By Susan Usher, Wayne Buffet, Rock Marois
This case study, produced by Health Innovation Forum with collaboration from Mr. Rock Marois from Emergency Medical Services, and Mr. Wayne Buffet from the Department of Health, looks at New Brunswick's effort to consolidate and upgrade ambulance service by teaming up with Médavie Blue Cross. — Produced as part of the MUHC-ISAI's 2008 program.
Ambulance service is for some patients the entry point to the health care system. Increasingly, the care they receive on the way to the hospital determines how well they fare once they’re admitted. With greater specialization of hospitals, transportation times to the right hospital can be longer, and transfers between hospitals have become more frequent. The New Brunswick government recognized ambulance service as a vital component of health care and, in 2005, improved access by abolishing fees. Increasing the quality of care, however, presented significant challenges as services were being provided by 39 different operators across the province, ranging from regional health authorities (RHAs) to municipalities to First Nations to private companies. Each had its own medical director, care protocols and training requirements for paramedics.
In 2006, New Brunswick announced its intention to consolidate all land, air and dispatch ambulance services under a new public sector agency called Ambulance New Brunswick (ANB). Its mandate was to enhance paramedic training, standardize response times to 22 minutes or less (90% of the time) in rural areas and 9 minutes or less (90% of the time) in urban areas, and implement common protocols. Medavie Blue Cross (Blue Cross) won the tender to develop a plan to overhaul the province’s ambulance service to meet the government’s new objectives.
The company then won the bid to implement the plan and, in 2006, its subsidiary New Brunswick EMS Inc. (NB EMS) signed a 10-year performance-based contract with ANB to implement the design and manage day-to-day operations. The company receives an annual management fee and a share of savings it achieves. Blue Cross already had a long-term relationship with the provincial government concerning the administration of the seniors’ drug program and had run ambulance services in Nova Scotia for over a decade. “The New Brunswick model builds on the experience we gained in Nova Scotia, and that team provided valuable expertise to guide plans,” says Mr. Rock Marois, Chief Operating Officer of NB EMS.
“We’re trying to marry the efficiency of business and the governance of government,” says Mr. Wayne Buffet, Director of Health Emergency Management Services at the New Brunswick Department of Health. The Department sets out the legislation, standards and regulations according to which ambulance service is provided, provides ANB the funding to deliver ambulance services and hired a full-time medical director to develop protocols for all ambulance calls.
During the redesign, all existing paramedics were hired by ANB as public employees represented by the Canadian Union of Public Employees (CUPE). This was done because the province wanted to respect existing bargaining arrangements. The CUPE local also represents a large number of RHA employees. Part-time or on-call paramedics were converted to full time, making the jobs much more appealing. Mr. Buffett describes the process as fairly smooth, especially as many paramedics saw their wages and benefits improve. NB EMS, as the management layer, is responsible for hiring, firing and discipline, but the government Office of Human Resources looks after relations between unions and public agencies, and would involve NB EMS in negotiations. Mr. Marois considers it an advantage that there was already a collective agreement in place while bringing the new system on line.
Ambulance NB is initiating a broad program to facilitate a change in paramedic training standards (from EMT to Primary Care Paramedic) by offering advanced training to the 800 existing paramedics, and hiring about another 200.
NB EMS acquired assets from other companies that had been providing ambulance service on behalf of ANB and will manage them for the duration of the contract.
The contract NB EMS signed with ANB stipulates performance measures the company must meet, including response times, call taking time and customer satisfaction indexes. If performance targets are not met, financial penalties can be imposed on the company. The clinical staff comes under medical oversight, which is independent of NB EMS and will conduct its own audits of incident reports.
“Many benefits in terms of improved service come from replacing a fragmented ambulance system with an integrated system,” says Mr. Marois. “It allows you to have consistency in protocols, in equipment, training and facilities. And you have all the assets of the system at your disposal so you can fully leverage them.” What NB EMS brings to the table is expertise, he says. The company is also starting to see economies of scale as its purchasing power for supplies grows.
Potential for expansion
Through its subsidiary companies, Blue Cross is now involved in the provision of ambulance services in Nova Scotia, PEI and New Brunswick. Blue Cross also administers health and drug benefit programs for a number of government agencies.
NB EMS is discussing a potential role expansion for ambulance services in the province, especially in conjunction with current efforts to improve trauma care. “Pre-hospital care is an important component in trauma care,” says Mr. Marois, “and now that the ambulance service is standardized, providing more refined triaging of trauma victims — so that they can be brought directly to the right department of the right hospital — becomes that much easier.” In a largely rural province, he adds, “other possibilities, such as follow-up at home for some patients, could be imagined.”