Incentive–Compatible Prehospital Triage in Emergency Medical Services

The Emergency Medical Services (EMS) system is designed to handle life-threatening emergencies, but a large and growing number of non-emergency patients are accessing hospital-based healthcare through EMS. A recent national survey estimated that 17% of ambulance trips to hospital Emergency Departments (EDs) were medically unnecessary, and that medically unnecessary trips make up an increasing proportion of all EMS trips. These non-emergency patients are a controllable arrival stream that can be re-directed to an appropriate care provider, reducing congestion in EDs, reducing costs to patients and healthcare payers, and improving patient health, but prehospital triage to identify these patients is almost never implemented by EMS providers in the United States. By studying healthcare reimbursement structures, we find that prehospital triage is unlikely to occur with traditional fee-for-service reimbursements, regardless of how effective the triage process may be. However, offering bundled payments to EMS providers would provide them with an incentive to conduct prehospital triage, and, moreover, with incentive to improve their triage effectiveness. Bundled payments also align with a current trend for Medicare to move away from fee-for-service and toward value-based purchasing, making it a practical step to address hospital ED crowding.