by Kevin McGinnis, Program Manager, National Association of State EMS Officials
Unfortunately, the transformation of healthcare in general is an urban-centric proposition. While one might think that transitioning from “volume” to “value” would be good for rural healthcare access, the pressure that defining “value” puts on rural healthcare facilities and other resources, such as emergency medical services (EMS), is not. To assure “value,” health systems are transferring many community hospital services to urban/suburban centers, and “hub and spoke” arrangements are becoming the norm. Routine and specialty inpatient services and specialty outpatient services are focused in the urban/suburban hubs. Out on the spokes, many community hospitals are now limited-service critical access hospitals. Federal legislation is under consideration to further reduce these services to outpost emergency departments/urgent care services.
In this context, consider the traditional rural EMS service: a low-volume, volunteer emergency service with basic life support capabilities and occasional advanced life support personnel. Service members are called away from home and work to go on ambulance calls. The time commitment is felt to be manageable with family and employers because of the low volume and time commitment of calls with transport just to the local community hospital. Services are often not charged for, with the ambulance agency dependent on fundraising to operate.
Reducing the capacity of that local hospital to provide inpatient and specialty care in the evolving hub and spoke model creates a need for increased transportation services (routine and emergency ambulance transports) to get patients to the hub hospitals and clinics for services no longer provided locally. Providing additional ambulance transports, some demanding advanced life support/critical care personnel, is likely to become insupportable by the traditional volunteer ambulance model.
There are choices for rural EMS in this setting:
- The service closes, requiring coverage from neighboring services, which usually means decreased response times. This added pressure on neighboring services may jeopardize them if they cannot adopt a business model that successfully consolidates the jurisdictions.
- The service starts to provide incentive pay for calls that members go on. The service starts to charge patients. The service may start to pay part-time and full-time personnel when incentive pay to volunteers does not work.
- Services proactively work to consolidate into regional provider agencies with an effective business and staffing model.
Without planning to mitigate the impact of the “rural healthcare transformation,” access to EMS will decrease and the level of care now needed to get acutely ill patients to distant, definitive care will be jeopardized.
The Rural and Frontier EMS Agenda for the Future (National Rural Health Association, 2004) proposed “informed self-determination” as a model to address these issues. It calls for an objective evaluation of the current state of EMS in the jurisdiction served by an ambulance service. The evaluation would present alternatives for providing different types of EMS access and levels of EMS care with the cost of each. Residents of the jurisdiction would then choose the level and type of EMS access they want and the investment they are willing to make.