ACA and EMS The implementation of the Affordable Care Act (ACA) is sure to change the way EMS operate in the coming years. Accountable Care Organizations (ACO), for instance, are now responsible for overseeing how reimbursements are paid out to those agencies that provide health care -- and at the same time they are responsible for gauging whether or not quality care is delivered by providers (Koury et al., 2014). This is a tall order for a new functioning body and the ACOs tasked with these orders will have an indirect impact on how EMS operates. To see how that impact will be effected, an examination of the ACOs and hospitals interact requires examination -- because it is that interaction that will inevitably alter the way in which the EMS goes about their business. This paper will examine the relationship between the ACA, ACOs, hospitals and EMS and show how an EMS Administrator might prepare for the changes. Specifically, this paper will discuss the ACA legislation, what Emergency Care means, how insurance coverage is a factor in impacting EMS, where revenues come into play, how sustainability will be a factor to consider over the long-run (with ACA co-ops already closing their doors, the long-run outlook is having a decidedly short-run impact), and how healthcare integration will alter EMS. This alteration will be the main focus of the paper.

ACA Legislation

One of the most direct ways in the ACA legislation impacts EMS is the awarding of "competitive grants for regionalized systems for emergency care response" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). These grants go to 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 is defined as service that provides "acute, prehospital, and trauma care" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). These monies for pilot projects are reserved precisely for networks of care providers, who 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 states that the federal government will grant money to health care providers who work to integrate EMS, hospitals, and tracking services and uniting these entities under a single umbrella. Holding that umbrella will be the federal government, which will collect the data and evaluate the variables that impact prehospital care as well as outcomes related to interfacility actions. The ACA thus sets up local and regional actors to be integrated into a federalized system of care. This may be viewed as akin to what the state governments of the original thirteen colonies underwent when the ratification of the U.S. Constitution presented itself as fact: the matter of states' rights vs. federal authority would no longer be a question -- the federalization of power was made a reality by the consolidation expressed in the Constitution. In the ACA legislation, consolidation is the driving force, and the federal government is the pivot upon which health care providers will turn. As for EMS, the concept of emergency care will likewise undergo a federalization and take on new meaning and new dimensions as a result.

What Emergency Care Means

and How Healthcare Integration Will Change the EMS

Emergency Care according the ACA is that type of service which 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 the ACOs which will monitor the quality of care delivered by integrated health providers, including EMS. With new oversight comes new expectations and a need to conform to new standards and regulations. EMS, for instance, will be expected to alleviate the pressure placed upon hospitals to ensure that quality of care expectations are being met (Ludwig, 2013). This will include obliging EMS to make home calls to patients post-discharge for up to three days in order to reduce the risk of complications arising and patients needing to be re-admitted. Re-admittance is a factor that will serve as a red flag to ACOs and cause hospitals to lose reimbursement funds that would otherwise be granted them through the ACA.

This in turn would burden EMS with the need to be part of an integrated tracking system that monitors where patients have been recently and which facilities are willing to accept them (Ludwig, 2013). In other words, the ACA and the ACOs will ultimately place greater restrictions on hospitals by demanding specific bureaucratic goals be met that will in turn cause EMS (intermediaries in emergency cases) to shoulder the responsibility for helping hospitals and other healthcare facilities to comply with ACO regulations so that the latter might not lose out on federal reimbursement monies. This sets the stage for a number of potential dramas -- none of which will appeal to an EMS Administrator. First, it ups the ante on fraud. Medicare fraudulence is most prevalent among hospitals and healthcare providers/facilities precisely because of hospitals' need for reimbursement (Hill et al., 2014; Iglehart, 2010). Healthcare costs are not made more affordable by the ACA -- but more pressure is placed on providers to give regulators and overseers like the ACO the impression that quality care is being given so that they can receive federal funds (Ludwig, 2013).
The main issue here is that some patients with whom EMS is continually in contact are patients who use ED services in order to secure Medicare coverage because normal healthcare providers refuse to treat them. Such patients allow medications to run out and rely upon EMS to transport them to hospital EDs. Now, with ACOs placing restrictions on the number of times a patient may be readmitted within days of discharge in order for reimbursement of Medicare to be given, hospitals will look to steer such patients away -- even from EDs. This puts EMS in an unenviable position of having to find a facility that will accept patients whose situation is such that they only receive Medicare if they can find a provider who can afford to treat them continuously.

Thus, healthcare integration will cause EMS to pursue slightly different aims in the future, having to adjust to the needs of hospitals seeking to avoid being blacklisted from federal funds as a result of missing ACO guidelines. EMS will be on the receiving end of this adjustment, being forced to adjust the manner in which the deliver patients in need of emergency services and care. As Alpert et al. (2013) report, somewhere between 12% and 16% of all EMS runs result in patients who may be safely delivered to non-ED destinations because of the nature of the calls. The issue according to Alpert et al. (2013) is that EMS should be reimbursed both by Medicare and private insurers for redirecting patients to destinations where they will receive adequate care. Hospitals would also support this arrangement as it would solve an issue related to reimbursement and ACO oversight on their end. The issue is complicated, however, by the nature of the ACA itself, and how the Supreme Court has interpreted it -- as both a law and a tax -- and all agencies and individuals are impacted by this decision, which has many scrambling to make sense of how and whether they should and can afford to comply with recommendations (Hall, 2013).

What an EMS Administrator Can Do

Recommendations for an EMS Administrator include taking into consideration this alteration and being prepared for when it happens (Ludwig, 2013). As Eckstein (2013) reports, "the need for EMS will increase dramatically over the next several years as more Americans gain health insurance under the Affordable Care Act" (p. 2068). Indeed, this increase is likely to "generate approximately 900,000 additional emergency department visits annually" (Eckstein, 2013, p. 2068). Where this become an issue is at the EDs, where individuals will ultimately need to be delivered. If hospitals are not admitting patients with too frequent ED visits, the problem begins to weigh on EMS and the type of service they are expected to provide. As Eckstein (2013) observes, "government-provided health insurance rates of reimbursement do not lend themselves to a successful business model, especially one in which lives are on the line" (p. 2068). The question that EMS Administrators will have to answer is whether their ambulance services can survive in such an economic climate, where the incentive to avoid treating expensive patients becomes all too…