Talk to practically any paramedic or ER doctor in the United States, and they can tell you that a large proportion of the patients they transport and treat every day are not actually experiencing a health emergency. Many people throughout the country use 911 as a catch-all for all health problems because they do not know any other way to access medical care. High 911 utilization presents a massive drain on both EMS and emergency department resources. They waste precious time and effort on patients whose conditions are not severe enough to warrant emergency medical care.
This steady stream of non-emergency patients leads to the overwork of EMS and emergency room workers. It prevents them from focusing on real emergencies. Research has shown that between 11 and 52 percent of 911 calls are for conditions not severe enough to require transportation via ambulance.
This strain on resources also negatively impacts patients in addition to medical workers. Emergency departments are often not equipped to respond to the types of non-urgent medical problems they are called to deal with. When a patient is brought in for an acute upper respiratory or viral infection, alcohol or drug addiction, or a chronic condition like diabetes, they often receive worse care than they would in a primary care setting. The emergency department is too busy to explain the patient’s condition or the necessary follow-up adequately. From there, the cycle continues. Since the patient does not receive adequate care initially and often does not understand the necessary steps to recover, they often call 911 again later, often for the same problem.
The issue of super-utilizers, or “frequent flyers” (Julota prefers the term preferred customers) as they are often called, is one faced by EMTs and emergency rooms throughout the country.
One Alameda County EMT estimated that in a 12-hour shift, “50 percent to 75 percent [of calls] are frequent fliers or do not need an ambulance.” The county maintains a list of the top 25 “frequent fliers” who call 911 regularly and found that in just two years, 25 people have collectively called the 911 line 4,291 times. Almost every EMS agency across the country can relate to this.
A 2015 review of more than 60,000 annual 911 calls in Milwaukee, Wisconsin, found that 7 percent, or 4288 calls, came from the same 100 people. A 2009 MedStar study found that in the Fort Worth, Texas area, 21 patients had been transported to local EDs a total of 800 times over 12 months. The Tucson Fire Department had been able to identify 50 individuals who accounted for more than 300 non-emergency 911 calls over 12 months.
So how can we fix this problem? The solution is not to deny emergency medical care. While these 911 callers’ problems do not constitute an emergency, their medical needs are still real and must be addressed. If these individuals cannot access care by calling 911, most would likely forego seeking medical attention entirely because they do not know how to access it otherwise.
Thankfully, there is a better solution. A new healthcare model called Mobile Integrated Healthcare–Community Paramedicine (MIH-CP) utilizes patient-centred, mobile resources in an out-of-hospital environment to increase access to primary care for medically underserved communities while lowering resource waste and overall cost. While the specifics of MIH-CP programs vary from place to place, the basic principle remains the same—expand the role of paramedics to allow them to address the underlying health needs of the patient while integrating them into the larger spectrum of community healthcare and technology: mental health, drug treatment, social services, public safety, and telemedicine.
At this point, you are probably thinking, “This all sounds great, but how does it lower costs?”
1. MIH-CP programs lower the number of super-utilizers, naturally reducing ambulance charges and emergency department expenses
When Medstar in Fort Worth, Texas, first implemented their MIH-CP program in 2009, they found that 21 patients had been transported to local EDs a total of 800 times over 12 months, generating over $950,000 in ambulance charges and even larger ED expenses. Between the program’s formal launch in July 2009 and August 2011, the volume of 911 calls from the program’s 186 enrollees fell by 58 percent, from an average of 342.3 monthly calls during the six months before enrollment to 143.3 monthly calls afterward. This reduction led to a corresponding drop in MedStar’s charges and costs, with annualized EMS transport costs for these patients falling by over $900,000 (from $1,577,472 to $660,128) and charges falling by over $2.8 million ($4,929,600 to $2,062,899).
Other programs across the country have found similar reductions in cost. One article found that “81 percent of [MIH-CP] programs in operation for two or more years reported success in lowering costs by reducing 911-call use and emergency department visits for defined groups of patients.” By addressing patients underlying health needs, MIH-CP programs allow patients, especially uninsured patients, to be less reliant on 911 and ER visits to receive care, thus outright reducing the number of 911 calls and hospital visits and their associated costs.
2. MIH-CP programs allow paramedics to divert non-emergency patients to cheaper alternative destinations
Studies indicate that many people treated in EDs could safely be treated in less expensive and more appropriate locations. Rather than taking patients suffering from an infection to an emergency department, they can instead be taken to urgent care or primary care office where they will not only be able to receive better quality of care, but they will avoid an expensive emergency bill.
Similarly, inebriated individuals can be taken to a sobering center; those suffering from mental health crises can be taken to appropriate mental health facilities; those suffering from drug addiction can be taken to a treatment center, and a paramedic can treat those dealing with chronic conditions or minor ailments in their own home. These alternative destinations not only improve the patient’s experience of care but have been shown to save medical systems hundreds of millions of dollars each year.
The cost-benefit of utilizing alternative destinations is two-fold.
Firstly, these destinations are generally cheaper than an emergency room, reducing costs by avoiding a large ED charge. However, even more importantly, these alternative destinations are better able to meet the patient’s medical needs, which lowers the chance that they will need to call 911 again in the future, either because their medical problem is resolved or because they become aware of alternative ways to access care besides calling 911.
Suppose a patient knows that they can go to urgent care or a primary care physician next time they have an upper respiratory infection. They can receive better and faster care than they would be by calling an ambulance and being transported to an ER. In that case, they are more likely to do so in the future. Thus, future ambulance costs and ED charges are avoided entirely.
3. MIH-CP programs reduce hospital readmissions.
One specific subset of “super-utilizers” are those who rely on 911 calls and ED visits to treat flare-ups of chronic conditions. These flare-ups could often be avoided with proper condition management, so MIH-CP programs allow these patients to avoid expensive ED visits by helping them keep these conditions in control.
Community paramedics can provide long-term follow-up care to patients who might otherwise receive acute care in an ED, but then upon discharge, return right back to the habits that exacerbated their condition in the first place.
Through home visits, paramedics can help manage a patient’s medications, provide counselling on hospital or clinic discharge instructions, assess the patient’s lifestyle, and educate them on how and why they may need to change certain things. This kind of at-home preventative care allows patients to control their chronic conditions and avoid the need to call 911 and visit the ER in the future, thereby reducing costs associated with emergency transport and treatment.
Additionally, beginning in 2013, a provision of the Affordable Care Act that financially penalized hospitals for excessive readmissions were phased in. According to an analysis by Kaiser Health News, about 80% of the 3,241 hospitals CMS evaluated in 2018 will face penalties of up to 3% of their Medicare payments.
About 20% of all Medicare fee-for-service patients are readmitted within 30-days of discharge. MIH-CP programs allow hospitals to avoid these financial penalties by reducing readmissions through improved patient education and follow-up care.
4. MIH-CP is now easier to implement than ever
A 2018 survey conducted by the National Association of Emergency Medical Technicians (NAEMT) identified over 200 EMS agencies in over 40 states operating MIH-CP programs. The number of programs has undoubtedly grown since then. As research continues to show the efficacy of these programs, both in improving patient outcomes and reducing costs, they have continued to be implemented throughout the US.
All of these programs have shown how vital data is to the successful implementation of an MIH-CP program. 92% of the 129 respondents in the NAEMT’s 2018 MIH-CP survey said they utilize some data collection system. Unfortunately, many times this data collection system is nothing more than an excel spreadsheet.
This data is necessary to identify the super-utilizers who would most benefit from these programs to coordinate patient care across EMT agencies, hospitals, clinics, and community health organizations and track patient outcomes
The good news is that data collection technology has become easier than ever to implement and use, allowing the various healthcare providers involved in an MIH-CP program to collaborate easily and effectively.
With Julota, for example, a community’s health systems, EMS, law enforcement, social services, mental health, and other community care organizations can benefit from more collaboration, better health, and lower overall costs.
As a complete HIPAA, 42 CFR part 2, and Criminal Justice Information System-compliant solution that manages secure multidirectional sharing of consented information, Julota helps patients get better and more fitting treatments that they would otherwise lack.