Letter From America March 2013: The EMS Pond Narrows
Rob Lawrence is chief operating officer of the Richmond Ambulance Authority in Virginia. Before coming to the U.S., he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He writes a regular “Letter from America” column for the UK publication Ambulance Life. This column is reprinted with permission from Ambulance Life.
I recently sat down with the very transatlantic chair of the International Academies of Emergency Dispatch, Jerry Overton, and London Ambulance Service Director of Operations Jason Killens to film an international roundtable debate hosted in Washington, DC, at the EMS Today conference. The topic was the political and medical hot potato of the final four years of the Obama administration, the Affordable Care Act (ACA).
The international cast was prodded by esteemed EMS broadcaster Chris Montera to highlight the (former) differences and (soon-to-be) commonalities between U.S. and U.K. systems and the road map needed here to respond to this new challenging mandate.
This now covers admission and arrival avoidance—hear, treat and, if necessary, transport elsewhere, as highlighted over half a decade ago at home by NHS adviser Peter Bradley, et al. (The “Bradley Report” refocused the NHS ambulance service into a hear-and-treat, treat-and-release mind-set.) The biggest issue in comparing is that a step here toward national socialized healthcare will not be spawned from the same conditions that created the NHS.
As we know,the Luftwaffe played a major part in the formation of the NHS, which was a solution to healthcare for the masses after the country was bombed almost to bankruptcy by 1945. The model conceived by Aneurin Bevan created one ministry controlling every aspect of health, with care being free at the point of delivery—cash was, and is, poured in at the top via national taxation. The “war” in the U.S. was the last and very vocal presidential election, but those currently delivering care are generally not bankrupt.
Ambulance income is currently derived from a Part B Medicare payment—in other words, only by transporting patients to hospitals. That’s exactly where the ACA doesn’t want people to go, as inpatient treatment bills are eye-watering. The dilemma for EMS is how to access the new world where a non-transporting “hear, see and treat” environment is the vision.
The issue for EMS is that this is all covered under Part A payments, which are the preserve of doctors, physician assistants and nurse practitioners, not paramedics. The solution is to develop innovative and proactive programs using things like community paramedics and nurse call takers, and create a funding stream for them. But a challenge to this obvious solution has reached periscope depth and is on its way to the surface.
In this land of the free, the free market is realizing a business opportunity to try to grab that Part A payment from under our noses. There is industry talk of private physician companies and the like creating their own community services to fill gaps that have opened up. To my mind, the race is now on to place EMS where it needs to be: here, in the forefront of community medicine, risk reduction and, yes, good old admission-avoidance programs. We are the obvious honest broker of prehospital care, but as an industry we need to make sure we get on the train before we end up under it. Unfortunately there is no overarching federal EMS/ambulance ministry to look after our interests at a national level, which is also on the “to do” list. Luckily we are still in the station, but the fat controller is already yelling “all aboard.” It is going to be an interesting year.
Finally, I can share another bucket-list moment in this amazing international ambulance journey on which I seem to have embarked. On the eve of the 2012 U.S. election, I pulled duty in the Secret Service command post for what was the umpteenth pre-election visit to Richmond, this time by the second-in-charge himself, Vice President Joe Biden, and his wife, Dr. Jill Biden. At the end of the rally, in the backstage security-cleared area, the invite came to go out and mingle with the VP, whom we were told is a huge fan of public safety staff and the work they do. Despite our close shadowing by many gun-toting Secret Service members, I have never met a more down-to-earth VIP in my life. Politics aside, both Bidens and their guests, John Cougar Mellencamp and his girlfriend (sorry, more name dropping), Meg Ryan, were easy to talk to and genuinely interested in what we had to say, although at one point I was asked which part of Australia I was from!
Rob Lawrence is chief operating officer of the Richmond Ambulance Authority. Before coming to the USA three years ago to work with RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a graduate of the Royal Military Academy Sandhurst and served in the Royal Army Medical Corps. After a 22-year military career in many prehospital and evacuation leadership roles, Rob Joined the National Health Service, initially as the Commissioner of Ambulance Services in the East of England. He later served with the East Anglian Ambulance Service as director of operations. He is also a member of the EMS World editorial advisory board.
