result, the overwhelming majority of local EMS agencies lack the necessary business acumen or entrepreneurial spirit to be successful when it comes to EMS innovation. Likewise, most agencies lack the resources needed to apply for (or be competitive for) grants that seek to promote innovation in health care, public safety, or public health. We must acknowledge that our industry needs leaders trained in the acumen of business and financial planning. Despite the efforts of many national organizations to cultivate leadership skills and elevate the importance of higher education, there remains a knowledge gap. Thus, even after we overcome some of the challenges to obtaining meaningful outcome data and other clinical or administrative information, it is likely that EMS agencies will not have the critical measurement skills or resources necessary to perform accurate modeling and/or economic analyses of effectiveness. Since partnerships will often need to be driven by local EMS agencies, they require both adequate business knowledge and entrepreneurial spirit. Should an agency be in possession of all the aforementioned resources and skills, it may still face financial challenges to innovation due to the fact that other partners in the health care system, including hospitals, physicians, and other care providers, and third party payers may still be operating in a fee-for-service environment fraught with perverse financial incentives. FRAUD & ABUSE Another barrier to economic innovation is the perceived prevalence of fraud and abuse in the ambulance industry. A September 2015 Office of Inspector General (OIG) report 51 documents that Medicare paid $24 million for ambulance transports
that did not meet certain Medicare requirements justifying payment and paid $30 million for potentially inappropriate ambulance transports for which the beneficiary did not receive Medicare services at any origin or destination. While the findings in the report may involve only a handful of ambulance suppliers from the major metropolitan areas of Philadelphia, Houston, Los Angeles and New York, they cast a shadow over all ambulance providers making it difficult for some payers to trust EMS agencies enough to test alternate economic models. Fraud may not always be the doing of rogue EMS providers or agencies, but rather sometimes is a function of hospital or other facility staff requesting ambulances for patients who may not warrant them. The American Ambulance Association (AAA) and others have made efforts to combat this serious problem for some time. They offer education, training, and compliance programs to their members to support proper adherence to Medicare regulations. They disseminate best practices and have worked with Congress on concerns related to non-emergency dialysis transports. However, until this issue is more definitively resolved from either within the industry or through regulation or enforcement action, it will continue to be a major barrier to EMS innovation. STRATEGIES FOR OVERCOMING FINANCIAL BARRIERS TO INNOVATION DECOUPLING PAYMENT FROM TRANSPORTATION Solving the fundamental structural challenge of the link between EMS reimbursement and transportation will require a sustained effort on
51 “Inappropriate Payments And Questionable Billing For Medicare Part B Ambulance Transports.” Office of Inspector General . Last modified September 2015. https://oig.hhs.gov/oei/reports/oei-09-12-00351.asp
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MOUNT SINAI HEALTH SYSTEM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
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