Chasing the costs of ambulances

On a given day in Michigan, anyone with a scanner listening for 911 medical calls might hear something like this: "trouble breathing," "pain in abdomen," "swallowed something."

Some are emergencies. Others are not.

In most municipalities, there is a good chance first on the scene will be a crew of medically-trained responders from the nearest fire station. The patient is most often whisked by ambulance to the emergency room.

The ambulance bill is typically at least $500. The emergency room visit will rack up hundreds of dollars more.

But for true emergencies, few would quibble about cost. After all, who puts a price on the loved one with a heart attack who pulls through?

And in that sense, in most jurisdictions,Michigan's Emergency Medical Services system works. It saves lives.

But for all that, experts and some EMS providers question its efficiency. Is sending a fire truck loaded with paramedics to an unknown medical situation a smart use of resources? Could some patients be safely diverted from the emergency room?

"You get a call and someone says, 'My dad has collapsed,' said Brian Walker, general manager of Universal-Macomb Ambulance Service in Sterling Heights. He has been in the ambulance business for 40 years. "You don't really know what is happening until somebody is there. Does that somebody have to be eight guys and a fire truck? You are subsidizing a very expensive piece of equipment going out on medical runs.

"Nobody goes out in front of a city council and admits that what you do is not an emergency. That does not get you millage. Crisis gets you tax dollars."

Response crisis in Detroit

Walker's firm has been helping Detroit with a bona fide EMS crisis, as it sends ambulances under a mutual aid pact into that city while Detroit grapples with reports of delayed response and broken-down ambulances. Unlike many large cities, Detroit does not use fire-based medical responders and relies instead on a separate ambulance fleet paid from the Fire Department budget.

Almost no one believes it functions as it should.

 In 2010, then-Detroit Fire Commissioner James Mack, Jr. conceded: "There are times during the day that we may not have units available, period."

Making matters worse, Mack asserted, just 10 percent of its 130,000 EMS calls a year were true medical emergencies. In 2011, the city rolled out a response policy intended to weed out low-priority 911 calls for concerns like toothaches and boils.

Experts say it is vital dispatch centers discern medical emergencies from issues that can wait, much like the triage protocol that governs emergency room treatment.

"It is critical," said Mike Thompson, medical consultant for Utah-based National Academies of Emergency Dispatch. The nonprofit organization sets certification standards for individual dispatchers and accreditation standards for dispatch centers.

Thompson believes dispatch centers around the country, including Michigan, are guilty of EMS overkill out of fear of facing lawsuits.

"Virtually everywhere we have these EMS centers out there and when you call 911 with a complaint, virtually everyone in the country will send you an ambulance. We over-treat, we over-provide because we are afraid of being sued."

From 'patchwork' to authorities

Michigan is divided into 65 medical control authorities, charged with overseeing EMS response within each jurisdiction. Put in place in 1978, the system replaced a patchwork of private and public responders that lacked unified performance standards and strong oversight. In the decades since then, most of Michigan's 1,062 fire departments have added EMS to their firefighting duties.

Still, there is widespread variation within these authorities in how EMS is rendered.

Most communities send medically trained firefighters as first responders, backed by advance life support. Some -- like Lansing -- staff and maintain their own ambulance fleet. Others -- like Grand Rapids -- contract that service to private providers.

For urban areas, the gold standard set by the National Fire Protection Association is to get a first responder on the scene within four minutes 90 percent of the time and advanced life support within eight minutes.

But as EMS consultant Thompson indicated, there is ongoing debate about the need for such aggressive responses for all 911 calls.

One national study identified seven clinical conditions that account for 66 percent of all adultEMS transports and seven that account for 86 percent of pediatric transports. Of these conditions, only cardiac arrest -- the second least frequent of all the conditions -- appeared to require rapidEMS response.

In the days leading up to the 2011 Super Bowl inTexas, Forth Worth-based MedStar EMS encountered a freak snow-and-ice storm that prompted it to suspend use of lights and sirens for 48 hours. That slowed response times.

MedStar found no difference in patient outcomes during that period.

EMS touted as 'perfect fit'

In the St. Joseph County community of Three Rivers, Fire Chief Dan Tomlinson would rather not take that chance.

Tomlinson calls its EMS system the "perfect fit" for those it serves. Established in 1982, its fire-based system deploys medically trained firefighters for basic life support, advanced life support and transport to the hospital.

"When you look at the traditional primary mission of the fire service and that's to save lives and protect property, statistically we can save more lives more often than not on the EMS side than on the fire side."

Tomlinson concedes that not all EMS calls turn out to be emergencies. But he would rather err on the side of caution, noting that 72 percent of the more than 1,500 EMS calls a year triggered advanced life support.

"From my standpoint, if it were up to me, every call would be an emergency until we have a professional on the scene."

Kentucky diversion program shows promise

But in Kentucky, medical officials are taking an alternative approach.

Concerned that too many 911 calls were needlessly transported to the hospital, Louisville EMS launched a program two years ago to screen low-priority calls and divert appropriate patients from the emergency room. Officials there know of no other program like it in country.

Kristen Miller, chief of staff for Louisville EMS, said it has exceeded expectations.

"I am 100 percent (sold) on this program. When we first started working on it, we were all a little skeptical about how it would work."

Miller said dispatch phone operators are trained using a carefully-scripted protocol to identify 911 callers who may not need an ambulance. They are routed immediately to a nurse for further consultation. In many cases, they are sent instead to an intermediate care center, physician or clinic.

Instead of by ambulance, they arrive by a contracted ride service that charges $26 a trip. The majority of these patients would have landed in the emergency room under previous practice, Miller said.

"I tell people, 'I can have you picked up within 30 minutes and get you seen within 90 minutes or you can go to the emergency room and wait eight hours," Miller said.

Among the calls re-routed from emergency transport: sore wrist or back from a fall, pink eye and leg pain.

Miller said patient satisfaction with the system is "above 90 percent" as Louisville EMS recently decided to expand it by adding a second nurse. While Louisville could not provide exact figures, it reported cost savings from the diverson program, too.

Miller said the biggest hurdle to overcome is fear.

"People are generally risk-averse. Once we put away all the unfounded anxiety, we figured out what we were doing was immensely helpful."

Ted Roelofs worked for the Grand Rapids Press for 30 years, where he covered everything from politics to social services to military affairs. He has earned numerous awards, including for work in Albania during the 1999 Kosovo refugee crisis.