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Ambulance Services SuZanne Troske Ambulance Services SuZanne Troske

Ambulance Services SuZanne Troske - PowerPoint Presentation

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Ambulance Services SuZanne Troske - PPT Presentation

Community and Economic Development Initiative of Kentucky University of Kentucky November 16 2018 Ambulance Research At CEDIK we have three studies of ambulance services in the US Ambulance Ownership Type and Quality of Service ID: 908627

service ambulance medicare hospital ambulance service hospital medicare services number kentucky beneficiaries data emergency times year miles ems quality

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Slide1

Ambulance Services

SuZanne TroskeCommunity and Economic Development Initiative of KentuckyUniversity of Kentucky

November 16, 2018

Slide2

Ambulance Research

At CEDIK, we have three studies of ambulance services in the U.S.:Ambulance Ownership Type and Quality of ServiceAmbulance Usage by Medicare BeneficiariesEMS Response Times and Hospital Closures

Slide3

Ambulance Research Goal

Goals:Understand quality and costs of ambulance serviceCharacteristics related to usage by patients and how it varies across the U.S.Understand emergency healthcare especially in rural areasHow to deliver the most effective healthcare for the lowest cost

Slide4

1865

1980s

First hospital-based ambulance services.

Federal government involvement in EMS sector.

Federal financial support declines.

Today

EMS managed and financed at the local level.

A number of models are used to fund and staff EMS and ambulance services.

Ambulance Service History

1970s

Slide5

Note: Data are missing for CA, IL, VA and WA.

Source: Federal Interagency Committee on Emergency Medical Services, 2012

Slide6

Kentucky Ambulance Facts, 2017

220 Ambulance agencies

1,235 licensed ambulances183 agencies with Class I ground ambulance services. They operate at ALS or BLS level to provide emergency and nonemergency transportation.

13,447 Providers; 27% Paramedics, 68% EMTsSource: Kentucky Board of EMS, 2017

Slide7

Kentucky EMS Agencies by Ownership Type (%), 2018

Source: Kentucky Board of Emergency Medical Services, 2018

Class 1 organizations with ground and emergency transport (n=178)

Slide8

Ambulance

Service Ownership and Management: How it Affects Quality of Service Delivery for Medicare Patients

How does ownership of an ambulance service affect the quality of emergency services for Medicare beneficiaries?

Measure quality as response times.

What is the most efficient ownership structure to operate an ambulance service?

Consider quality and costs.

Slide9

Relevance of Our Study

Pegasus Institute in 2018 study surveyed Kentucky mayors about problems with ambulance service.

“More than 70 percent listed “high costs” as a concern for residents, and more than 40 percent complained of “slow response times.” ”

Slide10

NEMSIS (National

Emergency Medical Services Information System)

Years 2010 to 2015

9-1-1 emergency calls transported by EMS to ED by ground transport

In 2015, 47 states and DC reported data

Kentucky is one of first states to have mandatory reporting and in 2017 100% of services reporting.

Ambulance Service

Slide11

E

mergency

911 Call

Scene Time

Transport Time

Total Response Time

Time to Scene

Ambulance Call Times

Slide12

Ambulance Call Times (minutes), NEMSIS and Kentucky

Source: Kentucky Data: Kentucky Board of EMS, 2017; NEMSIS, 2010-2015

Slide13

Mean (% of calls)

Patient

Male

40%

Female

60%

Age (65 to 105 years)

79

years

Ambulance

service

Ownership type

Community, Non-Profit

16%

Hospital

14%

Private, Non-Hospital

21%

Government, Non-Fire

21%

Fire Department

27%

Location

Rural/Wilderness

11%

Urban/Suburban

89%

Description of Ambulance Call Data

Slide14

Staff medical status

Mean (% of calls)

EMT Basic and Intermediate

10%

Paramedic

85%

Other

5%

Staff composition

Mixed

21%

Non-volunteer

76%

Volunteer

3%

Ambulance

Service Level

Basic

Life Support

29%

Advanced Life Support

71%

Description of Ambulance Call Data

Slide15

Fire Department ambulances in

rural areas18% or 7 minutes faster than Community Non-profit ambulances22% or 9 minutes faster than Government non-fire ambulances

6 minutes faster than hospital and private non-hospital ambulancesFire Department ambulances in

urban areas

5 to 6 minutes faster than other ambulance services

Results for All States in NEMSIS

Slide16

Quality measured by response times

Fire department ambulance services seem to provide the highest quality of service, if the quality is measured by response time to

a hospital.

Possible explanation:

Fire departments locate close to residential areas

Not much difference in quality across other ownership types.

Efficiency and difference in costs.

Most costs fixed - 60% personnel, 14% vehicle (excluding fuel) and equipment

Crude measures of costs in our data

Comment on Quality, Next Costs

Slide17

Community Non-profit

Fire Department

Government Non-Fire

Hospital

Private Non- Hospital

Staff Medical Status

Paramedic

67.6

87.7

89.9

85.0

88.8

EMT-Basic and Intermediate

27.4

7.8

6.8

6.3

5.8

Other

4.9

4.6

3.2

8.7

5.4

Staff Composition

Non-volunteer

43.9

68.2

85.3

93.3

89.7

Mixed

44.3

28.8

13.6

6.5

9.8

Volunteer

11.8

3.0

1.1

0.1

0.6

CMS Service level

Basic

Life Support

40.4

27.3

27.0

32.8

20.8

Advance

Life Support

59.7

72.7

73.1

67.4

79.2

Cost Factors by Ownership Type (% calls)

Slide18

Wage Estimates for EMTs and Paramedics

Percentile

10%

25%

50%

(Median)

75%

90%

Hourly Wage

$10.03

$12.25

$15.38

$20.27

$26.49

Annual Wage 

$20,860

$25,490

$31,980

$42,150

$55,110

Source: Bureau of Labor Statistics, 2015

Assess injuries, administer emergency medical care, and extricate trapped individuals. Transport injured or sick persons to medical facilities.

Slide19

Community Non-profit appear to be cheapest to run based on personnel and level of service.

Limitations of the data do not allow us to make strong inferences about costsLocal governments must rely on other factors to decide on most efficient form of EMS

To better inform policy

Need data on other quality measures such as patient outcomes

Need complete data on costs

Comment on Efficiency

Slide20

Ambulance Services for Medicare Beneficiaries: State Differences in Usage

Are there state differences in ambulance usage among Medicare Fee-for-Service Beneficiaries?

Slide21

Definitions

Data: Medicare Fee-For-Service Provider Utilization and Payment Data Physician and Other Supplier Public Use File

Ambulance Service Provider: Providers that submitted Medicare Part B non-institutional claims by the zipcode of the provider. No hospital-based services included.

Beneficiary

: Medicare Fee-for-service Part B.

Transportation: Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

(Centers for Medicare and Medicaid, 2016)

Slide22

Data

Number of unique Medicare beneficiaries in a year using a service. (BENE)Number of miles beneficiaries are transported via ground ambulance service in a year. (MILE)

Summation over one year of the number of unique beneficiaries using a service per day.

= (BENEDAY)

Total number of Medicare beneficiaries. (MEDICARE)

 

Slide23

Summary for all states and Kentucky, 2012

All

states

Kentucky

Ambulance

service

companies

9,693

179

Unique beneficiaries receiving services in a year

14.7 million

138,000

Number of miles

transported

157.9 million

4,142,000

Distinct Medicare beneficiary/per day services

25.4 million

281,000

Total number of Medicare Fee-for-service beneficiaries (Part

A and/or Part B)

37.2 million

804,758

Slide24

Ground ambulance service by state, 2014

Number of Medicare beneficiaries transported by ambulance (in thousands)

Number of miles transported (in thousands)

Slide25

Statistics on Usage

We calculated the following ratios for each state per year:

(1) Number of unique beneficiaries per all Medicare beneficiaries. (BENE/MEDICARE)

(2) Number of miles transported in a year per unique beneficiary. (MILE/BENE)

(3) Number of days of service used by beneficiary in a year. (BENEDAY/BENE)

(4) Number of miles transported per day per unique beneficiary. (MILE/BENEDAY)

Slide26

Summary for all states and Kentucky, 2014

Mean over all

states

Kentucky

Beneficiaries per all Medicare beneficiaries

12.2%

15.9%

Miles

transported per beneficiary

22.1 miles

31.4 miles

Number of days of service per

beneficiary

1.8 days

2.0 days

Number of

miles per trip per unique beneficiary

12.5 miles

15.5 miles

Slide27

Measures of Ground Ambulance Service by State, 2014

Slide28

Regional Difference in Ambulance Usage

Highest percentage of Medicare beneficiaries using ground ambulance was in New England whereas the least was in the Mountain states.Medicare beneficiaries in the South traveled the most miles in a year and the ones in the West traveled the fewest miles.

Alabama, Kentucky, South Carolina, Tennessee, and West Virginia were the top five states in ambulance usage by all measures for 2012-2014.

Alaska, Arizona, Colorado, Hawaii, Nevada, and Utah were the bottom six states in ambulance usage by all measures for 2012-2014.

Slide29

EMS Response Times and Hospital Closures

When a hospital closes in a community what are the short-run changes in ambulance response times?Do patients spend more time in an ambulance being transported to an emergency department?What is the importance to patients and communities?

Slide30

Patients

Change in distance to an ED when a hospital closes affects time in an ambulancePatients make different choices when closest ED closes which affects number of transports in an ambulanceChange in access to emergency care could affect patient health outcomes when transported further in an ambulance.

Slide31

Ambulance Service and CommunityIncrease transport times when going longer distance to next ED

Increase transport times as time demand increases for current number of ambulance vehiclesLevel of service could change if it is hospital-based.Long-run effect

Slide32

Hospital Closures 2011-2014

91 Hospital Closures

Red = RuralBlue = UrbanOne closure in HI (not shown)

Slide33

Rural Hospital Closures in Kentucky 2009-2016

Hospital

City

County

Medicare Payment Type

Closure Year

Number of beds

Status

New Horizons Medical Center

Owenton

Owen

CAH

2016

25

Outpatient/Primary Care/Rural Health Clinic

Westlake Regional Hospital

Columbia

Adair

MDH

2016

49

Urgent or Emergency Care

Parkway Regional Hospital

Fulton

Fulton

PPS

2015

48

None

Nicholas

County

Hospital

Carlisle

Nicholas

CAH

2014

16

None

Jenkins

Community Hospital

Jenkins

Letcher

CAH

2009

25

None

Slide34

DataAll the ambulance call data from NEMSIS for one year before and one year after a hospital closes

Calls are in zip code where a hospital closedWe compare average call times before and after closure for various groups

Slide35

Mean Transport Times One Year Prior and One Year After a Hospital Closure (minutes), 2010-2015

Slide36

In Kentucky

“Owen County: Owen County closed its hospital for good in 2017, increasing the average EMS transportation times in the county from 20 minutes to 40 minutes.”

Source: Pegasus Institute, 2018 and Combs, M. (2017, July 31). WKYT Investigates: Paramedic shortage, concern to local EMS 44 providers. Retrieved from http://www.wkyt.com/content/news/WKYT-Investigates-Paramedicshortage-concern-to-local-EMS-providers-437721983.html

Slide37

ConclusionsIn the short-run, when a hospital closes rural patients spend an additional 11 minutes in an ambulance, a 76% increase in their time when transported to a ED.

They spend more time than urban patients facing closures.There is no change in the time to scene in rural areas.The scene time increases by a few minutes in rural areas.

Slide38

Concluding Remarks

National Advisory Committee on Rural Health and Human Services in a 2016 policy brief emphasized the need for ambulance services when discussing preserving access to emergency care in rural areas.

Slide39

QuestionsCommunity and Economic Development Initiative of Kentucky

https://cedik.ca.uky.edu/Rural and Underserved Health Research Centerhttps://ruhrc.uky.edu/Institute for the Study of Free Enterprise at UKhttp://isfe.uky.edu/