Quality Corner: EMS and Health Insurance

Health insurance companies are considered by many in medicine to be the bane of their existence. Since the early 1980s, the health insurance industry has been exerting an ever-increasing influence on medicine. Through a very successful congressional lobbying campaign the health insurance industry has succeeded in reducing reimbursement rates, as well as heavily conditioning the circumstances under which health care providers qualify for the full reimbursement of those rates.

But on the flip side, financial reimbursements have driven many landmark improvements in patient care, including Medicare’s requirement for hospitals to meet the 90 minute door-to-balloon (D2B) time for STEMI (ST-segment elevation myocardial infarction).

Since the sooner revascularization is achieved in the injured heart the more heart muscle is saved, this is obviously a good practice. And 90 minutes D2B is not an unreasonable requirement in most cases. This standard alone has forced hospitals to focus more on time to intervention, which has already saved countless lives.

As you might imagine, there was quite a bit of anxiety and trepidation when the 90 minute D2B requirement was first announced. Today, not only is the 90 minute D2B standard frequently met, shorter D2B times are increasingly more common.

In an attempt to meet the Medicare standard, Doylestown Hospital in Bucks County, PA, recruited its local EMS service—Central Bucks Ambulance—to help improve its D2B time by transmitting 12-lead ECGs when calling in a STEMI alert. The transmitted 12-lead is routed to the interventional cardiologist as well as the emergency room physician. If both physicians agree on the paramedics’ interpretation, the patient qualifies for ER bypass.

ER bypass at Doylestown Hospital consists of a brief stop in the resuscitation room, where the patient is met by the ER physician. The patient remains on the EMS litter with their cardiac monitor still attached. The ER doc quickly assesses the patient to confirm their condition is stable enough for ER bypass. If approved for bypass, the EMS crew is escorted to the cath lab, which is already prepped for the emergency catheterization.

Most emergency medicine throughout the country today still consists of EMS doing its patient care separate from the hospital, with care being transferred at some point in between. But with the possible exception of hospital-based EMS agencies, there is no actual system which coordinates patient care between the hospital and EMS. This leads to duplication of effort and a lot of wasted of time and resources.

STEMI treatment driven by Medicare’s D2B requirement is the first time most EMS agencies and hospitals have been forced to work together as a team or in a system model of patient care. And the results obtained by Doylestown Hospital and Central Bucks Ambulance are promising for the future of emergency medicine. The very first ER bypass case—with all the wrinkles and imperfections that might be expected from a first attempt at such a thing—resulted in an incredible 28 minute door-to-balloon time.

As a result of its aggressive and imaginative approach to improving patient care by utilizing EMS, Doylestown Hospital not only succeeded in meeting the 90 minute D2B standard, it achieved an average D2B time of 60.2 minutes. These excellent times to intervention were instrumental in Doylestown Hospital being named one of the top 50 cardiovascular hospitals in the nation for 2012 by Thomson Reuters.

Quality coordinators in hospitals and EMS have labored to varying degrees to improve the quality and safety of patient care. Overall their efforts have resulted in limited success. The greatest reason for this limited success may well be that they are agents of—and ultimately answerable to—the very organization they are policing. So it stands to reason that despite the most diligent efforts by the most conscientious quality coordinators, they will always be constrained to some degree by the convenience and perceived limits of improvement imposed by the institution they serve, rather than the patient or a patient advocate such as their insurer.

Whether you’re a rookie EMT or an experienced physician, no one welcomes the added burden of time or efficacy standards being forced on them. But, while the indiscriminate reduction of insurance reimbursements is unfair, disheartening and destructive, financial incentives targeted to efficacy of treatment will unquestionably prove to be the most effective means of improving patient care in the future.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.