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
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Slide1
Ambulance Services
SuZanne TroskeCommunity and Economic Development Initiative of KentuckyUniversity of Kentucky
November 16, 2018
Slide2Ambulance 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
Slide3Ambulance 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
Slide41865
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
Slide5Note: Data are missing for CA, IL, VA and WA.
Source: Federal Interagency Committee on Emergency Medical Services, 2012
Slide6Kentucky 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
Slide7Kentucky EMS Agencies by Ownership Type (%), 2018
Source: Kentucky Board of Emergency Medical Services, 2018
Class 1 organizations with ground and emergency transport (n=178)
Slide8Ambulance
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.
Slide9Relevance 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.” ”
Slide10NEMSIS (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
Slide11E
mergency
911 Call
Scene Time
Transport Time
Total Response Time
Time to Scene
Ambulance Call Times
Slide12Ambulance Call Times (minutes), NEMSIS and Kentucky
Source: Kentucky Data: Kentucky Board of EMS, 2017; NEMSIS, 2010-2015
Slide13Mean (% 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
Slide14Staff 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
Slide15Fire 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
Slide16Quality 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
Slide17Community 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)
Slide18Wage 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.
Slide19Community 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
Slide20Ambulance Services for Medicare Beneficiaries: State Differences in Usage
Are there state differences in ambulance usage among Medicare Fee-for-Service Beneficiaries?
Slide21Definitions
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)
Slide22Data
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)
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
Slide24Ground ambulance service by state, 2014
Number of Medicare beneficiaries transported by ambulance (in thousands)
Number of miles transported (in thousands)
Slide25Statistics 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)
Slide26Summary 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
Slide27Measures of Ground Ambulance Service by State, 2014
Slide28Regional 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.
Slide29EMS 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?
Slide30Patients
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.
Slide31Ambulance 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
Slide32Hospital Closures 2011-2014
91 Hospital Closures
Red = RuralBlue = UrbanOne closure in HI (not shown)
Slide33Rural 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
Slide34DataAll 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
Slide35Mean Transport Times One Year Prior and One Year After a Hospital Closure (minutes), 2010-2015
Slide36In 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
Slide37ConclusionsIn 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.
Slide38Concluding 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.
Slide39QuestionsCommunity 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/