Most of the discussion surrounding the Affordable Care Act thus far has centered on if volunteer fire departments would be seen as employers. Yet while the law never mentions fire-based EMS, there are some distinct opportunities for fire departments.
During last week's Congressional Fire Service Institute's seminars in Washington, D.C., four panelists examined what some of those opportunities are, and the barriers to reaching them.
Whether the motivation is additional revenue or additional community service, the law opens the door for fire-based EMS to fill a void in the health care system through community paramedicine, or as it is called: mobile integrated health care.
It works like this, said Chief Kenneth Knipper, chairman of the National Volunteer Fire Council's EMS and rescue section, if a patient returns to the hospital within 30 days for treatment of the same illness, nobody gets paid. One hospital administrator told Knipper that it costs the hospital at least $8,000 every time someone walks through the door.
And that administrator said he'd much rather pay a fire department a few hundred dollars per patient if they can prevent the patient's return.
A cheaper option
Dr. Lori Moore-Merrell, assistant to the general president of the International Association of Fire Fighters, agrees that the key will be finding cost-saving opportunities and someone willing to pay for that service.
"What we knew before the law was passed is that people are often discharged from the hospital prematurely," she said. "They go home and don't do proper wound care, they didn't hear their discharge orders, they don't do their prescription regiment appropriately. They become ill again for the exact same reason they were in the hospital."
And to turn this into an opportunity, Moore-Merrell advises to know your community and develop the right plan.
"Maybe this is getting your frequent flyers on the front end and having them transported somewhere other than the ER that's very expensive and finding a payer for that," she said. Or, it could be in-house post-discharge visits and follow-up phone calls to patients.
And for those wondering if there's really revenue in this new community medicine model, Moore-Merrell says several private firms have already set up shop in that segment. In fact, some have walked away from emergency response all together in favor of community medicine.
"If you think there is not going to be revenue in this, watch how the privates are moving," she said. "If you want to do this, it is time to step up and change your paradigms."
But shifting that paradigm will involve a good deal more than hanging a "community paramedicine" shingle on the firehouse. There are significant barriers to entry.
One barrier is that no standard for this exists, said Ken Willette, division manager of public fire protection for the National Fire Protection Association. A fire chief wanting to have a concrete blueprint for what the program will be and how it will be done for labor and municipal leaders won't have it.
"I did some research, and I can't find any," he said.
Setting the standard
NFPA is exploring such a standard. But a standard that is accredited and open to public comment takes time — as long as 18 months. Another early problem is getting the medical community to accept NFPA's ability to create such a standard, as it is seen as a fire rather than health organization, he said.
Along those lines, Moore-Merrell said it will be important for departments to have a medical director who is on board with a community paramedicine program. That may mean finding a different doctor if the jurisdictions current medical director will not embrace such a program.
Dr. Bruce Moeller, executive director of safety and emergency services for Pinellas County, Fla., and with the International Association of Fire Chiefs, outlined his five "wicked problems" to getting such a program off the ground. In addition to the cost effectiveness and data to show fire-based EMS can provide good care, he listed staffing, culture and politics as problems.
With fire departments accounting for the second-largest budget item in most municipalities and actual fires decreasing by nearly half, EMS may be what saved the fire service in a city or county manager's eyes, Moeller said. "My concern is can we adapt."
Knipper said that while many think the volunteer fire departments are the least capable to adapt a community paramedicine program, he doesn't share that concern.
"Every run a volunteer firefighter makes is an inconvenience," Knipper said. "You are interrupting something they are doing."
Yet community medicine isn't pager-based, he said. It can be scheduled for times that suit volunteers, and that will make it more appealing to them.
Additionally, volunteers tend to find ways to get things done they believe are important, he said.
Knipper does caution fire chiefs about the planning phase.
"Volunteer organizations must have a seat at the (negotiating) table or they will be overrun," he said. "You have to demand a place at the table, otherwise the hospitals, nurses, lawyers and a few others are going to control you."