Thriving Fire-based EMS and Cooperating with Managed Care

EMS Update by Gary G. Ludwig, MS, EMT-P

July 02, 1996

In a previous column, I encouraged chiefs who do transports to start looking at managed care and, at the minimum, start talking to the managed care organizations within your service areas. Since then, I have received numerous requests for more information.

I suggest you do so before 50 percent of your population (or more) is covered by a managed care plan and it is too late. Many experts say MCOs are not managing care but are managing their money. MCOs will push forward to manage their money with or without us. If fire agencies do not want to form partnerships with MCOs to provide services, the MCOs will certainly find someone else who does. The new buzz word for contracting services with other agencies is called - out-sourcing.+ At this point, the commercial sector is usually more adept than the fire service when it comes to operating in the managed care arena.

The name of the game is the number of transports. Usually, the more transports an ambulance service makes, the more money it can make. Managed care managers believe that when you operate on a fee-for-service concept, services tend to be delivered that don+t need to be. In a recent article written by Tom Scott, a manager with MedTrans, he cited unpublished data from a JEMS 200 City Survey that showed the percentage of 9-1-1 responses transported varied from about 50 percent for dual-role cross-trained fire departments to 71 percent for county third services. The other major transporters are private services, hospital-based services, and non-profit services.

One can suppose that fire agencies are leaving patients behind or the other agencies are transporting more patients than they should be. Managed care managers believe more people are being transported than should be. As a result, you can expect the managed care people to try to reduce transports. The Oakland County area is a prime example of this. There has been a 17 percent decline in 9-1-1 calls and the county has had to increase the subsidy to the private contractor and relax response time criteria.

Other ways of managing care or money is through capitation. Capitation pays a set amount of money to an -out-sourcer+ for its services. As an example, an MCO may have 100,000 people in its plan for your community. Hypothetically, the MCO has determined 8.25 percent of those 100,000 people will need an ambulance in a fiscal year. If the bill for an ambulance transport is $200, the MCO may sign a capitated agreement with you for $1,650,000 or $137,500 per month, or $16.50 per member per month. Stay under 8,250 transports and you make money. Go over and you lose money. Therefore, the reward will come for EMS agencies who safely move or refer those patients to alternate sources of care - a primary physician or urgent care facility.

MCOs look for certain standards when contracting with an ambulance service. They want full service contracts and one- stop shopping. This would include doing non- emergency or routine transports. They also want the service to be fully indemnified and heavily insured. Plus, they will define the standard of care.

Washington State Lawsuit

Chief Craig Williamson has provided an update from Washington state on the lawsuit filed by A+ Ambulance against numerous fire and government agencies. A judge has dismissed the lawsuit at a hearing for a summary judgment. The judge cited there was no violation of state law and there was no previous case law supporting A++s position.

Infectious Disease Notes

Our infection control guru, Katherine West, says fire departments should stop throwing away leather gear that has been contaminated with blood. If the item is made of suede, it can be dry cleaned. The dry cleaning process uses solvents that can kill just about anything. If the item is made of porous leather, it can be washed with saddle soap. West can be reached at 703-644-5032.

Gary G. Ludwig is on the board of the EMS Section and is the Chief Paramedic for the St. Louis Fire Department. He can be reached at 314-533-4175; FAX 314-289-1977; AOL at GaryLudwig.