For the record, I am not a nay-sayer, or against community paramedicine initiatives, nor am I a troglodyte who denies that the world is changing and that by merely ignoring the outside world, survival is guaranteed. In fact, I am accused of being the complete opposite. I would, however, offer for careful consideration the following discussion and thoughts which are derived from work with clients in a variety of businesses engaged in transformative efforts (including health care and transportation) and hopefully can help identify landmines as well as describe a possible route of success in your post ACA adaptations. In spending a lifetime in studying and working with organizations I have come to adopt a very simple, yet very powerful (notice how almost everything that is truly powerful is simple?) model that contains the elements that are present in all successful and sustainable organizations and change efforts. This simple model holds that there are three elements, all critical and all interacting and depending on the other two.
That is to say that any successful concept, ideal, initiative, program or organization, must have the physical structure (staffing, governance and appropriate relationships) within which reside systems that are uniquely designed and positioned to support and provide feedback (guidance) on the success of the Guiding Idea. Viewing your response through the prism of this model helps highlight the implications of applying the current conventional wisdom of community paramedicine as a go-to strategy
Systems
Most EMS providers have internal systems that are ill-equipped to deal with the needs of a community paramedicine delivery product. The current paradigm of EMS delivery is focused on acute / episodic care. Data systems are designed around procedures and protocols and quality measures are almost always about the application of these elements. Community paramedicine, on the other hand, is an element of a Population Health Management (PHM) strategy driven by incentives designed for a comprehensive approach to health management and not the episodic / acute needs of the EMS provider.
The successful EMS Provider data system will transition and integrate in several significant ways, some of which are offered below:
• Clinical data transitions from procedure success to more biometric data or lab data, and possibly health risk assessment (HRA) data, that contributes (on a real-time basis) to the identification of risks and cost drivers within the PHM system and is used to monitor the program’s success.
• Utilization data will focus on the utilization patterns and integrate with the PHM providers data on, for example, how are people accessing their healthcare and what were the obstacles to care?
• Elements of ‘Adherence’ will replace the word ‘compliance. This refers to how well members and providers are adhering to evidence-based medicine guidelines. Are they filling their prescriptions consistently? Are they getting preventive or scheduled care? To what extent are predicted re-admissions not happening?
• Operational data becomes participation data, productivity data, disability data and other information that helps to monitor and develop the programs as opposed to response times and system status levels.
• Financial data is integrated with clinical and operational data to illustrate how this healthcare activity that you’re offering translates to dollars and opportunities for real hard dollar savings in the population involved.
• Satisfaction data is necessary to monitor how sponsers, participants and key stakeholders view your efforts.
The industry is heading in these directions with NEMSIS-3 and HL7 integration, however many, if not most, current data system elements ranging from data capture (i.e. ePCR) to analytics, are not designed around these guiding ideas nor is there any meaningful focus on potential integration with legacy systems - that will not be abandoned by their owners.
Structures
Aside from the somewhat obvious need to alter staffing models to include levels and standards of care in a different proportion to what is most often found, the organizational structure of the post ACA-organization requires careful design consideration.
Most current supervision structures rose out of a classic command-and-control model and models of control are primarily internally facing, monitoring unit availability, time on task and protocol adherence, etc. Successful community paramedicine efforts must develop an equally weighted focus on external factors as these initiatives are only an element of a comprehensive population health management effort.
While primarily in the public sector, both public and private sector delivery models must carefully evaluate and monitor the relationship and interaction between operations based, ‘positional’ authority (rank or seniority) and clinically based, ‘specialization’ authority. It is a tension that has been in EMS as long as EMS has existed, and it is apparent that this dynamic will only be exacerbated in the new environment.
The Guiding Idea
Often organizations launch new initiatives almost in panic, believing that to not follow the new ‘conventional wisdom’ is to doom itself to extinction. I am reminded of the almost blind following of hospitals and medical groups into the capitated reimbursement environment of the late 1980’s, only to be amazed by research conducted by Health Leaders some 10 years later wherein 72% of CEO’s surveyed agreed with the statement that they didn’t "fully understand capitated reimbursement agreements," but felt that failure to enter into the market with them would doom them to uncompetitiveness.
In the airline industry, the early 80’s were manifest with efforts at horizontal and vertical integration in order to reduce the impact of economic cycles and capture more of the travel dollar. The peak of these efforts was the Allegis conglomerate formed by United Airlines, Hertz, Hilton and Weston that exploded in dramatic failure in 1987. The ultimate success of the airline industry business model came when the industry identified how to effectively manage its capacity and increase the available revenue per seat mile in the post 9/11 travel world. The driver of this success was the realization that the belly space of scheduled airline flights could be utilized for cargo with a big increase in marginal revenue. In fact, the entire dynamic pricing structure found in the airline industry today, is a function of the discovery that the airline industry is a cargo business with the top cabin being self-loading, and the belly contents requiring some help (my apologies to Southwest Airlines and their mantra of being a service industry that flies planes, but the rule always has an exception, right?).
The point is, that success in both of these approaches to the conventional wisdom came from rethinking the application of things that were already familiar - competencies that were already possessed. Elements of the business in which there was confidence and trust, not only in the company’s ability to deliver, but confidence on the part of the market that they could actually be delivered. Likewise, it is prudent to assume that Community Paramedicine is A need in the current environment, it is not THE need.
It is highly likely that successful PHM initiatives by EMS and medical transportation providers will come from existing relationships and competencies that providers have already established with their partner-client facilities or groups. The ability to display prior competencies in a particular, specific area of your clients’ needs, whether it be patient flow management, logistics, or comprehensive transportation management, will likely be the area where organizations will be successful in redefining their role in the new post-ACA environment.
In this environment, one thing is true: That which creates value will be paid for. Community paramedicine can be an important strategy for creating value in the management of health populations. However, merely redirecting your existing capacity of delivery will not deliver success. There is much consternation on compensation and reimbursement mechanisms associated with the post ACA world. Your organization must integrate, measure and report in meaningful ways to even begin to discuss compensation. All of this means your future revenues are tied directly to decisions you make today regarding the ideas you have about where you are best positioned to create that value. The effectiveness of that positioning will depend completely on the the extent to which you can structure and develop appropriate systems throughout your organization in support of your chosen value creating position.
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