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9 Improving Emergency Medical Services for Children: Looking to-the Future Comprehensive. care for illness and injury in..~hildren includes orga- nized and co.ord~nated systems of emergency medical services (EMS) that can provide~timely access to appropriate forms of care As.this report sho.w.s,'however, throughout most of the country the ability to provide that car.e~to children is limited by lack of attention to children's unique needs in emergency care. The report has addressed in detail certain areas where significant steps must be taken to ensure that children's emergency care needs can be met. The committee is concerned that other. important issues affecting .emer- gency medical services for.children (EMS-C) have not been addressed. A systematic assessment of benefits and costs of EMS-C is needed, :but seri- ous conceptual arid practical questions remain unanswered. Matters of.health care reform, access to primary care, and pressures on emergency care facili- ties and providers.are..of considerable significance for EMS-C but lie be- yond the scope of ethos Committee's charge. Nevertheless, they should not be overlooked. Tllis chapter briefly examines certain major issues that form the backdrop against which.the committee's recommendations will.h~ave to be played out. BENEFITS AND COSTS In an era of severe budget constraints at the national, state, county, and municipality levels, the difficulties of paying for programs such as EMS and EMS-C loom large. To persuade officials to find the necessary funds, 321

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322 EMERGENCY MEDICAL SERVICES FOR CHILDREN some estimates of the costs of the programs and the benefits expected from them ought to be generated. Ideally, both costs and benefits would be precise and methodologically defensible, would cover many different types of costs and benefits, and would be denominated in dollars. Practi- cally, costs (and expenditures) can be difficult to calculate, particularly across the many different activities, settings. and types of personnel en- countered in EMS and EMS-C, furthermore, separating out EMS-C costs from those for EMS poses an especially great challenge. Benefits are even more difficult to define and measure; in addition, they can almost never be couched in dollar terms. Instead, they have to be stated in terms of mea- sures of effectiveness and outcomes, such as lives saved, debilitating im- pairments averted, illnesses and injuries prevented, or time to complete recovery reduced. In principle, then, this committee would have liked to develop estimates for costs and benefits of EMS-C; in practice, it determined that at this stage, doing so was fraught with too many drawbacks and limitations in the knowledge base. Work is needed to resolve these problems. Offered here is a discus- sion of some key issues in addressing benefits and costs. Benefits Most of what has been documented about the benefits of emergency care for children concerns reduced morbidity and mortality from injury (see Chapter 2~. Some measures are applicable to adults and children. Assess- ments of preventable deaths are often used to evaluate the effectiveness of trauma centers (as remarked in Chapter 7J. Other, indirect measures include less delay in reaching definitive care and reductions in suboptimal care, from which inferences are made about long-run benefits to health and well- being. Other outcome measures commonly used for adults include return to productive activities (chiefly work, especially the same work as held before a severe injury or illness) and extent of recovery of physical and cognitive functioning. Depending on the age of the pediatric patient, these types of measures may be fairly appropriate (return to regular, full-time schooling, for instance, as a substitute for work-related activities) or fairly implausible (cognitive functioning in an infant). As in many other areas of health services and health policy research, however, the appropriate measures of benefit for children in health-status and quality-of-life terms are not well developed. Benefits also may be estimated in terms of costs of health care that might not be incurred (by virtue of preventing or reducing the morbidity that results from trauma or illness) and in terms of incomes earned over a productive lifetime that might otherwise not be earned. These costs can be

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IMROVING EMS-C: LOOKING TO THE FUTURE 323 more difficult to conceptualize and certainly more difficult to measure for children than for adults. Making lifetime estimates of such variables re- quires major assumptions about length of life, other health events that may occur during that lifetime, earnings, and rates of discounting future dollars (or indeed any benefits) to the present (which is, in effect, when the EMS funds will be spent)' all such assumptions are likely to be more heroic in studying children than in studying adults. These points are essentially technical, methodologic issues ones that make benefits difficult to estimate accurately. There is no question, how- ever, that benefits of EMS systems can be demonstrated, at least for adults suffering major trauma. For example, Shackford and colleagues (1986) compared the frequency of suboptimal care and preventable deaths of major trauma victims before and after the establishment of a regionalized trauma system. Suboptimal care occurred in 32 percent of the cases before the system was instituted and in only 4 percent of cases afterward; of deaths, the proportion judged preventable dropped from 14 percent to 3 percent. Champion et al. (1992) reported that the presence of a trauma center re- sulted in 13 more survivors per 100 patients treated per year among those patients with high injury severity scores. On the basis of those findings the authors estimated that 6,900 lives could be saved annually by having trauma centers nationally. Translating these figures into concrete estimates for children is not straightforward. What can be said, however, is that deaths among children account for the loss of many more years of healthy life or quality-adjusted life years than do deaths among adults. Thus, good EMS and EMS-C programs can be expected to have very great impact for children, in terms of productive lives saved, disability and impairment forestalled, and other problems averted. Benefits of injury prevention programs have been documented as well. For example, through an energetic and effective nationwide injury preven- tion effort, Sweden reduced the rate of fatal injuries in 1- to 4-year-olds from 55 per 100,000 population (in 1957-59) to 7 (in 1986) (Bergman and Rivara, 19911. As noted in Chapter 6, the "Children Can't Fly" initiative in New York City, through several different tactics (installing window guards in houses, enacting legislation requiring such guards, and conducting vari- ous educational and outreach efforts), reduced falls from windows by 50 percent (Speigel and Lindaman, 1977; National Committee for Injury Pre- vention and Control, 1989~. A study in Ontario, Canada, documented a high incidence of unsurvivable injury (owing to the severity of the initial injury) and concluded that over the long run, "promotion of injury preven- tion programs will likely prove more cost effective in reducing injury mor- bidity and mortality than any changes in trauma care systems" (Dykes et al., 1989, p. 7291.

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324 EMERGENCY MEDICAL SERVICES FOR CHILDREN Despite these encouraging facts as well as the many advances in EMS- C documented in this report, the dearth of information about the benefits, in terms of health outcomes, of EMS-C programs per se is clearly a hindrance to developing quantitative estimates of cost-benefit or cost-effectiveness ratios. This is one reason that so much emphasis was put on patient out- comes (and costs) in developing the research agenda for EMS-~. What clinical expertise, personal observation and experience, and common sense tell us now about the value of EMS-C can then be rendered in monetary terms better suited for making programmatic and funding decisions. Costs and Financing Costs and financing issues rank in significance with patient outcomes and benefits. The committee has argued for a concerted initiative in the public and private sectors at the national, state, and local levels to expand EMS-C programs across the country. In the committee's view, this must happen by ensuring that EMS-C resources and planning become integral elements of the broader EMS scene; further, EMS-C must be solidly linked to broader child health concerns. However, in a period of growing anxiety about costs of care and rising inability of the nation to believe it can pay for the health care system it has now and wants to maintain, such calls for expansion of one portion of that system must acknowledge that funding such efforts will require difficult trade-offs between many worthy pro- grams. The public sector is severely affected by fiscal constraints. The private sector is also affected, and this includes health care organizations, facilities, and individuals (i.e., the providers of emergency care services and the con- sumers of those services). Hospitals, particularly trauma centers, face seri- ous reimbursement problems. For example, reimbursements based on diag- nosis-related groups tend to underestimate the level of care required for victims of major trauma; the numbers of uninsured patients are not decreas- ing and may indeed be increasing; and trauma center costs cannot be cov- ered, with cross-subsidies less available and~infusions of state funds less likely. Reimbursements for primary care are also problematic, and to the extent that they are very low in the Medicaid program, they are a disincen- tive for office-based physicians to accept Medicaid patients and an incen- tive for such patients to continue to rely on hospital emergency departments (EDs). One conclusion to be drawn from all these factors is that a partnership between the public and private sectors will be required neither can handle the costs alone. It is partly for this reason that the committee has advocated an agency-plus-advisory-council structure that deliberately involves the pri-- vate sector.

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IMROVING EMS-C: LOOKING TO THE FUTURE 325 The committee's desire to see EMS-C incorporated into the larger EMS system means that EMS-C funding mechanisms must largely reflect existing arrangements. The merits of those funding mechanisms and any alterna- tives which include public funds drawn from general revenues and special fees, fee-for-service charges (which may or may not be covered by insur- ance), excise taxes or fees for 9-1-1 telephone service, subscription drives for private services, as well as reliance on volunteers as providers of prehospital services and medical control should be assessed. Beyond simply financing EMS and EMS-C programs lie additional costs for training and for equipment and supplies; these are a particular concern when EMS systems are trying to expand in ways that will provide high- quality EMS for children. Moreover, other activities advocated by this committee related to planning, evaluation, quality assurance and improve- ment, and research (data collection and analysis, in particular) are all sig- nificant programmatic efforts that can consume equally significant amounts of money. They are, however, essential for ensuring that EMS systems provide clinically sound care in an efficient and cost-effective manner. In short, meeting all these monetary needs will be a major challenge one that the committee believes the national and state advisory councils should con- sider placing high on their respective agendas. They will need to do so in full recognition that aggregate outlays for health care are high and growing more rapidly than the economy as a whole and that reallocations of health- sector dollars among competing needs may be the likely near-term solution. A CHANGING HEALTH CARE ENVIRONMENT The health care system within which EMS-C exists faces significant questions regarding its shape and structure in the future. Although EMS-C concerns are not likely to determine the answers to these questions, EMS-C will certainly be affected in important ways by the decisions that are made. Health care reform promises to have the most far-reaching effects, but in- creasing pressures on hospital EDs are a more immediate concern. The committee found it neither feasible nor appropriate to address these larger issues in detail, but it was unwilling to ignore them and their possible implications for EMS-C. They are briefly explored below. Health Care Reform No one confronting health care policy and delivery issues today can fail to notice the intense debate about health care reform now occurring in this nation. Whatever directions reform takes, it can be expected to have an impact on EMS-C, and most experts argue for special attention to the health needs of children in whatever reforms are made. Those calls tend to focus

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326 EMERGENCY MEDICAL SERVICES FOR CHILDREN on primary care, however, and some on the committee thus were concerned that EMS-C might not command the attention it deserves. Arguably the most pressing issue confronting the health care system today is the continued upward escalation in health care expenditures and costs of care (or, more precisely, the continued growth in the rate at which expenditures increase). Spending levels in this cot try are expected to be name than $gO3 hilltop in 1993 (14.4 percent of the nation-s gross domes- tic product tGDP]) and nearly $1,740 billion (18.1 percent of GDP) in 2000 (Burner et al., 1992~. These figures well outstrip health care expen- ditures of other industrialized countries. The disparities in spending have not, however, translated into better (or sometimes even equivalent) cover- age of the population, nor have they given us better health outcomes as reflected in standard population indices such as the infant mortality rate. Furthermore, virtually every part of the health care sector has experienced increases in expenditures both the private and public sectors, both fee- for-service and prepaid capitated systems, and both inpatient and outpa- tient care. Increases in employers' group health insurance premiums have been very steep in recent years, although the upsurge may have been dampened by other changes in the health insurance picture; these include more utilization management, more health maintenance organizations (HMOs), preferred provider organizations, and point-of-service plans, and greater cost-sharing by employees. The other leading concern is access to care that is, the ability of indi- viduals needing health services to recognize that need and to seek and obtain appropriate care in a timely way. These elements are hallmarks of emergency care. Appropriate care might be thought of as necessary and effective care that can maintain or improve the health status and quality of life of individuals and populations. Some of the barriers to that care lie in residence, language, cultural values and expectations, and the presence of impairments or stigmatizing diseases. More fundamental concerns for access, however, are problems that have been clear for some time: something approaching 35 million, perhaps even 40 million, people in this country have no or at best sporadic health insur- ance coverage and concomitant poor access to care; the bulk of those indi- viduals (although clearly not all) are from poor families; and this lack of access affects children hardest. These are not new problems what is new is the erosion in health insurance benefits that the middle class once took for granted and the apprehension that health care may not be available, or at least affordable, should it be needed. Demographic and socioeconomic factors contribute to the challenges facing our health care system. The "graying of America" reflects the fact that an increasing proportion of the population is over the age of 65; it raises concerns about the large number of the elderly who live alone, the

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IMROVING EMS-C: LOOKING TO THE FUTURE 327 aging of this population itself, and the remaining high levels of poverty among the elderly. Some suggest that emergency care for the elderly de- serves attention much like that being recommended by the committee for EMS-C (Sanders, 19921. Moreover, the proportion of the total population accounted for by immigrants and nonimmigrant minorities is growing, and differences in socioeconomic and health factors between blacks and lIis- pa;nic groups, on the one hand, and the white population, on the other, are dramatic. Families themselves are changing; single-parent households, non- traditional households of various sorts, and homelessness are all on the rise. Patterns of illness are changing. The control of many infectious dis- eases and the emergence of chronic illness has shifted most deaths to later ages. Some implications seem clear: death is a less relevant endpoint to measure; health-related quality of life is a more salient one. The same can be said for the emergence of impairments and disabilities we save more people from genetic illness and life- or limb-threatening injuries, for ex- ample, leaving them to live longer lives but often of poorer quality. Super Imposed on this picture Is a complex set of sociomedical problems ac- quired immune deficiency syndrome (AIDS), use and abuse of illegal drugs, alcohol, and tobacco, and both interpersonal and intrapersonal abuse and violence. Some of these (especially the last) have immense ramifications for EMS in general and EMS-C in particular. Something else is changing: people's attitudes toward health and health care services. People expect to be able to exercise some autonomy and to express their preferences about how they will be cared for. This means they expect to be informed about all reasonable options open to them and what the benefits and risks of those options are. Although patients with life- threatening emergencies typically are not physically capable of entering into decisionmaking or expressing preferences, other patients requiring emer- gency care, the families of patients, and perhaps especially the parents of acutely ill or injured children may well have concerns in this regard. EMS and EMS-C systems around the country must, therefore, consider these points. The number of health care reform proposals circulating in Washington by year-end 1992 was large and growing (AMA, 1991; Blendon et al., 1992), with most observers expecting a landmark reform proposal to be introduced by the incoming Clinton Administration by spring 1993.i Fur- thermore, action on the state level is accelerating (Blue Cross of California, 1992; IlIPP, 1992; Iowa Leadership Consortium, 1992~.2 Some plans are quite comprehensive, others narrowly focused, and some are quite well thought out and others less so, but all appear to take a long-term view of improvement of the health care system. Significant reform will require painful choices for many parties and trade-offs among several desirable objectives. It will also demand that a considerable array of difficult topics be competently addressed: who pays;

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328 EMERGENCY MEDICAL SERVICES FOR CHILDREN what are the covered benefits; who makes the rules; how universal is cover- age and access; how best should we reach special populations in need; how will we contain costs; how can we maintain and enhance the infrastructure for health care (e.g., the information and knowledge base; health personnel and facilities); how central do we want characteristically American prefer- ences for diversity and choice to be and how can we maintain, if not Me, the quality of health care and the value received for our health care dollar. Answering these questions will have immense ramifications for EMS and EMS-C. This committee takes the position that those responsible for the future of EMS and EMS-C must become knowledgeable in the technical aspects of health care reform proposals.3 The proposed national advisory council (and state councils in those states where significant reform changes are under way) could easily be expected to track these issues carefully to ensure that the interests of EMS-C and EMS more generally are reflected in national or state reform bills. Because, in the committee's view, EMS-C should also operate against the broader background of children's health care, how (and how well) proposals for restructuring the health care system attend to particular needs of children will be especially important (NRC/ IOM, 1992a). Special Challenges for EMS Systems Regardless of the outcome of the health care reform process, EMS-C must contend with more immediate challenges that arise out of problems facing EMS and the larger health care community. The Demand for Emergency Services EMS systems, particularly in major urban areas, face increasing de- mand for their services, often in circumstances in which emergency care resources are scarce or overburdened. In some areas of the country, the call for ED and inpatient care exceeds the capacity of the hospitals in question, making it difficult for them to provide optimal care.4 In rural areas, prehospital EMS providers may need to serve large regions with limited staff and equip- ment. Moreover, lack of 24-hour physician coverage in EDs and loss of ED services secondary to the closure of small rural hospitals (200 between 1980 and 1988 alone) place increasing demands on the remaining prehospital providers (OTA, 1989; GAO, 1991a). In urban areas, hospitals and EDs are closing as well, often because of, or to avoid, the financial burden of un- compensated care, particularly for trauma patients (GAO, l991b). To the extent that Medicaid eligibility is broader for children than for adults, the financial risk from potentially uncompensated emergency care of children

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IMROVING EMS-C: LOOKING TO THE FUTURE 329 may be somewhat less than for similar care of adults (Mitchell and Remmel, 1992~; in practical terms, however, this may turn on whether persons eli- gible for Medicaid (or parents for their children) have actually enrolled in the program. Overcrowding in remaining EDs and in hospitals results in long waits for care and even long delays ire providing beds to patients requiring inpa- tient care (Andrulis et al., 1991; Baker et al., 1991; Bindman et al., 1991, GAO, 1993~. Such delays may be attributable in part to increased visits for violent acts, illegal drugs, alcohol use, and AIDS-related illnesses as well as to hospital occupancy rates above 60 percent (GAO, 1993~. Some EDs in seven major cities report responses to overcrowding such as refusing to accept transfer patients and even refusing to receive any ambulance pa- tients; for patients seen in some of these EDs, waiting time for beds was more than a day (sometimes several days) (Andrulis et al., 1991~. Emergency Care Personnel Emergency care providers themselves are among the scarce resources in EMS. The loss of volunteer emergency medical technicians (EMTs) and paramedics, who are the only providers of prehospital care in some locali- ties, is a special concern for some EMS systems (OTA, 1989; McHenry, 1991~. The GAO (1993) reported that nursing shortages in the ED were significant factors in delays for physician examination and for transferring admitted patients to inpatient beds. Stresses associated with the demands of emergency care are contributing to loss of providers and difficulties in re- placing them. Work stress has been documented among all levels of provid- ers EMTs and paramedics, nurses, and physicians (McHenry, 1991; Neale, 1991; Back, 1992; Gallery et al., 1992~. Providers are increasingly con- cerned about violence in the community and even in the ED (Keep et al., 1992), as well as about the risk of infection from treating patients carrying dangerous diseases. Caring for children is often reported to be extremely stressful, a situa- tion of particular concern for EMS-C. In fact, the critical-incident stress debriefing program in Virginia's EMS system has found that.40 percent of its debriefings are related to the death of a child or adolescent, and only 26 percent to adult deaths (McHenry, 1991~. As the roles of EMS and EMS-C evolve, these work force issues must receive serious attention. The Impact of "Anti-Dumping" Regulations Hospitals, EDs, and EMS systems are facing concerns over the impact of requirements for minimum levels of care and appropriateness of transfers of patients between facilities. Since August 1986, federal legislation (the

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330 EMERGENCY MEDICAL SERVICES FOR CHILDREN Consolidated Omnibus Budget Reconciliation Act of 1985 ECOBRA] and the Omnibus Budget Reconciliation Act of 1989 [OBRA]) has required that hospitals that meet Medicare "conditions of participation" must evaluate any unstable patient or woman in labor (regardless of insurance or payment status) who arrives at the hospital's ED. A hospital must (within its staffing ails ~plllc~lt ~1~) UO WHal IS neGeSSary to stabilize the patient LEA ~.~;~ ~ ~_~:1:~: _ x I _ 1 before transferring that patient to a different facility, a mandate set in place to counter inappropriate transfers for economic reasons (a practice widely characterized as patient "dumping". The legislation poses several complexities for individual hospitals and for an integrated EMS system, in which transfers can play a considerable role. First, the level of service required before a patient can be discharged or transferred may not be clear; for hospitals with comparatively minimal EDs or with extremely overcrowded EDs, pressures for staffing and equip- ment (and consequent costs) may be intense. Second, acceptable grounds for transfer or refusal of further care need to be defined clearly. Cases in which the primary reason for the transfer is explicitly identified by the sending facility or physician as "indigent" or in which no specific reason is given are certainty suspect. but many oth~.r An mew he 1~c rmn~lil_ sive. , . __J _ _~< _ _ - ~ _- ^~} ~ BAA- ~- ~1110) Em 1 ~ll~lU Third, who makes the assessment to determine that a patient is stable (and able to be transferred) or unstable (and thus eligible for care in the original facility) may be a critical factor. Decisions may differ depending on whether the assessment is made by a physician or a nurse, or whether the clinician making the assessment has special training in emergency medi- cine. Fourth, dumping can be a particular problem for pediatric tertiary centers. In particular, referring hospitals can claim that they are transfer- ring patients to a higher level of care (i.e., a solely pediatric institution) when the reasons may be more economic than medical. Fifth, COBRA and OBRA can complicate efforts to make appropriate referrals to primary care providers, if ED obligations to patients without a need for emergency care are not clear. The demands created by these requirements along with the financial burden of inadequately reimbursed care are leading some hospitals to limit us snare one emergency services they provide. Thus, the net effect may prove to be a reduction in the health care resources available to the very patients whom the legislation was intended to help. Again, the committee did not explicitly take up the topic of evaluating the impact of COBRA and OBRA on EMS and EMS-C in part because their overall impact is still not well documented or understood and in part because doing so would have exceeded its charge. As with other matters raised here, the committee suggests that the proposed national advisory council might be well advised to consider this issue. ~ _ _ 1 _ ~_ . _ , 1~

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IMROVING EMS-C: LOOKING TO THE FUTURE The Role of Primary Care 331 Although some (possibly most) of the demand for emergency care is associated with real needs for that level of care, many other patients seek care in emergency settings for conditions that could be treated successfully all a primary care setting. This [act s~gxiif~GaIl~ly complicates the ability of EMS systems to respond appropriately or adequately to all patients. The GAO (1993) reports that from 1985 through 1990, visits to EDs increased 19 percent overall, chiefly in hospitals with fewer than 100 beds (30 per- cent) and in rural or small urban areas (respectively, 27 and 24 percent). Of the nearly 100 million ED visits in 1990, only about 17 percent were for clearly life- or limb-threatening (emergency) problems; about 40 percent were for urgent problems (needing treatment within 12 hours but not threat- ening life or limb). The remaining 43 percent of patients did not need immediate care and could probably have been treated in a physician's of- fice, but lack of a primary health care provider was the main explanation for ED use. Lack of primary care increases the numbers of patients using emer- gency services in two ways. When children (or adults) do not receive appropriate treatment early in the course of an illness, their condition can deteriorate to a point at which urgent care is necessary. Lack of basic preventive care such as immunizations also contributes to this need for ED care. In addition, when primary care is unavailable (or difficult to obtain), parents seek care in the ED for their children's minor illnesses and injuries. (Conversely, however, providing alternative, accessible primary care ser- vices can change ED use tPaneth et al., 19791.) Many factors can make primary care services difficult to get, particu- larly for working-poor and low-income families who may lack health insur- ance altogether. On a very practical level, clinic and office-based services may be unavailable in the evening, on weekends, or when working parents would more easily be able to bring their children for care (Glotzer et al., 1991~. This leaves the ED as the most recognizable source of care. Even among families with adequate income and health insurance, the ED may serve as a backup to regular sources of care (Chessare, 1986; Smith and McNamara, 1988; Yarboro, 1990), and for some, the ED may be especially appealing when their primary care visits are not fully reimbursed by insur- ance. Insurance coverage for ED visits and not for physician visits is a strong financial incentive to use an ED rather than a primary care provider. Transportation obstacles or appointment requirements may discourage use of a primary care provider by an anxious parent who is able to reach the ED more easily. For some parents, lack of telephone service is a barrier to use of appointment-based services. Difficulties in obtaining primary care services under Medicaid pose

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332 EMERGENCY MEDICAL SERVICES FOR CHILDREN special challenges to the EMS system (particularly EDs). Low reimburse- ment levels and a high administrative burden are limiting the number of physicians willing to participate in the program. Between 1978 and 1989, surveys found that the proportion of pediatricians caring for at least some Medicaid patients dropped from 85 percent to 77~?ercent (Yudkowsky et al., +1990~. The-average Medicaid reimbursement for a well-child visit was only 53 percent of their usual fees (Yudkowsky et al., logo) and was roughly 80 percent of Medicare rates for comparable office visits (McManus et al., 1991~. Perhaps not surprisingly, growth in ED use between 1985 and 1990 was greatest among Medicaid patients (34 percent) (GAO, 1993~. Higher reimbursement rates may increase the willingness of physicians to participate in Medicaid, but increased participation will improve access to care only if the additional services are in areas (such as inner cities) where patients can use-them (McManus et al., 1991; Margolis et al., 1992~. Furthermore,t barriers to enrollment must still be overcome. Factors such as lengthy and detailed application forms, documentation requirements to verify information supplied, literacy and language difficulties, as well as the com- plexity of the Medicaid program itself (with multiple eligibility categories and income scales), lack of automation of the eligibility determination pro- cess, lack of outreach to provide assistance to potentially eligible individu- als, and inadequate staffing in the Medicaid offices have been found to hinder Medicaid enrollment in the District of Columbia (GAO, 1992~. Many of these problems are doubtless generalizable to other states and localities. A Changing Role for Emergency Departments? Nowhere are these issues current demands on hospitals and the avail- ability" of primary care for children felt more keenly than in the nation's EDs. As we have seen, many children, particularly those from disadvan- taged families but increasingly middle-class children, lack adequate access to primary care and preventive services. EDs are called on more and more to provide those services. Several questions can be raised about this trend: Is this an appropriate role for EDs? Are they now equipped to fulfill it? If not, should they be? Some proponents of a wider responsibility for EDs argue that patients in the pediatric age group will continue to constitute a significant portion of their workload. They take the view, therefore, that EDs ought to be pre- pared to render a broader range of services, specifically including those that are traditionally thought of in terms of office-based or clinic practice (such as immunizations). EDs may provide important care that children would not otherwise receive and may serve as a gateway to other health and social services that now reach entirely too few pediatric patients. In fact, several communities participating in a federally assisted effort to increase early

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IMROVING EMS-C: LOOKING TO THE FUTURE 333 immunization of children have included ED access to immunization ser- vices in their plans (Woods and Mason, 1992~. To the extent that children receiving nonurgent care are insured (at least by Medicaid) and services are reimbursed by third parties at levels suffi- cient to cover the ED's costs, having the capacity to deliver primary care services may make it easier or more affordable for hospitals to acquire and maintain high-technology equipment and to have adequate numbers of spe- cialists on the staff to cover true emergencies around the clock. Most agree, of course, that this is an expensive way to provide primary care. As was noted above, however, the financial incentives for patients and providers do little to encourage greater use of''primary care: private insurance is more likely tat cover ED visits than primary care visits and Medicaid reimburse- ment's~ to primary care providers are '-significantly below their usual fees for ~ in. .. . Ottlce VlSitS. Others see little future in reshaping '' the role of the ED. The sheer' impossibility of doing so, for already overstretched EDs in urban hospitals that cannot cope today with the volume of severely ill and injured patients they see, is one argument against trying to expand the role. Providing additional services to uninsured populations is clearly not financially viable for any sustained period. In facilities where maintenance of even standard ED capabilities (let alone capacities for, say, advanced trauma care) is threatened by increasing demand for basic emergency services, any move to greater primary care functions for the ED is likely to be unsustainable. The loss of core emergency care functions in an effort to address a broader social need is clearly not the outcome that the EMS and EMS-C communities would desire. Some make a different argument against expanding primary care services in EDs: providing those services because society will 'not talce the steps to underwrite primary care in traditional settings simply postpones a day of reckoning about how this nation will care for its' younger genera- tions. There was no consensus on these issues among the members ' of the com- mittee, and addressing them formally was beyond the scope of the committee's charge. Nevertheless, the dilemma is clear. In some locales, primary care provided in hospital EDs may permit EMS-PC interests to thrive; in others, primary care may swamp ED resources and erode capacity to meet true emergency needs. In the short term at least, it will not be possible to expand the primary care system quickly or broadly enough to' relieve bur- dens on hospital EDs, and those now under stress will doubtless continue to experience problems. The committee did agree that the role of the ED in health care delivery in general and the implications of that role for delivery of genuine emer- gency care should be addressed explicitly in studies that may be done on the future of primary care, the future of case management and managed care

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334 EMERGENCY MEDICAL SERVICES FOR CHILDREN programs, the future of trauma systems, and the future of the American hospital. Similarly, it agreed that, as the role of EDs evolves, the ramifica- tions for education and training of professionals who staff EDs will need to be better understood. FINAL THOUGHTS Attempts to ensure that children receive adequate emergency medical care are a recent development in the field of EMS. This committee takes the position that EMS-C efforts in the future must consider all the elements that constitute good emergency care and good health care generally, work- ing through channels in both the public and private sector. The needs of children must be more widely recognized and made a genuine priority for policymakers at national, state, and local levels, particularly those in a posi- tion to influence the future directions of EMS and EMS-C. The committee intends for the conclusions and recommendations presented in this report to foster increased public attention and action at the highest levels toward an EMS-C system for the 21st century in which all parties can be confident and all can be proud. . NOTES 1. This report went to press before the Administration's health care reform proposals had been made public. The main outlines for this plan indicated it would be a form of managed competition under the discipline of global budgets, in which "health insurance purchasing cooperatives" (HIPCs) across the country would offer "accountable health plans" (AHPs) to most, if not all, individuals in their respective regions. AHPs might be expected to take the form of large managed-care organizations, sometimes referred to as Super-HMOs. AHPs would compete in part on the basis of a standard basic benefit package, which would be established by a National Board. Exactly where EMS services would fit in this benefit pack- age is unclear. Many observers expect that the basic benefit package would emphasize pri- mary care more comprehensively than in the past; if this is so, such an approach might dampen the current demand on EDs to provide primary care services. 2. The Robert Wood Johnson (RWJ) Foundation has taken a major lead in state health care reform, in a move perhaps reminiscent of its leadership in the EMS arena of two decades ago. RWJ will award sizable grants to 12 states (Arkansas, Colorado, Florida, Iowa, Minnesota, New Mexico, New York, North Dakota, Oklahoma, Oregon, Vermont, and Washington) to develop innovative ways to expand health insurance coverage and contain costs; program outcomes will be tracked over several years by an evaluation team headed by staff of the RAND Corporation and the Urban Institute. 3. In Assessing Health Care Reform, the Institute of Medicine gave its perspectives on health care reform to help clarify the critical issues in the debate (IOM, 1993b). Necessary steps include the following: making insurance compulsory if universal access is a goal; ending medical underwriting and continued segmentation of the risk pool if the private insurance market is to be a responsible part of the financing of health care; developing clearer and more realistic estimates of expenditures and genuine options for financing and for cost containment; enhancing efforts in quality assurance and improvement and practice guidelines; and attending

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IMROVING EMS-C: LOOKING TO THE FUTURE 335 to certain infrastructure issues such as education and training for health care personnel, the future of public health programs, the knowledge base, and health services research. Two other IOM reports examine specific issues in greater detail. One addresses the complexities of employment-based health insurance, with particular emphasis on financing and cost-contain- ment options (IOM, 1993c). The second identifies indicators of access to care, which will aid in evaluating progress in implementing health reform plans (IOM, 1993a). 4. Services from pediatric intensive care units (PICIJs) are also at ~ premium. As noted elsewhere in this report, about 300 PlCUs with about 2,900 beds operate across the country (American Hospital Association, 1991). One analysis indicates that these beds are unevenly distributed, and children in economically poorer states are less likely to have access to them (Cuerdon et al., 1991).