AAMS

The price/value equation 

As with many of these columns, written in advance, I find myself winging westward at 38,000 feet, allowing the mind to wander and muse. In publishing time, the AMSAC meeting on my agenda for tomorrow will have come and gone long ago. The work engendered by the meeting, similar to the recent AAMS mid-year, however, will still be in formative stages. It seems that writing columns is a mixture of reporting on the past and thinking about the future.

So let's take a few moments to consider the future. Without question, the spotlight will continue to focus on air medicine. With a tremendous amount of progress being made on the safety front, media questions are turning more to the consideration of value. For some time I have delivered a mantra regarding safety, pointing out that we serve a unique passenger—a patient who generally neither gets to make a carriage decision, much less a carrier decision. Hopefully, this has helped focus the safety equation we present to the public, as it requires us to operate at a higher level of safety in order to earn the public's trust. Equally relevant, however, is the issue of value, as we make economic decisions and clinical decisions on behalf of those we serve.

The Institute of Medicine (IOM) is in the middle of the first look at the emergency care system in the United States in 30 years. Refer to www.iom.edu/Emergencycare. We have just provided the briefing for the IOM, which is considering the initial information en route to a commissioned paper on air medicine. The IOM study is definitely focused on the future, and in large part the air medicine interest arose due to concerns about safety and rapid growth in the number of programs and aircraft—a question of “why this is so.” Simultaneous to the request from the IOM was a similar request from the National Association of State EMS Directors (NASEMSD) looking to work with AAMS on developing a national best practice template for state EMS air medical regulation and integration, which must interface with federal aviation regulations and the Airline Deregulation Act.

Although questions regarding safety and rapid growth sometimes bring undesired guests to the table, the media (ultimately the arbiter between the public, producers, and policy makers) have reframed the question to not one of whether air medicine is safe—it is, although like all of medicine not risk free—but rather the economics and whether the numbers of current patients should be flown in the first place. This is not surprising when there is rapid growth in use, coupled with increasingly visible and noisy competition, tied to an expensive and emotion-based individual medical intervention, with uncertain results, all in a time of cost-concern in health care.

Moreover, the questions from the media, both national and regional, are becoming more complex, with deeper background. While air medicine will continue to grow and thrive because the larger drivers in health care require continued growth, the questions are not going away.

While the cost of the intervention—flight from a scene or hospital to tertiary—is by and large nearly equal with the cost of the first hour of tertiary care, and there is some evidence that early intervention in time-dependent disease processes is cost effective, questions remain as to the true value of air medicine. Indeed, the primary interest in the IOM subcommittee, rather than debating safety and accident rates, was in calling for research as to the cost effectiveness and benefits of air medicine. Although we, who practice in the arena, are convinced of the value equation, many of our thoughtful colleagues in medicine and policy are yet to be convinced.

Value, an equation matching price and quality, is generally defined by the user. An open and free market exists when a purchaser has sufficient information to make an informed purchase decision as to cost and reliability—whether this intervention will work, a choice of purchase, an acceptable price point at which they will or will not purchase, and a variety of vendors that compete to improve the value equation. In economic theory, a market is an effective mechanism to define value and reduce costs. Our great challenge is that medicine is incompatible with a market-based approach.

First, our user, the patient, does not have sufficient information or knowledge to make an informed choice of whether to receive care. This is especially true in an emergency setting. While the rapid growth and availability of medical information on the Internet is changing health consumer behavior, at the end of the day, the public will always have to rely on expert clinicians for information to make a yes/no decision on undertaking or forgoing a health care intervention.

Further, the patient, as end user, is not usually the purchaser. The third party purchaser may be any combination of public and or private insurance serving to de-align the purchase and price decisions. Third, the price is seldom known in advance. In the emergency arena where we nearly exclusively practice, it is in fact against the law to bring price into the discussion regardless as to whether an individual consumer would say, “Wait a minute, what are my other options?”

Fourth, price is determined by and large by the producers rather than the purchasers. Increasing the availability of cardiac intervention centers has not decreased the cost of catheterization. Rather, the need to support the increased numbers of facilities has overall increased health care costs due to Roehmer's Bed Law, which predicts that a hospital bed, once created, will be filled. This is further complicated by the rapidly increasing capital costs and reach of medical technology.

Finally, there is the geographic constraint and organization of resource (hospitals, physicians, EMS) availability—where you live is where you receive care, further misaligning the purchase and price equation. Coupled with geographic determination of provider regardless of choice are uncertain results and variable quality. This is especially true in time-dependent care; geography limits choice of vendors and quality regardless of price and is further often enshrined in legislation. A local example: in Maine, a law states that patients should not have to travel farther than 80 miles for virtually all care, which serves to disperse rather than concentrate specialist hospital services.

Although all medical providers are caught in this imperfectly designed system that is both heavily regulated on the requirements for care and unregulated on market entry, pricing, and quality (another misalignment of an economic market), those of us at the pointy ends—emergency and time-dependent care in which we cannot say no—face the most complex task of defining the value equation. We are driven by the health care market, and we facilitate the drivers of that market. Without air medicine there wouldn't be much of a reason to compete for cardiac catheter labs greater than the immediate neighborhood.

Without question, patient safety, inherent in the value equation, will continue to be a primary driver, but the costs and benefits—did we actually improve the individual's health at a cost society is willing to afford?—are going to be the primary challenges we and all of our colleagues will face in the next decade. Is the air medical system operated in the public's interest? Will the public we serve, our patients, our colleagues in medicine, and policy makers accept the value equation we present? Would patients design the system as it is, or would their design look very different? This is the next bar we must leap over.

The good news is that FARE is up and running. Multiple initiatives, from Vision Zero to public and policy maker education to funding a research agenda, are under way. The research track at this year's AMTC is the largest in the conference's history, and multiple data and standards projects are being implemented across the community. Better data and understanding are the first steps in understanding the value (and safety) equation.

AMTC's theme—high performance in the high consequence environment—is ultimately a data-driven challenge in both the clinical and economic environments. Purchasers and policy makers are already rapidly developing improved data and understanding of the interplay or lack thereof between price, quality, and outcomes. They are looking at the value equation. The question is: who will get there first?

See you in Austin,