EMS System Review - State of New Jersey

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State of New Jersey, DHSS, OEMSConsulting Services: EMS System Reviewoperations. Each project has a quality management component that is administered by EMSphysicians and EMS providers who are dedicated to assuring that only the most qualifiedprofessionals are credentialed.The paradox occurs when evaluating the continued viability of hospital-based projects.During the 1970s through the mid 1990s, ALS projects were profitable for hospitals. Whilespecific data are not available, anecdotal information indicated that reimbursement rates wereacceptable and that projects drew patients to the sponsoring hospitals. From a financialperspective, this has clearly changed. ALS projects that rely on outside agency BLStransportation providers are not able to earn sufficient Medicare/Medicaid funds to assureprofitability or break-even status. In May 2007, the United State General Accounting Office(GAO) reported that this gap will continue to increase. On average the margin between Medicarepayment and costs will be – 6 percent (95 percent Confidence Interval. = -14 to 2 percent). Forhospital-based services who do not share costs with governmental entities, translates to anaverage Medicare payment of $394 and a cost of $415 per transport. 62 Compared to all areas,margins in urban areas are consistent with an average reimbursement of $350 reimbursement toan average cost of $370. 63This shortfall affects non-transport ALS providers because as the cost of BLStransportation increases, there is less to negotiate for. What appears to be a gain for BLSproviders and a loss for ALS providers will likely backfire as the economic viability of the ALSsystem must be a concern for all. To keep the current model, BLS services may have to makesome sacrifices to continue the viability of ALS. 64We suspect that hospitals are considering the financial viability and future of ALSprojects. One hospital in northern New Jersey was advised by a consultant to discontinue its ALSproject and force local municipalities to take responsibility. Municipalities can bill for serviceand use tax bases to fund their services making financial viability less problematic.During our visits we had opportunities to read publications encouraging people andbusinesses to make New Jersey their home. These publications featured advertisementsintroducing the features of quality medical care available. Most of these advertisements featuredadvanced cardiac, stroke and trauma care as their prime products. Even though the success ofthese advanced care projects depend greatly on EMS, none of the advertisements featured their62 GAO. 2007. Costs and Expected Medicare Margins Vary Greatly, 23-24.63 Ibid., p. 24.64 Wolfberg, D.M. and Wirth, S.R. (2004). ALS/BLS Intercepts: The Clinical and Legal Aspects of Tiered EMSSystems. Mechanicsburg, PA: Page, Wolfberg & Wirth, LLC.TriData, a Division of 112September 2007System Planning Corporation
State of New Jersey, DHSS, OEMSConsulting Services: EMS System ReviewALS units or pictured an EMS professional. This was not a slight, but an indication that manyhealthcare systems are not appreciating the value of EMS. Therefore, no one should be surprisedthat they may be considered expendable.Another threat to project viability are human resources issues. New Jersey ALS projectshave been blessed with a cadre of providers that have spent many years with their project. Thetime has arrived that many of these providers are reaching retirement age. Unfortunately,hospital-based EMS projects rarely offer the guaranteed pension benefits that municipalproviders offer. The closest benefit to this is 401K plans that require the employee to havecontributed over the years to earn enough to live on. There are very few paramedics who havebeen able to retire without having to continue full-time work. While working, many of theseproviders already work for two or more ALS services. In comparison, EMS providers who arefirefighters or police officers have access to a premium pension project. Even those municipalproviders who are eligible for only the civilian employee plan (PERS), have good pension plans.This issue will be discussed further in the EMS Workforce chapter.Too many or too few paramedics? – As of 2007, New Jersey had 1,450 practicingparamedics affiliated with ALS projects. Many paramedics work for more than one project.There is a perception that a paramedic shortage exists within the state. It is difficult to determinewhether the problem lies with numbers or distribution. The NJOEMS requires that prehospitalALS units must be staffed with a least two paramedics. This includes both transport and nontransportunits. Many paramedics and medical directors like the two paramedic system becausethey believe it provides better patient care. Unfortunately, these beliefs have not been quantifiedin New Jersey or anywhere else. A study in Melbourne, Australia revealed that a mixedPM/EMT crew had no difference in skill success rates and slightly shorter on-scene times than atwo PM crew. The two PM crew accomplished more ALS procedures than the paramedic/EMT-B crew. This study can only be viewed as an indicator because it was not large enough to makesignificant conclusions. 65 Unions in New York and Chicago fought the reduction of twoparamedics to one paramedic and one EMT, but were unable to offer concrete evidence tosupport their concerns.There are several options to consider regarding the one or two paramedic requirements.There is general agreement that many ALS-level calls can be successfully managed with oneparamedicand one-EMT. There are probably a small number of ALS patients who could benefitfrom having a second ALS provider on-scene. The challenge is to provide the best levels of care65 Ludwig, G. (2005). How many paramedics does it take to… EMS Responder, [Online Version], November 1,2005, http://www.emsresponder.com/print/Firehouse-Magazine--EMS-Features...TriData, a Division of 113September 2007System Planning Corporation
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