earlier, EMS only receives reimbursement for transport and mileage. Preventing emergency department visits by following up with patients, assisting with disease management in the home, educating patients about self-care or connecting them with alternative and less expensive destinations than the hospital, isn’t billable.
EMS is making some progress. EMS advocates have had success in changing state laws in a few states to allow for mobile integrated healthcare and community paramedicine. Some innovative EMS agencies have also developed contractual arrangements with insurers, home health agencies, hospice organizations, and Medicaid managed care organizations to reimburse EMS for providing those types of services. But support at the federal level to fund and evaluate mobile integrated healthcare and community paramedicine is badly needed for these innovations to become widespread.