FIRE BASED VERSUS PRIVATE EMS -
A DIFFERENCE OF PHILOSOPHIES AND SERVICE
Unlike private contractors and other single-role providers, fire departments have the flexibility to provide prehospital emergency medical care by utilizing fire apparatus staffed with cross-trained/dual-role fire fighter emergency medical technicians (EMTs) and paramedics. Fire-based systems can maintain the shortest possible response times while avoiding duplication of services by cross training employees t function effectively in fire suppression, rescue, and EMS. Fire departments can deploy emergency response units in superior numbers from strategic locations than single-role private providers can while maintaining their profits.
Third party payers, such as private health insurers, Medicare, and Medicaid, only underwrite the portion of prehospital emergency medical care associated with transporting a patient to the hospital. Private contractors, therefore, attempt to maximize profit by transporting a maximum number of patients with as few ambulances as possible. Efforts by private EMS corporations to maximize productive time for ambulances could result in a decreased level of service to the community.
It may not be cost effective for a private ambulance company to maintain multiple ambulances available for timely response in a way that is acceptable to the community. Reliance on an ambulance/transport based system to provide critical initial response to medical emergencies thus results in increased response times for service to any given call. This tradeoff between profit and response time interval is at the heart of the EMS privatization dilemma.
It is in the economic interest of a private ambulance company to have their response time benchmark of performance set as high as possible. If response time benchmarks are not established high enough, private providers may rely on fire departments to “frontload” the system. Frontloading advanced life support systems occur when a fire department provides paramedics on first responder vehicles and a private ambulance company provides transport, and therefore collects the revenue.
Private-for-profit EMS contractors and other single-role providers maintain that their performance should be measured against a response time standard of 8 minutes and 59 seconds. Research in EMS indicates that if emergency medical intervention is delayed as long as 9 minutes, patient survival of cardiac arrests approaches zero. Even the private-for-profit ambulance contractors agree that, in the face of their 9 minute response time, the fire service is best positioned to provide the required time-critical medical interventions in less than 9 minutes to ensure optimal victim survivability.
Response time intervals must weigh heavily in an assessment of a specific EMS system’s effectiveness. The National Institutes of Health suggest first responders should arrive on the scene in less than 5 minutes, 90% of the time. Fire departments, on average, deliver basic life support (BLS) and advanced life support (ALS) response times in 3-5 minutes.
As response time requirements become more stringent, a private provider, without fire department involvement, is forced to maintain and support increasing levels of surplus production capacity (more staffed ambulances) to handle the demand pattern fluctuations that prevail throughout this industry. The effect of this excess production capacity means an increase to the provider’s cost per patient served. Public officials must realize that ambulance transportation alone does not represent patient care or an EMS system. There are two factors at the heart of prehospital emergency medical care: the call for service is potentially life threatening and time critical; and (2) the time and location of any particular medical emergency cannot be predicted. Given these two factors, an EMS system that sacrifices response times in favor of patient transport or ambulance services is really rationing access to those resources that have the greatest impact on an individual patient’s chance of survival.
