ACA Impact on EMS: Integration, Revenue, and Sustainability

The implementation of the Affordable Care Act (ACA) is sure to change the way EMS operates in the coming years. Accountable Care Organizations (ACOs), for instance, are now responsible for overseeing how reimbursements are paid out to agencies that provide health care — and at the same time they are responsible for gauging whether quality care is delivered by providers (Koury et al., 2014). This is a tall order for a newly functioning body, and the ACOs tasked with these responsibilities will have an indirect impact on how EMS operates. To understand that impact, it is necessary to examine how ACOs and hospitals interact, because it is that interaction that will inevitably alter the way EMS goes about its business.

This paper examines the relationship between the ACA, ACOs, hospitals, and EMS and shows how an EMS administrator might prepare for the changes ahead. Specifically, it discusses the ACA legislation, what emergency care means, how insurance coverage impacts EMS, where revenues come into play, how sustainability will be a long-run consideration (with ACA co-ops already closing their doors, long-run concerns are having a decidedly short-run impact), and how healthcare integration will alter EMS. This last point — healthcare integration — will be the main focus of the paper.

One of the most direct ways the ACA legislation impacts EMS is through the awarding of "competitive grants for regionalized systems for emergency care response" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). These grants provide monetary support to local or regional pilot projects "that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care and trauma systems" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). Emergency services are defined as those providing "acute, prehospital, and trauma care" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). These funds are reserved for networks of care providers that form an integrated emergency services care plan — complete with transports, facilities, tracking resources, and an interfacility data management system that "submits data to the National EMS Information System" among various other agencies (ACA, 2010, Sec. 1204, 124 STAT., p. 519).

In short, the legislation holds that the federal government will grant money to health care providers who work to integrate EMS, hospitals, and tracking services under a single umbrella. The federal government will collect data and evaluate variables that impact prehospital care as well as outcomes related to interfacility actions. The ACA thus positions local and regional actors to be integrated into a federalized system of care. This may be viewed as analogous to what state governments underwent when the U.S. Constitution was ratified: the matter of states' rights versus federal authority was settled by the consolidation of power at the federal level. In the ACA, consolidation is likewise the driving force, and the federal government is the pivot upon which health care providers will turn. For EMS, the concept of emergency care will also undergo a form of federalization, taking on new meaning and dimensions as a result.

According to the ACA, emergency care is the type of service that provides acute, prehospital, and trauma care for individuals. However, as the legislation is enforced and regional and local providers begin to integrate and compete for federal grants, this definition is likely to incorporate new concepts and be expanded to fit the needs of ACOs, which will monitor the quality of care delivered by integrated health providers, including EMS. With new oversight comes new expectations and the need to conform to new standards and regulations. EMS, for instance, will be expected to help alleviate the pressure placed on hospitals to ensure that quality-of-care expectations are being met (Ludwig, 2013). This will include requiring EMS to make home visits to patients post-discharge for up to three days in order to reduce the risk of complications and readmissions. Readmittance will serve as a red flag to ACOs, causing hospitals to lose reimbursement funds that would otherwise be granted under the ACA.

Additionally, EMS will be encouraged to take patients to separate care providers or different levels of care facilities so that the same hospitals are not repeatedly tasked with accepting the same patients — which would also cause hospitals to lose Medicare reimbursements under ACO guidelines. This would burden EMS with the need to participate in an integrated tracking system that monitors where patients have recently been and which facilities are willing to accept them (Ludwig, 2013). In other words, the ACA and ACOs will place greater restrictions on hospitals by demanding that specific bureaucratic goals be met, which will in turn cause EMS — as intermediaries in emergency cases — to shoulder responsibility for helping hospitals and other healthcare facilities comply with ACO regulations so that the latter do not lose federal reimbursement funds.