Public Utility Model vs. Fire Based EMS in Indiana

[firedoc5]

I might be showing my ignorance here, but...When I first started out I worked as a volly for a Basic service. We were partially tax supported but each patient was billed what I now know, or assume, was a co-pay. And since I had so little experience at the time didn't think anything about it.

A little less than a year later I was hired on a private service in a large town, or at least large to me. The city Fire ran the calls and provided the care with our cooperation and we did all the transport. Sort of like "Johnny & Roy". The private service still billed the patient even though the Fire Dept. was totally tax supported. It was explained to me that the patient was only being billed for the transport. Later on I found out that if there was an EMT-I or Medic on the call they were billed for ALS transport. This would occasionally throw up a red flag, but nothing would ever come of it. After a couple of years, when I was an EMT-I and was now handling some of the front office stuff I noticed that the billing from the private service began to charge for monitor use, IV, anything ALS, even though most of the time the equipment and practically everything ALS done was done by the Fire Medic. I really thought this was wrong and started to ask questions. Of which I was told to stop asking questions. Eventually a huge red flag was popped up. This time it became a big issue. City Board, FD, County Board, etc. called a few meetings. Eventually the meetings became close doors. After that none of the EMS personnel could help with the office duties. I didn't complain, I hated to do it with a passion. But even to this day I don't know what came of the meetings. After I became a Medic I realized that by going over the copies of each run sheet, they would notice what was done and would bill for it, no matter what agency's equipment was used. Two years later I got on the Fire Dept. Of course since it was tax supported there was no billing, unless it was HazMat. At one time the "powers to be" told us that on a call for us to use our equipment as much as possible. I thought that maybe we would have to start itemizing whose equipment was used or not used. But it never came to that. And since I no longer worked for that private service I had no idea how they were billing. At one point I was told that they stopped billing for equipment used, and only charged whether or not it was an ALS or a BLS transport. But personally, I still think there was something fishy going on. I'm not saying anyone was getting kick-backs or anything, but I think some laws were bent. Or at least swerved around.

Now that I'm out of it altogether, and there are now more than just one private service in the city, I have no idea how any of it is done. But I do know the City Fire does not charge for a single thing.

I hope this is relevant to the topic, which I thought it would. If not, sorry.

[Dustdevil]

I hope this is relevant to the topic, which I thought it would.

Not so much.

Let's please try to stay focused on the big picture here, not the minutiae.

[UMSTUDENT]

The theory is correct, but several underlying factors destroy the really awesome idea that the PUM is. The most successful systems that I've seen (from the perspective of a paramedic) seem to utilize a hybrid version of the public utility model system, generally adopting its principals and virtues and leaving behind the nitty-gritty contract requirements and technical details of a true public utility model system.

The first flaw in this argument is that it is wrong to charge the "insurance companies" and poor "patients" for the service. PUMs really take advantage of a free market economy by trying to place the burden for service in the hands of the people who are actually using the service. When you take into account the cost-of-readiness, staggering cost of inflation on medical practice, and really crappy Medicare/Medicaid reimbursement policies, a thousand dollars for ambulance transport is probably a reality. The only reason most services get by with charging typical Medicare Schedule fees is because they are offset by local tax revenue. Even worse is the organization that refuses to bill thinking they are providing a valuable "community service" to their constituents. The only people they're helping is the insurance companies for whom the "real customer" pays premiums.

Stout, Finch, Dean, etc were all famous for bringing to light the real problem with health care in general...especially in EMS. "The User is not the customer, is not the payer." As Stout is famous for saying, "Emergency victims make poor shoppers." EMS is an example of a fragmented economy. The PUM simply looked to reduce costs and increase quality of service by making the industry somewhat competitive to a consumer base. By creating an oversight authority (a central theme within the PUM), Stout wanted to create accountability for the people while trusting elected officials to continually reevaluate competitive private firms.

Important to Note:

1.EMS Systems function best when there is only one provider (Natural Monopoly)

2.The goals of any system are to provide response time reliability, provide a quality service, and do this at the lowest costs to the consumer.

3. Like a utility company, powerful economies of scale exist. The more people, the cheaper it becomes to provide a service. PUMS work best with large populations which is why regionalizing services beyond simple geopolitical areas works so well (Ex: Oklahoma-Tulsa). When was the last time you saw a power company provide a service to just one county?

The largest problem with PUMs seems to have occurred when nobody got in the business. Without a plethora of private firms bouncing around the country competing with each other, communities, with their well-established ambulance authorities, lack a true choice. I think that when you really look at the contribution of the PUM, you're forced to look at number 2 above: 2.The goals of any system are to provide response time reliability, provide a quality service, and do this at the lowest costs to the consumer. Stout and friends introduced our world to accountability and effective, patient care oriented businesses.

In essence the PUM became relatively extinct because people couldn't come together to really make it work. I think this is why when you find systems that did it the right way, all of the time, you see great success. Places like EMSA and Pinnellas County, FL.

You must also look at the PUM from the perspective of a manager-not a paramedic. When forced to provide a quality service to the public in a feasible, cheap way, while still retaining enough revenue to provide for continued development and reinvestment...the PUM works. Look at any large, successful company from Wal Mart to Starbucks and you will see some of Stout's basic economic principles at work.

[brentoli]

I can't shed light on the system.

The property tax system in Indiana, is a mess.

Any system that doesn't rely on taxation is a step foward from what we have. They still haven't approved local government's 2007 budgets that were submitted.