Calling 911 is a terrifying moment. The wait for an ambulance always seems endless, but however long it takes, whether those who arrive manage to save a life is usually what matters most.
Many cities and towns in Massachusetts still judge the performance of their ambulance services using metrics like response times, which can miss the point. An additional two minutes waiting for an ambulance will rarely make a difference for a trauma patient facing emergency surgery that may take hours.
Patient outcome is a more valuable measure of whether a medical service is doing right by people. In many areas of health care these days, it is the gold standard, a key factor in determining how much insurance companies pay service providers. Changing the terms of ambulance companies’ contracts to make good patient outcomes the goal could greatly improve the quality of medical care across the state — and save lives.
I know first-hand from six years on the job as a paramedic in the private ambulance industry. Many paramedics in the Boston area work for private companies that have contracts with cities and towns to provide ambulance services — at least 35 communities with more than 1.5 million residents use this system. In return for the right to answer 911 calls and charge patients for the service, these firms generally agree to dedicate a certain number of ambulances to meet a community’s needs and to achieve certain response time requirements.
Because it costs roughly $1 million annually to staff and maintain a single ambulance, letting a private contractor take care of ambulance services can be attractive to many cities and towns. However, while many private ambulance companies work diligently to meet their obligations, they are for-profit entities that may be reluctant to go significantly above and beyond contract specifications. In much of Massachusetts, it’s time to update those contracts.
Nationwide, the best-performing emergency medical service systems methodically track patient outcomes, constantly adjusting their approach in order to improve the care they provide. The City of Boston’s municipal provider, Boston EMS, takes this approach, and it has paid dividends.
A standard measure of EMS performance is the ability to resuscitate victims of cardiac arrest. Boston EMS excels in this area. While a large 2011 study by the Resuscitation Outcomes Consortium found that 6.1 percent of cardiac arrest patients survive across the United States, Boston EMS achieved a survival rate of 11 percent over the same time period. That’s huge — nearly double the national average — and it translates into about 25 additional lives saved each year. It is also the second-highest survival rate among the 50 largest cities in the country. Assume this standard of excellence applies to Boston EMS’s treatment of the many other emergencies to which it responds, and that adds up to possibly hundreds of lives saved each year before patients even reach the hospital.
Yet private ambulance companies’ contracts with communities rarely discuss patient outcomes. The recent bidding process for the contract to provide service in Quincy is one example. While the 22-page document for bidders informed them that they must agree to respond to EMS calls within six minutes 90 percent of the time and to meet specific requirements regarding vehicle age and maintenance, standards for patient outcomes were not mentioned once.
You might think that response times and patient outcomes must be closely linked — that the faster an ambulance gets there, the more likely it is someone will survive. But the link between the two is actually pretty weak. In virtually all Massachusetts communities, police officers or firefighters get to medical emergencies before EMS staff, and they provide the most time-sensitive care. A number of peer-reviewed studies drawing data from thousands of patients have shown that when this is the case, there is not a strong association between quick EMS response times and improved patient outcomes. What does affect outcomes greatly, though, is the skill level of the EMS providers on the scene.
If ambulance contracts were restructured so that patient outcomes were central — a municipality collected patient payments for EMS services and then reimbursed the EMS provider in proportion to patient outcomes, for example — companies would have a strong incentive to improve the care they provide. Instead of focusing on meeting irrelevant benchmarks, they would be encouraged to carefully monitor the status of the people they are caring for and make adjustments as needed. Firms might also be willing to invest more heavily in training their personnel beyond minimum standards set by the state.
As health care shifts more and more toward considering patient outcomes in paying service providers, ambulance services can’t be left behind. The consequences are grave. Our paramedics must be focused on something bigger than a ticking clock.
Tom Kimball is a paramedic for Cataldo Ambulance Service. He will be attending medical school this fall.