Problem Identification:
The relationship between the City and those hospitals which receive EMS patients is very informal. There is a noticeable lack of written agreements which outline any mutual expectations. Furthermore, hospitals vary to the extent that they exchange supplies and provide training and billing information. These practices need to be standardized throughout all hospitals receiving the City’s EMS patients.

Recommended Action:
Develop and negotiate contracts with hospitals receiving patients from the City’s EMS system.

Organizational, Revenue Enhancement, Service

Functional/Operational Area:

Estimated Annual Impact:
While the immediate financial impact cannot be estimated, sharing billing data with hospitals could improve the quality and timeliness of the City’s EMS collection efforts.

Estimated Implementation Costs:

Barriers to Implementation:
Possible unwillingness of hospitals to participate.

Projected Implementation:
1 year

Next Steps:
Utilize the Health Department’s regular meetings with local hospital administrators to broach this subject.

Some leading and well-developed EMS systems have similar EMS system-hospital agreements in place. New York City and San Diego County are among them. New York City established these agreements in 1974 and is currently in the process of revising them. At a minimum, these contracts should address the following areas:

– Providing patient financial data to the City for billing purposes;
– Restocking supplies and medications in City EMS units;
– Participating in EMS quality improvement initiatives including clinical feedback;
– Provider notification to EMS personnel when patients are diagnosed with communicable diseases; and
– Indemnification of participating parties.

In order to reduce the burden on taxpayers, City officials are obligated to maximize all available fee-for-service revenue from ambulance services. The likelihood of getting paid for services is a function of the quality and completeness of data provided the third-party payors. Hospitals that receive EMS patients are in the best position to provide complete and accurate demographic and billing information. Hospitals should be providing this data in an electronic format no later than several business days after receiving patients. This could help reduce the City’s EMS accounts receivable aging cycle.

Hospitals appear to have different practices regarding the replenishment of ambulance supplies. Furthermore, current practices for managing EMS drugs are flawed. The current means for restocking and checking medications is inefficient and lacks an audit trail. At present, ambulances must drive across town to a BCFD facility to replace used narcotics. In addition, considerable paramedic time is wasted rechecking drug boxes from shift-to-shift. An exchange box system should be implemented for managing the inventory of medications. The best approach would be to adopt the practice used throughout the nation’s hospital industry for managing their cardiac arrest/crash cart supplies and medications. Under this model, the hospital pharmacy serves as the restocking and control point. Each hospital would be required to have their pharmacy restock ambulance medication boxes. When a patient is brought to a particular hospital, an opened and used drug box would be exchanged for a sealed and complete numbered drug box. To ensure accountability and inventory control, the currency of medications would be signed off by the pharmacist and a tamperproof lock would be used to close the box. A supply of boxes would be under lock and key within the emergency department for rapid exchange. Participation would be required for all hospitals receiving EMS patients.

Pre-hospital care providers face an array of occupational hazards. One of the greatest threats is from exposure to communicable diseases. The list of diseases includes tuberculosis (TB), hepatitis B and C, and human immunodeficiency virus (HIV) among others. In addition, these exposures place the families of these workers at risk. State law mandates that hospital provide EMS providers with follow-up information regarding those patients who are found to have positive lab results; however, these feedback systems are generally inadequate. Hospitals wishing to participate as 911 ambulance receiving facilities should be required to demonstrate a failsafe system for promptly alerting EMS personnel when their patients are subsequently found to have communicable diseases.