5. Experimentación
5.3. Estudio de rendimiento
The Pittsburgh Department of Public Safety – Bureau of Emergency Medical Services (EMS) is comprised of the following functions:
Advanced Life Support (ALS) emergency medical response and transportation via thirteen ambulances;
Medically directed rescue services for accident scenes, confined spaces, and other non-fire ground emergencies, delivered via two, specially equipped Rescue trucks;
Leadership of a joint police-EMS River Rescue team and a joint EMS-Fire Hazardous Materials team; and,
EMS billing and general administrative support.
Bureau staffing to deliver these services is shown in the chart below (position totals are as of January 1, 2004, as specified in the adopted FY2004 Budget).
Number of Positions
Num ber of
Positions # Change % Change
Position Classification Status FY 2003 FY 2004 FY03 - FY04 FY03 - FY04
EMS Chief 1 1 0 0.00% Deputy Chief 1 1 0 0.00% Assistant Chief 1 1 0 0.00% Assistant Chief 1 1 0 0.00% Division Chief 1 1 0 0.00% District Chief 10 10 0 0.00%
Patient Care Coordinator 1 1 0 0.00% EMS Billing Supervisor 1 1 0 0.00%
Supervisory Clerk 1 1 0 0.00%
Account Clerk 2 2 0 0.00%
Clerk Typist 2 1 1 0 0.00%
Laborer 2 2 0 0.00%
Crew Chief 53 53 0 0.00%
Paramedic Fifth Year 93 98 5 5.38%
Paramedic Fourth Year 0 6 6 n/a
Paramedic Third Year 7 0 -7 -100.00% Paramedic Second Year 6 5 -1 -16.67% Paramedic First Year 3 0 -3 -100.00% Emergency Medical Technician Senior 10 0 -10 -100.00% Emergency Medical Technician 1 14 0 -14 -100.00%
Total 209 185 -24 -11.48%
Sw orn Civilian
According to departmental data, Pittsburgh’s EMS system responds to approximately 56,000 calls per year, making nearly 38,000 transports. From a fiscal perspective, the breakdown of transports across payor classes is as follows:
Payor Number of
Transports Percentage of Transports
Medicare patients 12,800 33.68% Medicaid patients 9,600 25.26% Commercial insurance 7,400 19.47% Self pay 3,500 9.21% Un-billed/Uninsured 4,700 12.37% Total 38,000 100.00%
The current reimbursement level for these transports is roughly $6.9 million annually, with a budget for EMS billing of approximately $250,000.
Initiatives
EM01. Continue to Explore Alternative EMS Organizational Models.
In recent months, representatives of the City and the Pittsburgh medical community have come together in a joint Study Committee to analyze a potential transition to a hospital-based EMS system. Participants have included representatives from the University of Pittsburgh Medical Center, West Penn Allegheny Health System, Pittsburgh Mercy Health System, Fraternal Association of Professional Paramedics, Local 1 (FAPP), Center for Emergency Medicine, Allegheny General Hospital, and Children’s Hospital. In a prior separate effort, other stakeholders have evaluated the potential benefits from integrating EMS and the City Fire Bureau. In both cases, significant time and creativity have been devoted to exploring potential cost savings and revenue enhancements under such alternative organizational structures. In developing this Recovery Plan, the Act 47 team has reviewed the detailed reports produced by these working groups, and has interviewed City management, FAPP union leadership, and members of the regional medical community involved with these efforts. Based on this review, the Coordinator believes that the concepts under evaluation hold significant promise for
improving both the quality and cost-effectiveness of Pittsburgh’s EMS system, and recommends that these exploratory efforts continue. At the same time, however, the Coordinator has not found that any consensus framework has yet emerged with sufficient clarity and definition to be included as the basis for a quantified savings initiative within this Recovery Plan. As this process continues to evolve, the Act 47 team further notes the following views with regard to certain key considerations:
Clear consensus has emerged that significant opportunities are available to improve EMS revenues through modified billing and collection practices, regardless of the organizational structure adopted for overall service delivery. Consequently, this Recovery Plan does include a specific Initiative EM02 for the immediate outsourcing of EMS billing.
The Municipal Authority model currently under development by the Intergovernmental Cooperation Authority appears to hold promise as a structure for expanding hospital involvement in the EMS system while increasing flexibility to optimize the system’s service mix and fee structure – e.g., special events coverage; geographic expansion; and non- emergency transport. At the same time, this structure would preserve many of the benefits of public sector involvement, including tort immunity and a focus on equitable access to services. The Coordinator believes that it is preferable that this structure be adopted and implemented by a group of the major hospitals in Pittsburgh.
Given current financial strain in the healthcare industry, relatively low medical assistance payments for EMS in Pennsylvania, and the experience of urban systems nationally, it
appears highly likely that an ongoing City subsidy for EMS will be required over at least the next several years regardless of the operational design in place. Proposals for alternative system design that feature little or no direct City subsidy typically rely instead on substantial user subscription charges that are generally equivalent to a new local tax.
Combining the City’s Fire and EMS systems is not recommended. While there are
examples nationally of dedicated individuals in such combined systems working together to achieve positive results, these two, distinct public services feature significant differences that mitigate against full consolidation. For example, high-performing EMS systems typically adopt a system status management approach that varies the number and location of ambulances in service throughout the day on the basis of historical call patterns. Traditional Fire systems, on the other hand, tend to rely on fixed locations, with much less peak period staffing. The logistical and cultural obstacles to merging such distinct operations typically outweigh any benefits of enhanced coordination.
Potential operational savings ranging from $1.0 million to $2.6 million per year have been identified from the incorporation of lower cost Basic Life Support (BLS) ambulances into the overall City EMS system as substitutes for all ALS coverage. This approach merits further exploration, but should be balanced against the impact on flexibility and quality of response.
EM02. Outsource EMS Billing in Conjunction with Restructured Rates
Analysis by the EMS Study Committee has identified multiple opportunities projected to increase net EMS revenues by approximately $2.5 million annually. Accordingly, the City shall move forward to implement the following changes in billing and collection rates and practices:
Improve pre-billing procedures: Ensure that all transports result in a billable patient, obtain demographic/insurance information from all patients, ensure timely billing of transports (within 3-5 days), perform timely and recurring follow-up procedures; incorporate new technologies to streamline and automate such data collection and transmittal.
Bill City residents directly for EMS services, consistent with current billing practices for non- residents. In addition to generating additional cost recovery, this measure will create stronger incentives for system users to cooperate with efforts to collect from third-party insurers.
Increase current EMS rates, which have not been adjusted since 1999 and are below the current market, to the levels proposed by the Study Committee as set forth in the following table. Charge Type Current Fee Proposed Fee % Increase BLS Base Charge 375 500 33%
ALS-1 Base Charge 450 650 44%
ALS-2 Base Charge 450 700 56%
Patient Loaded Mile 9.35 10 7%
Outsource billing and collections. Major cities from coast to coast have successfully improved EMS revenues by leveraging the state-of-the-art billing and collections systems, expertise, and technology through the use of contracted collections. The City shall issue an RFP for EMS collections no later than September 1, 2004, with a new provider beginning service on or before January 1, 2005.
In the aggregate, the Study Committee projects potential revenue gains of $2.5 million annually from the multi-pronged approach outlined above. The Act 47 team has reviewed the
Committee’s findings, as well as vendor analyses of Pittsburgh’s EMS billing and collections. In addition, the Coordinator has reviewed the experience of other governmental billing and collections operations that have successfully transitioned to outsourced operations. For example, through contracted billing in conjunction with ongoing rate structure adjustments, Nassau County, NY increased ambulance revenue collections from approximately $3 million per year in FY2000 to nearly $10 million by FY2003. Based on this review, the Act 47 team believes the $2.5 million projection to be achievable for Pittsburgh, with discounts applied to the first years of implementation to reflect start-up lag and general conservatism.
Discounted Fiscal Impact
FY2004 FY2005 FY2006 FY2007 FY2008 FY2009
Discount % 0% 25% 20% 10% 0% 0%
Fiscal Impact $0 $1,875,000 $2,000,000 $2,250,000 $2,500,000 $2,500,000
EM03. Reevaluate River Rescue
The EMS Bureau leads the City River Rescue unit in conjunction with the Bureau of Police. At an estimated cost of nearly $600,000, two paramedic divers and one police officer provide river- based emergency response on two shifts for approximately five months of the year. The City’s Five-Year Plan indicates that state and federal funding will be pursued in support of this service, given ongoing close coordination with the U.S. Coast Guard and other federal and state
agencies. The Coordinator endorses this approach, and recommends that the City reevaluate the appropriate staffing levels for this service if non-local funding is not available to support current activity.
In addition to the recommended measures detailed above, the Act 47 team has reviewed each initiative proposed by the City in its Five-Year Financial Plan 2004 – 2008, several of which would require increased spending. Where not specifically addressed elsewhere within this Chapter, the Coordinator has assumed that such spending initiatives can be funded, where warranted, from new grants, contributions, and/or reprioritization of existing budgetary resources.
Along with the recommendations outlined above, the following initiative(s) impacting the EMS Bureau are detailed in other sections of this Recovery Plan: