The recommendations of the NJ EMS Council related to the TriData study, and its subsequent proposals, impacts the Advanced Life Support (ALS) system in several ways. The New Jersey Association of Paramedic Programs is encouraged by the overall direction that the Council took in crafting its draft, and would like to highlight a few specific areas that are believed to be the underpinning of a high functioning, high quality EMS system.
The key points are as follows: 1. Support for a regionalized ALS system that is hospital based; 2. The desperate need for adequate funding of the entire system; and, 3. Support of the consolidation of the many different “advisory” and “governing” groups into a single omnibus organization called the “Emergency Medical Care Advisory Board (EMCAB).
Regionalization The EMS system in New Jersey is unique throughout the country in that we have an advanced life support system that, by state mandate, is a regionalized, hospital based ALS system, known as the Mobile Intensive Care Unit (MICU). The Executive Summary of the TriData report states, “TriData suggests that New Jersey restructure their EMS System by creating a regional approach…”1 While this comment applies to the EMS system overall and may seem new, the fact is that the ALS system has operated in a regional model since its inception and has proven to work well.
First, the regionalized ALS system in NJ is hospital based. This means that the paramedics who work in the system are responsible to the standards and continuous quality improvement requirements of the acute care hospital system. There exists a strong relationship between the paramedics in the field and their hospital Medical Director. As an agency fully vested within the health care system, the paramedics in New Jersey’s MICUs can maintain a singular focus on providing the highest quality medical care in the time of a patient’s most dire need.
Second, regionalization of ALS services ensures that this quality is maintained through high volume. Recent studies have demonstrated that there is a direct correlation between more cases treated per paramedic and higher rates of survival to discharge of the patients.2 The regional approach ensures that there are fewer overall paramedics caring for high risk and high acuity patients as compared to EMS systems in which the existence of many locally based ALS services result in greater numbers of paramedics caring for the same number of patients. It has been shown that in systems such as the latter, limited exposure to critically ill adult and pediatric patients has the result of less expertise and poorer clinical outcomes.3
Issues of Funding The issues of funding our EMS system must be taken into account in crafting any solution for the future. From the ALS perspective, the rules implemented by the Centers for Medicare and Medicaid in 1996 have caused erosion of the insurance reimbursement dollars available to help fund the ALS system. It is important to note that the provision of the statewide ALS system is accomplished without any taxpayer subsidy. Unlike municipal or county based systems that rely on tax based subsidies to fund their programs, New Jersey’s MICU system operates under the insurance reimbursement model and has not historically passed along any financial burden to the tax base. Unfortunately, insurance reimbursement (particularly Medicare and Medicaid) have declined while expenses have increased.
Some may argue that the absorption of the ALS system into the existing locally based EMS systems may result in fewer dollars needed to fund the overall system. We must point out that this would only serve to erode the regional model that leads to high quality care and better patient outcomes. In addition, it has been shown that regionalizing and outsourcing of these functions has in fact saved taxpayer dollars in systems throughout the country.4
EMCAB The creation of this overarching body would be of great benefit to the system. Through this concept participation in the governance of the EMS system would be made more transparent, as well as more widely open to those individuals throughout the community who have an interest and willingness to participate. In addition, and in some respects more importantly, by giving the EMCAB the authority to work with the Commissioner of the Department of Health and Senior Services in crafting and promulgating regulations, the evolution of our system over time will become much more fluid. This would clearly solve one of the major issues facing the ALS system, which is the fact that many of the governing and clinical principals are directly tied to the legislation and are therefore too difficult to change even when the national standards of care on these issues are changing around us.
Scott Casper is the Director of Virtua Health Systems Emergency Medical Services and President of the New Jersey Association of Paramedic Programs (NJAPP).
1 NJ EMS System Review, TriData Corporation, August 2007; Page 3.
2 ASPIRE Trial, Michael R. Sayre et al
3 Does the Number of System Paramedics Affect Clinical Benchmark Thresholds; Kristin M. Vrostos, et al; Journal Prehospital Emergency Care; July 2008
4 The Reason Foundation; Policy Statement on outsourcing, privatization and public private partnerships; Emergency Medical Services Trends: www.privatization.org/database/policyissues/ems_local.html
This article was originally published in New Jersey Municipalities magazine. Vol. 86, No. 5, May 2009