Nov 19, 2014
The EMS model debate of fire-based EMS vs. private EMS is more active than ever on Facebook thanks to recent articles shared by JEMS, EMS World and EMS1, and I have been a frustrated, screaming at my computer participant. Both sides make some irrational arguments but when one searches through the mess, they can find some well thought out compelling cases made for both sides of the debate.
It is no secret that I am a big advocate for EMS based EMS, whether that is in a private model or more preferably in a municipal model. Like many others, I feel that when you serve two masters you cannot perform both jobs as effectively as a person could perform one of them. Furthermore, I think that in fire-based EMS systems dedicated, highly skilled practitioners are locked out of the system for one reason or another to the detriment of the general public.
The anti-private arguments are the ones that I always find interesting. The first one of “they are only in it for the all mighty dollar” amuses me. Almost any department regardless of their delivery model relies on the dollars that the business generates. With the model of health care that we have in this country, everyone is in it for the all mighty dollar.
The other argument always seems to revolve around private EMS not being able to differentiate their business. They send units on non-emergent calls while disregarding emergency calls. Or they strip coverage to get dialysis transfers done. As someone who has worked in the world of privates and spent a decent amount of time perusing request for proposals for EMS services, I cannot help but think that most of what people are complaining about is a direct result of low standards contracted providers.
When I worked in Massachusetts we had four contracted communities that we provided emergency services to. Once you moved past the out clauses, insurance requirements, and legal mumbo jumbo, the core of the requirements for each of these contracts came down to “you will provide X ambulances at the paramedic level and respond to calls in Y minutes or less.” That was it. Monthly reports were generated by the service, monitoring was low, and the service was left to do what they saw fit. As long as the calls were answered no one with the communities really cared beyond that.
I am happy to say that we did a pretty good job. We exceeded our response percentages, and had an extremely low response time. If you want to read more about that, I welcome you to check out the articles that I have written about AMR in Springfield, Massachusetts over the past couple of years.
When you keep standards low, you get what you pay for, or in many cases you get what you ask for because many of these contracts are what are referred to as “zero bid” contracts where a service receives no money from the community and makes their dollar from billing patients for service.
Comparatively, contracts from the west coast, for example, are a lot stricter. While our responses in Massachusetts were made up of about 50 pages, responses to these California county contracts frequently exceed 200 pages. The Alameda County bid that AMR ultimately lost to Paramedics Plus a few years ago was probably the most eye opening one. They wanted career advancement for the medics in the county, for example. Their trucks had to meet certain emission standards. Requirements went beyond response times and moved on to QA/QI benchmarks and deeper reports than I had ever seen. The most impressive thing about that bid though was the fact that there was a governing body that oversaw the provider. They made sure that not only did someone just show up, but that those who showed up were doing the right thing for their patients. They went far beyond the traditional RFP and required their ambulance service to go above and beyond. This is a trait that many communities miss out on, or do not have the people who have the knowledge to do an adequate job at monitoring ambulance services.
My point, ultimately, is you get what you ask for. If you leave loopholes in a contract somebody will find them. If you write an RFP to contract that a mid-level provider can jump on and do “fast and cheap” you will get exactly what you ask for. If a community reaches out to people with knowledge about EMS, and structures a bid like some of the county bids in California then you are going to position yourself to have a top notch private provider.
Of course the market also dictates this too. There needs to be somebody there capable of doing the job effectively. Ultimately though, quality of service comes down to the standards that we set. Communities need to set the bar at a level that challenges services to give their very best. In fact, these standards should not only exist for private EMS but for any EMS provider in any system. Ask for the best care possible, expect the best care possible, and monitor providers to make sure that they are following through on their promises.