In December 1998, Kaiser Permanente, the largest health maintenance organization (HMO) in the nation signed a reported five-year, $600 million national contract with American Medical Response (AMR).

The contract commissions AMR to manage and provide medical transportation services for Kaiser Permanente members across the country.   This is the first ever national contract of this magnitude between a managed care organization and an ambulance provider.  

Kaiser Permanente is a non-profit, group practice prepayment organization, headquartered in Oakland, California.   Kaiser employs about 90,000 technical, administrative, and clerical employees, 10,000 physicians, and serves total of 9.3 million enrolled members in 18 states and the District of Columbia. 

The program is designed to implemented in stages starting March 15, 1999, with final completion by January 1, 2000.

As is the emerging trend with managed care, payment for such services is paid by the health care organization prior to the member receiving any services. With "capitated payments", the organization (AMR in this case) providing the services is paid a set monthly fee for each member, each month.

The process will start with a Kaiser Permanente member calling a special 800 number; AMR dispatchers will screen the phone call.   Following established telephone triage protocols, the AMR dispatcher will determine, if for example, a person needs immediate care or if an appointment can be made at the doctor's office within a couple of days.   In essence, the AMR dispatcher is in a "gatekeeper" role.    With the "gatekeeper" concept, there is "access management," not  "demand management."   Most fire agencies operate in a "demand management" mode where every phone call for medical assistance regardless of the nature of the incident, receives an immediate response.  

Should the fire service be concerned about this type of arrangement?   Yes, for several different reasons.   First, enrolled members in Kaiser Permanente might be confused where to call during an emergency.  Do they call 911 or the 800 number?    James Cusick, a physician, who is Kaiser's director of emergency medical services in Colorado said, "The HMO still encourages Kaiser members to call 911 for emergency service in life or limb-threatening situations."   He further added in medical conditions that may require emergency transportation, but are not life-threatening, Kaiser encourages its members to call the HMO emergency number where AMR dispatchers will assess the severity of the patient's condition.  Obviously, the term "emergency" is very subjective and hard to define.   What may be an "emergency" to one person may not be an "emergency" to another person.     Thus, someone who is having a true medical emergency may call the 800 number, circumventing the 911 system. Even if the AMR dispatcher determines this is the type of call the 911 system should handle, routing the call back into the 911 system is a problem. Besides the obvious delay to the 911 system, the caller and the AMR dispatcher will most probably be in two different states.  The only way to route the call back into the 911 system is for the caller to hang up the phone and dial 911. Hopefully, the caller is capable of doing such.

Other consequences to the fire service of Kaiser members not calling 911 is fully insured patients are being removed from fire-based EMS systems, resulting in decreased run numbers and financial reimbursement.    Fire departments which have both AMR operating and Kaiser Permanente members living in their response area should be keenly aware of this issue and should monitor the impact to their systems.

The other burning questions affecting fire-based EMS systems concern transporting a Kaiser patient: Is it reimbursable or will it be denied as medically unnecessary?   Will AMR be responsible for reimbursing the fire agency since AMR has already received the funding to manage a member's medical transportation needs?   And if there is reimbursement for transport, what will the rate be?

The fire service needs to be aware this will not be the last large national or regional contract to be signed between a managed care organization and an ambulance provider.    Certainly a major component to the future success and profitability of other large managed care organizations will be their ability to control and manage health care costs through "access management."