Convince your administrator to invest in EMS
August 1, 1998
Convince your administrator to invest in EMS
Convincing administrators to make capital investments in EDM is often a struggle, says Robert Suter, MD, FACEP, regional medical director of North Texas, Questcare Emergency Services, in Dallas TX. "It clearly improves patient care, but it's still hard to convince the average administrator how important it is," he notes.
Statistics reveal that truth. "Between 12-16% of our ED visits come by EMS," says James Augustine, MD, FACEP, CEO of Premier Health Services in Dayton, OH, and chair of the department of emergency medicine at Miami Valley Hospital. "It is very interesting to note that when we started tracking EMS visits in 1986, we found that 37.8% of the patients they transported were admitted to the hospital. In the year to date 1998, the percentage is exactly the same. This is despite the fact that we admit far sicker patients than we used to."
EMS support functions should be done by ED personnel who are dedicated to that task. "The payoff is in improved quantity and quality of patients who arrive by EMS. That means patients who have been better cared for, arriving in a more timely manner, who we can treat in the ED more effectively," says Augustine.
The return on investment is through better EMS relations, which may mean more ED visits and fewer poor interactions with EMS that may raise risk management issues," says Augustine.
It's also an investment in the community. "A hospital's positive profile with EMS has a huge halo effect in the general community," notes Augustine. "In general, people follow the recommendations of EMS."
EMS relations can make or break an ED's volume. "In our experience, in every competitive market in our area, the ED volume leader is the one who is most favored by the local EMS community," says Augustine. "As we enter any market with our group, we always approach EMS as a primary and very important target market. No other group is as important to have as your friends."
Show revenues of EMS admissions
"To get administrator's attention, you need to lay out the number of patients and admissions you're talking about," says Suter. "Some may be skeptical and have been promised the moon before. It may sound too good to be true, but it is true."
First, determine the number of patients you receive by EMS and how many you can increase. "Generally, up to half of EMS patients get admitted, so you can project admissions based on that," says Suter. "From a dollar standpoint, what you need to do to get their attention is to claim credit for referral of admissions by your EMS program."
If the administrator accepts that, compute the numbers. "It's not unusual for an EMS admission to generate $13,000 in gross revenue," says Suter. "The bottom line impact can be $6000 or $7000 in incremental return."
"Even if you project that you will improve just one or two calls a day, with a 35-50% admission rate and a $6000 or $7000 return per admission, it's impossible to lose on that," says Suter." The trick is getting them to give you credit for the admissions revenue.
Make projections based on current EMS admissions and your market. "Consider how many calls are out there. Then, determine what you are currently getting and project how much you can increase your volume," says Suter. "It's educated guesswork."
One ED accidentally proved the success of its EMS program with a market survey that asked households which hospital they would choose. "This hospital was getting between 55-60% of all ambulance arrivals from patients picked up in its service area, in a very competitive market," says Suter.
Survey results indicated that only 13% of patients would choose the ED. "Since they were getting almost five times as many patients as patient preference would have dictated, they proved beyond a shadow of doubt that they were doing a good job of marketing to EMS," says Suter.
On the other hand, the hospital that the majority of people chose had the opposite result. "They had a very bad reputation with the EMS crews and felt that the nurses and physicians talked down to them. They got less than half the calls that would have been predicted," says Suter.
When negotiating with administrators to invest in EMS, here are some concepts to consider:
Make projections realistic. "If you are seeing 60 patients a week from EMS, then three or four additional patients a day isn't an unreasonable number to use," says Suter. "When you're sitting down to prepare your business plan, ask administrators what number they feel is reasonable. Ask them, if I project three additional patients a day, do you think that's reasonable?"
If the administrator is skeptical, adjust your numbers. "If they say three patients is not realistic, but I'll give you two, use that number," says Suter. "Even if you are absolutely convinced that you can increase by 10 patients a day, if they don't believe that, then you are wasting your time. You are better off showing much lower projections."
Compute outpatient and inpatient revenues separately. "Even if your administrator won't give you credit for inpatient revenue, maybe your proposal can justify itself with outpatient revenue alone, although it won't be a huge return," says Suter.
Factor in incremental supply costs for additional patients. "If you don't know those things, you can't negotiate with your administrator," says Suter. "You need to know what ancillary revenues can be generated for EMS patients and compare it to additional expenses."
Track your data. "You need to know how many ambulance arrivals you are getting and know who is bringing them," says Suter. "A lot of automated registration systems will do that automatically if they get the right data. If it's been told to registrars that it's very important that information be correct-it's much harder to get manually."
If you don't have an automated system, you can obtain the data another way. "If you are dealing with a public agency, their destination data are normally discoverable because it's public information. If all your EMS tracking is from fire departments, go to see their run data. If you have private providers, ask them for it and many of them will give it to you," says Suter.
Be aware of regulations. When investing in EMS, be aware of regulations. "Generally, you can go by the same guidelines as you would with referring physicians," says Suter. "But be alert to what the government has said they think is inappropriate. HCFA has said, for example, that restocking supplies from EMS runs violates anti-kickback regulations. Short of these sort of specific rulings, you should follow ethical guidelines used for referrals. Most hospitals feed doctors for free, so why not feed paramedics?"
Write a business plan. "This can be just a 6-10 page plan with charts and income projections," says Suter. "Be conservative when you make your projections on your business plan. Don't project that you will double your EMS volume. Instead, project that you will increase it by a couple of patients a day."
Give sensitivity training to staff. "It's very important that you teach your staff the importance of having a good relationship with the EMS crews. As a manager, this needs to be one of your major motivations," says Suter. "A lot of times, the staff may take the EMS people for granted, treat them badly, or not have a good relationship."
It's not only good business, but good medical care, Suter says. "When people have good relationships with other healthcare providers, the patient benefits because communication is better," he says. "You can approach this from either a financial or patient care perspective, because both are true."
In many situations, poor communication between ED staff and EMS can negatively affect patient care, says Suter. "The EMTs and paramedics are out there on the scene and have access to all kinds of information that the ED nurses and physicians don't have access to," he says. "They can tell you specifics about the type of accident somebody was in if they crash their car, what the appearance of the car was, whether the steering wheel was bent-all of which could be important to patient. If they are being treated badly by ED staff, they may just want to dump the patient and get out of there as quickly as possible."
Poor communication between ED staff and EMS can have negative outcomes for patient. "On the scene, the EMS have an opportunity to try to discover what the patient overdosed on, for example," says Suter. "But if they perceive that the ED staff doesn't trust them, they might abandon their search for evidence. If they are rudely told,'just bring the patient here as quickly as possible' and not regarded as members of team, they may cut off a radio call just before a pill bottle is found."
If paramedics feel uncomfortable, they may not share pertinent clinical information, says Suter. "A lot of times, the paramedics may have noticed something they may not be sure is clinically significant. If they feel respected, they may tell you anyway, and it may be important," he says.
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