LOS ANGELES -- A new health care model being test-driven in other states could result in Los Angeles County's 18,000 emergency medical services personnel taking on additional duties if the model is adopted here.
Some call it "community paramedicine" and others describe it simply as better utilization of "physician extenders," but many agree it could improve medical care and coordination while reducing costs.
The timing couldn't be better, proponents say. Up to four million more Californians are expected to have health insurance in 2014 under the federal health reform law, further taxing the responsibilities of doctors, nurses and other providers. Primary care physicians in Los Angeles County especially are expected to face a patient onslaught. The county has just over 11,000 primary care physicians for almost 10 million residents, according to research by the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute, as well as 2010 population numbers from the U.S. Census Bureau.
"Major social changes sometimes force you to look harder at the system," said Mitch Katz, director of the county's Department of Health Services. "This is not a random moment, and it's not a new problem. It all starts with the idea that all of us in health care need to work at the top of our license and to recognize that with health care reform, the demand for services is going to increase."
State and L.A. County officials are already thinking and talking along the same lines of efficiency as peers in Colorado, Minnesota, North Carolina and Texas who are asking paramedics to do more. In addition to beefing up the workforce, the move is expected to save money.
A preliminary Community Paramedicine Roundtable Discussion is scheduled for June 27 in Sacramento. Key players will evaluate coordination of interests and efforts that could expand paramedics' future roles.
"Paramedics are a group of highly trained professionals we entrust to give intravenous medication and put a breathing tube down someone's throat," Katz said. "We allow them so little in the way of choice about where to bring people. We don't let them use sound judgment and patient preference."
Emergency medical technicians, who provide foundational or entry-level patient care, usually complete course work of up to 150 hours. Paramedics are advanced providers of care whose course work typically includes anatomy and physiology, cardiology, medications and medical procedures that involve "breaking the skin." They undergo intensive training of between 1,600 and 1,800 hours.
"Health care reform demands that we look at innovative concepts for providing more integrated services in a more efficient manner," said Howard Backer, director of the California Emergency Medical Services Authority. "We must look at interconnectivity of health care services and at efficient and reduced costs as components. We need to identify gaps and how to potentially fill them. Paramedics are good mid-level providers who can be trained to a higher level."
At the West Eagle County Ambulance District in Colorado, Chief Chris Montera described a pilot program begun last year that saved $205,000 in its first six months by reducing emergency department visits in a mostly rural 1,100 square-mile service area. Grant money is the main funding source.
Primary care physicians referred 70 patients to his EMS personnel to receive in-home hospital discharge follow-up, blood draws, medication reconciliation and wound care.
"This is not just about, 'You call, we haul,'" said Montera. "We're taking what we understand about health care to the bedside."
Scoping Out the Possibilities
"A long-term goal is for paramedics to step up within their specific scope of practice," said Cathy Chidester, director of L.A. County's Emergency Medical Services Agency, the largest multi-jurisdictional EMS system in the nation.
"Scope of practice" refers to procedures and processes allowed for the licensed individual. Paramedics basically operate under the "control" of a physician.
"Scope of practice is a very sensitive issue closely guarded by health professionals," said Backer. Still, under the model of coordinated or integrated care proposed by the health reform law, looking at using the most highly trained people in the most efficient manner, there may be no reason paramedics -- who may be underutilized -- couldn't work as even more productive contributors, allowing for discretion and judgment, according to proponents of the new model. Doctors would supervise paramedics along with the other providers they already oversee, including nurse practitioners, physician assistants, medical assistants and licensed vocational nurses, he said.
Like her colleagues, Chidester is intrigued by the options but acknowledges, as do others, that change will ultimately be a time-consuming process. "A lot of different stakeholders have different ideas," she said.
"This won't be a slam dunk concept, no matter how much of a good idea it is," said Backer. "It won't move forward without significant debate and opposition."
Financing is also a challenge, said Chidester. "When we make a change to scope of practice, or add hours or a new skill, or incur a significant amount of training to add a new piece of equipment, now there's no mechanism to recover costs for provider agencies, fire departments or ambulances. We have to have their buy-in on it, too. At some point, maybe an insurance carrier or accountable care organization would participate in funding or maybe federal grants can help."
Still, if health care reform shines a light on emergency medical services, that's a good thing, she said. "We're seen as a safety net and yet people don't recognize treatment done in the field that actually improves patient outcomes in the long run."
An Answer to Excessive Emergency Calls
Reducing unnecessary ED visits and hospital readmissions remains a top priority for L.A. County health officials. In a Los Angeles Times story last month that cited more than half a million 911 calls in 2010, Chidester said one in five patients taken to L.A. County EDs might have been better served elsewhere, such as urgent care clinics or physician offices.
Now, unless a patient refuses transport, the only place he or she will be taken is the ED. Backer sees potential for paramedics to intervene before the ambulance heads for the hospital.
"Some people may not need ambulance transport and could benefit or get more cost-effective care at an alternate destination," Backer said. "When you transport, you tie up resources for some time, for an integral part of the EMS system is the guarantee that you respond in a certain amount of time to emergency calls."
"If those one-in-five ER visits could be diverted, at a conservative estimate of $250 per visit, that would save L.A. County $29.5 million annually," said Jim Lott, executive vice president of the Hospital Association of Southern California. "Unclogging the ER reduces costs to the patient, insurers and anyone else who's paying the bills. It's a no-brainer, and necessity is the mother of invention. We've got a conservative philosophy about what non-physicians are permitted to do in this state."
When a paramedic is in constant communication with a physician, they are better able to determine whether the patient needs to come to the ED, Lott said. "The skill set is there, and the system is in place to allow it, before a patient engages a more extensive part of the health care delivery system."
"What if a paramedic could recognize diabetic symptoms and connect that person to a nurse at their clinic, rather than turning on sirens?" asked Katz. "Let's tell your doctor, for example, that you have elevated blood sugar. Maybe they can authorize a change in medication or maybe they'll see you tomorrow. If you're uninsured and need medical care, you can't call an ambulance and say, 'Please take me to the doctor tomorrow.' We can often articulate an ideal that's more expensive, but how often can we articulate one that's less expensive?"