What EMS chiefs need to know about economies of scale

From EMS1:

Rural and/or volunteer EMS organizations can leverage scale in the same way to improve training, purchasing and service delivery while being perceived as local. Many aspects of an EMS organization benefit from scale. Two very large volunteer organizations including the American Red Cross and the Boy Scouts of America, organizations likely active in your community, leverage the use of volunteers while maintaining a strong sense of local control.

Vertical integration
Perhaps the most common application of EMS economy of scale in the United States is vertical integration. Vertical integration is best described as multiple elements of public services, emergency services or health care services working together under a common umbrella. Vertical integration exists in almost every EMS system that is described as “-based” such as county-based, fire-based or hospital-based EMS.

In vertically integrated operations the EMS organization shares oversight, support functions and/or facilities and staff as part of a larger organization. Support functions can include such items as training, human resources, finance, information technology, dispatch, vehicle maintenance or purchasing.

Other economies, such as shared staffing, either paid or volunteer may also exist. Shared staffing is probably most common in fire-based organizations when personnel are cross-trained to provide both firefighting and EMS. It is likely there are thousands of volunteer fire departments that provide fire and EMS in the United States, although there is currently no great method to count them.

Mental healthcare initiatives come to ERs’ rescue

From FierceHealthcare:

As more mentally ill patients seek care in emergency rooms, hospitals across the country are taking steps to shift the care burden to other settings.

One innovative approach is Oregon Health & Science University’s Unity Center for Behavioral Health in Portland. The center, a collaborative effort of the university, Kaiser Permanente, Adventist Health and Legacy Health, is a 24-hour resource for crisis resolution and mental health support, according to the Huffington Post.

The facility also features design elements aimed at reducing anxiety, such as reclining chairs rather than traditional hospital beds and a more calming architectural layout.

Drug shortages in American ERs have increased more than 400 percent

From the Washington Post:

Emergency rooms are health care’s front line — in the United States, nearly 45 out of 100 people visit an ER in any given year. But there’s an issue brewing behind the scenes in emergency medical facilities, one that can’t be fixed by a simple stitch or bandage. A new study published in the journal Academic Emergency Medicine shows that drug shortages in ERs across the United States increased by more than 400 percent between 2001 and 2014.

Of the nearly 1,800 drug shortages reported between 2001 and 2014, nearly 34 percent were used in emergency rooms. More than half (52.6 percent) of all reported shortages were of lifesaving drugs, and 10 percent of shortages affected drugs with no substitute. The most common drugs on shortage are used to treat infectious diseases, relieve pain, and treat patients who have been poisoned. Though the number of shortages fell between 2002 and 2007, they’ve risen by 435 percent between 2008 and 2014.

The primary reasons given for shortages were manufacturing delays (25.6 percent), supply and demand (14.9 percent), and availability of raw materials (4.4 percent). Pharmaceutical companies listed “business decision” as the reason for a shortage 2.1 percent of the time. But in over 46 percent of the shortages studied, there was no reason given.

White House takes aim at opioid abuse in rural areas

From Healthcare Dive:

  • President Barack Obama has launched a new interagency initiative to tackle the growing problem of opioid abuse and misuse in rural communities, according to The Washington Post.
  • The announcement follows congressional hearings last year on the opioid epidemic and the Food and Drug Administration’s Nov. 18, 2015, approval of an easy-to-use nasal spray version of the opioid antidote drug naloxone.
  • U.S. deaths involving opioids increased 200% from 2000 to 2014, according to the Centers for Disease and Prevention.

The initiative signals a ratcheting up of efforts at the federal level to address the epidemic in opioid misuse and abuse, which kills 30,000 people a year. U.S. rural communities with fewer economic opportunities and higher rates of poverty, are especially vulnerable.

Led by Agriculture Secretary Tom Vilsack, the initiative will centralize decisionmaking on drug abuse and other issues affecting rural America, such as poor mental and physical health and high suicide rates, the Washington Post reports.

Vilsack was tapped for the job because of his experience chairing the White House Rural Council. Among the council’s 15 members are HHS and the Office of National Drug Control Policy.

Last month’s budget agreement provides the administration $400 million in fiscal 2016 to address the opioid abuse crisis — up from $300 million last year. The agreement also allows the use of federal monies in needle exchange programs.

According to the CDC’s Jan. 1 Morbidity & Mortality Weekly Report, the number of deaths from the most commonly prescribed opioid painkillers jumped 9% from 2013 to 2014. “Deaths from synthetic opioids, a category that includes illicitly manufactured fentanyl and synthetic opioid pain relievers other than methadone, increased 80%,” the agency said. The increase dovetailed with law enforcement reports of growing availability of illicit fentanyl.

60 things to know about the hospital industry | 2016

From Becker’s Hospital Review:

Hospitals and health systems in the U.S. are undergoing a dramatic shift in their business models due to a number of forces — from providers concerned with the volume of services they provide, to providers who focus on offering high-value services that emphasize keeping populations healthy. For those unfamiliar with this shifting industry, or those who simply want to know more, here are 60 facts and statistics about the hospital industry in 2016.

1. There are 5,686 hospitals in the U.S., according to the American Hospital Association.

2. Of these, 2,904 hospitals are nonprofit and 1,060 are for-profit. Additionally, 1,010 are owned by state or local (county, hospital district) government entities.

3. Of all hospitals in the U.S., 1,971 serve rural communities and are considered rural hospitals.

4. Of rural hospitals, 1,332 are designated as Critical Access Hospitals by CMS.  CAHs are rural hospitals with no more than 25 beds and are at least 35 miles (15 miles in areas with mountainous terrain or only secondary roads) away from another hospital. CAHs are paid differently by CMS than traditional acute care hospitals; their payments reflect their operating costs, rather than volumes.

5. Despite the high number of rural hospitals, many of them are at risk of closing. According to September 2015 data, 57 rural hospitals had closed since 2010. An analytics firm called iVantage created and a hospital strength index based on financial stability, patients and quality indicators for 2,224 rural hospitals across the country.  iVantage determined 283, or nearly 13 percent, were vulnerable to closure. The vulnerable hospitals are located across 39 states.

Read more here.

Medical school program addresses rural physician shortage

From Eurkalert:

Mirroring national trends, 97 percent of the 101 rural counties in Missouri are designated Primary Medical Care Health Professional Shortage Areas by the U.S. Department of Health and Human Services. Many medical schools across the country have developed admission policies and clinical training programs to address rural physician workforce shortages in their state. Now, a recent study by the University of Missouri School of Medicine shows one of its programs enhances training and may increase interest in rural practice for graduating medical students.

“Clinical training alone is not enough to prepare, attract and retain new physicians in rural practice locations,” said Jana Porter, associate director of the MU School of Medicine’s Area Health Education Center and Rural Track Pipeline Program and lead author of the study. “We developed the Community Integration Program in 2006 as part of our pipeline program to further encourage students to practice in rural settings after they graduate. We wanted to better understand what the students’ experiences were with this service learning program, and if it might affect their decision to practice in a rural community.”

Rural hospitals taking on recruitment challenge

From the Lincoln Journal Star:

Dr. Anthony Krueger was still two years away from finishing his radiology residency at the University of Nebraska Medical Center when he started reaching out to hospitals for employment.

With Midwest roots, Krueger didn’t want to stray too far from home, which for him is South Sioux City and Newman Grove for his wife. One of the places he connected with was Columbus Community Hospital.

Even though he also had interest in working in large cities like Lincoln and Omaha, he chose Columbus when the job offers started to come in and began working in radiology at the hospital last June.

Working in a smaller, rural community hasn’t meant handling a lighter caseload.

“It is a lot busier than I expected coming to a town Columbus’ size,” Krueger said.

Being one of three radiologists contracted to work at CCH keeps him busy. Finding the right fit professionally was a goal, but even more important was a personal fit in a community for his family, which includes three young children.

Columbus had the right combination, so much so that he can see himself settling down here permanently.

“We don’t have any plans to leave. I want to stay until I retire,” Krueger said.

That is exactly what hospitals like to hear from their recruits. They not only want to get doctors on staff, they also want to retain them long-term.

With a growing nationwide shortage of physicians, recruitment and retention are becoming even more important. Rural hospitals aren’t an exception.

Hospitals in smaller communities, like CCH, are employing different strategies to fill the need for physicians.

One way hospitals are securing doctors is by reaching out to medical students who are early in their career planning.

Healthcare in the outlands: Administrators look for ways to attract RN to rural health jobs

From Nurse.com:

Taylor Graham, BSN, RN, graduated from nursing school hoping to find a job in or around Boise, Idaho, the city of 200,000 where she’d grown up, or another urban center.

But when larger hospitals turned her down, she thought about Steele Memorial Medical Center in Salmon, a mountain community of some 3,000 people in the center of the state. She’d done a student clinical rotation there and had been impressed with the leadership, support for nursing and quality of care in the 18-bed critical access hospital.

The idea of rural nursing frightened Graham. She couldn’t imagine being the only RN on a unit, 300 miles away from the nearest larger hospital. But Steele Memorial administrators promised she would always have manageable patient loads, other RNs working with her, and a residency program that included training, sessions with a preceptor and meetings with nurses at other facilities who also were new to rural nursing. “I knew I was going to get the support that I needed and I was going to get the opportunity to learn,” she said. She decided to give it a chance. A year and a half later, Graham is still at Steele Memorial and in no hurry to leave.

Her experience represents the payoff some desperately short-staffed rural facilities hoped for about 10 years ago when they invested in ways to attract new nurses to remote areas where salary and benefits couldn’t compete with urban and suburban counterparts, and many new recruits didn’t stay through the first year. Administrators began looking for people who wanted to be in a rural community or who had ties to the community, and then supporting them so they would stay — a policy called “recruiting for retention.”

Are America’s painkiller policies driving patients to heroin?

From The Verge:

Heroin use has spiked in the US, and some critics have charged that policy changes are to blame. Not so, say a group of government researchers, who exonerate the agencies they work for in a paper published yesterday. Outside drug use researchers find the paper’s claims debatable.

In the paper, published in the New England Journal of Medicine, researchers from the NIH, the CDC, and the Department of Health and Human Services discuss data that shows that heroin use started increasing in 2009 or earlier in various US locations — before governments implemented changes designed to curb painkiller misuse. These policies include stopping health care providers from dispensing painkillers from their offices in Florida, asking doctors in a number of states to check a patient database before writing a prescription, and developing prescription painkillers that are harder to crush. The government researchers argue instead that heroin’s purity and its low cost were key factors in the recent increase in the drug’s use.

The Impact of Continuity of Care on Emergency Room Use in a Healthcare System without Referral Management

From the Annals of Epidemiology:


To determine whether continuity of care (COC) is beneficial in national healthcare systems without referral management by controlling for endogeneity of COC.


We used National Health Insurance (Taiwan) claims data from 2008, encompassing approximately 23 million people, to determine whether COC is associated with reduced emergency room (ER) use by hypertension and diabetes patients in 2009. We used an instrumental variable approach to account for endogeneity associated with patients’ COC levels.


After controlling for endogeneity, the marginal effect of COC on ER use probability when the COC score increased from 0 to 1 was 7.6% (P < .001) and 14.8% (P < .001) for hypertension and diabetes patients, respectively.


We determined that COC is more effective for reducing ER use than are models that assume that COC is exogenous. It has been argued that in many countries, healthcare systems without referral management encourage physician-shopping and hinder physician-patient communication. However, there are benefits to disease-specific COC. Because current estimations have failed to take endogeneity biases into account, COC is more effective than is currently assumed.