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• W2016507687 abstract "To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non–peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions. To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non–peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions. IntroductionMost Americans expect that a call to 911 for medical assistance will result in an immediate response, with the appropriate staff and equipment. Although throughout the United States most calls to 911 will result in a response, the staff and equipment that are sent to the scene will vary according to chief complaint and geographic location. The care emergency medical services (EMS) providers give when they arrive at the scene will depend on local resources and protocols.1Committee on the Future of Emergency Care in the United States Health System Board on Health Care ServicesEmergency Medical Services at the Crossroads. National Academies Press, Washington, DC2006Google ScholarThe care provided within EMS systems has come under increased scrutiny in recent years. Although few would argue against the need for these systems, many have questioned the value of the range of out-of-hospital care services currently provided.2Callaham M. Quantifying the scanty science of prehospital emergency care.Ann Emerg Med. 1997; 30: 785-790Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar, 3Koenig K.L. Quo vadis: “scoop and run,” “stay and treat,” or “treat and street”?.Acad Emerg Med. 1995; 2: 477-479Crossref PubMed Scopus (12) Google Scholar, 4Koenig K.L. Unscheduled access to health care: reengineering the 911 system.Acad Emerg Med. 1996; 3: 989-991Crossref PubMed Scopus (18) Google Scholar, 5Reines H.D. Bartlett R.L. Chudy N.E. et al.Is advanced life support appropriate for victims of motor vehicle accidents: the South Carolina Highway Trauma Project.J Trauma. 1988; 28: 563-570Crossref PubMed Scopus (79) Google Scholar, 6Smith J.P. Bodai B.I. Hill A.S. et al.Prehospital stabilization of critically injured patients: a failed concept.J Trauma. 1985; 25: 65-70Crossref PubMed Scopus (254) Google Scholar, 7Spaite D.W. Criss E.A. Valenzuela T.D. et al.Emergency medical service systems research: problems of the past, challenges of the future.Ann Emerg Med. 1995; 26: 146-152Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 8Seidel J.S. Henderson D. Tittle S. et al.Priorities for research in emergency medical services for children: results of a consensus conference.Pediatr Emerg Care. 1999; 15: 55-58Crossref PubMed Scopus (15) Google Scholar, 9Spaite D.W. Criss E.A. Valenzuela T.D. et al.Developing a foundation for the evaluation of expanded-scope EMS: a window of opportunity that cannot be ignored.Ann Emerg Med. 1997; 30: 791-796Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 10Stiell I.G. Wells G.A. Spaite D.W. et al.The Ontario Prehospital Advanced Life Support (OPALS) Study part II: rationale and methodology for trauma and respiratory distress patients: OPALS Study Group.Ann Emerg Med. 1999; 34: 256-262Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar There are dramatic philosophic poles in this controversy. Some suggest a radical streamlining of EMS systems is neccessary,2Callaham M. Quantifying the scanty science of prehospital emergency care.Ann Emerg Med. 1997; 30: 785-790Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar whereas others advocate for a significantly expanded scope of services deployed in the out-of-hospital setting.11O'Connor R.E. Cone D.C. De Lorenzo R.A. et al.EMS systems: foundations for the future.Acad Emerg Med. 1999; 6: 46-53Crossref PubMed Scopus (11) Google ScholarAmong many involved in the dialogue related to the use of health care resources, there is a persistent concern about the lack of proof of effectiveness for many out-of-hospital care interventions.12Raskin I.E. Maklan C.W. Medical treatment effectiveness research: a view from inside the Agency for Health Care Policy and Research.Eval Health Prof. 1991; 14: 161-186Crossref PubMed Scopus (30) Google Scholar, 13Relman A.S. Assessment and accountability: the third revolution in medical care.N Engl J Med. 1988; 319: 1220-1222Crossref PubMed Scopus (510) Google Scholar, 14Roper W.L. Winkenwerder W. Hackbarth G.M. et al.Effectiveness in health care: an initiative to evaluate and improve medical practice.N Engl J Med. 1988; 319: 1197-1202Crossref PubMed Scopus (332) Google Scholar, 15Delbridge T.R. Bailey B. Chew Jr, J.L. et al.EMS agenda for the future: where we are … where we want to be: EMS Agenda for the Future Steering Committee.Ann Emerg Med. 1998; 31: 251-263Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 16Brice J.H. Garrison H.G. Evans A.T. Study design and outcomes in out-of-hospital emergency medicine research: a ten-year analysis.Prehosp Emerg Care. 2000; 4: 144-150Crossref PubMed Scopus (40) Google Scholar, 17Spaite D.W. Outcome analysis in EMS systems.Ann Emerg Med. 1993; 22: 1310-1311Abstract Full Text PDF PubMed Scopus (14) Google Scholar Even for those interventions with proven efficacy, such as care of nontraumatic cardiac arrest18Valenzuela T.D. Spaite D.W. Meislin H.W. et al.Case and survival definitions in out-of-hospital cardiac arrest: effect on survival rate calculation.JAMA. 1992; 267: 272-274Crossref PubMed Scopus (73) Google Scholar, 19Valenzuela T.D. Roe D.J. Nichol G. et al.Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.N Engl J Med. 2000; 343: 1206-1209Crossref PubMed Scopus (1146) Google Scholar, 20Zheng Z.J. Croft J.B. Giles W.H. et al.Sudden cardiac death in the United States, 1989 to 1998.Circulation. 2001; 104: 2158-2163Crossref PubMed Scopus (1335) Google Scholar, 21Eisenberg M.S. Horwood B.T. Cummins R.O. et al.Cardiac arrest and resuscitation: a tale of 29 cities.Ann Emerg Med. 1990; 19: 179-186Abstract Full Text PDF PubMed Scopus (763) Google Scholar, 22Nichol G. Stiell I.G. Laupacis A. et al.A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest.Ann Emerg Med. 1999; 34: 517-525Abstract Full Text PDF PubMed Scopus (271) Google Scholar, 23Cummins R.O. Ornato J.P. Thies W.H. et al.Improving survival from sudden cardiac arrest: the “chain of survival” concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association.Circulation. 1991; 83: 1832-1847Crossref PubMed Scopus (1172) Google Scholar and use of formalized trauma systems for severe trauma,24Bass R.R. Gainer P.S. Carlini A.R. Update on trauma system development in the United States.J Trauma. 1999; 47: S15-S21Crossref PubMed Scopus (49) Google Scholar, 25Mann N.C. Mullins R.J. MacKenzie E.J. et al.Systematic review of published evidence regarding trauma system effectiveness.J Trauma. 1999; 47: S25-S33Crossref PubMed Scopus (260) Google Scholar, 26MacKenzie E.J. Review of evidence regarding trauma system effectiveness resulting from panel studies.J Trauma. 1999; 47: S34-S41Crossref PubMed Scopus (126) Google Scholar, 27Jurkovich G.J. Mock C. Systematic review of trauma system effectiveness based on registry comparisons.J Trauma. 1999; 47: S46-S55Crossref PubMed Scopus (184) Google Scholar, 28Mann N.C. Assessing the effectiveness and optimal structure of trauma systems: a consensus among experts.J Trauma. 1999; 47: S69-S74Crossref PubMed Scopus (24) Google Scholar, 29Mann N.C. Mullins R.J. Research recommendations and proposed action items to facilitate trauma system implementation and evaluation.J Trauma. 1999; 47: S75-S78Crossref PubMed Scopus (23) Google Scholar, 30Spaite D.W. Criss E.A. Valenzuela T.D. et al.Prehospital advanced life support for major trauma: critical need for clinical trials.Ann Emerg Med. 1998; 32: 480-489Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar little is known about their cost-effectiveness.31Lerner E.B. Maio R.F. Garrison H.G. et al.Economic value of prehospital emergency care: a structured literature review.Ann Emerg Med. 2006; 47: 515-524Abstract Full Text Full Text PDF PubMed Scopus (27) Google ScholarLimited attention has been paid to the evaluation of the cost of EMS systems or the care rendered within them. A recent systematic review of the English-language literature revealed a paucity of investigations that evaluated the cost of EMS or the interventions provided.31Lerner E.B. Maio R.F. Garrison H.G. et al.Economic value of prehospital emergency care: a structured literature review.Ann Emerg Med. 2006; 47: 515-524Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar This review yielded only 32 studies that reported an analysis of the cost of out-of-hospital care, and the quality of the majority of these studies was inconsistent.Any cost analysis should follow guidelines for the standardization of economic analyses such as those suggested by the Panel on Cost-Effectiveness in Health and Medicine.32Gold M.R. Siegel J.E. Russell L.B. Cost-effectiveness in Health and Medicine. Oxford University Press, New York, NY1996Google Scholar However, when a cost analysis of out-of-hospital care is conducted, there is also a need for a conceptual framework specific to EMS to assist in the analysis. Use of such a framework will ensure that comparisons can be made across systems and across studies. To our knowledge, no framework exists that can be used by researchers, communities, or providers to determine the cost of an EMS system so that appropriate evaluations can be conducted. The objective of the EMS Cost Analysis Project is to create a comprehensive framework that allows users to determine the cost of providing out-of-hospital care from a societal perspective. This article presents the EMS cost framework that has been developed.Development of the FrameworkA panel (the authors) was assembled to generate an EMS cost framework. This team first developed a comprehensive list of all components of EMS cost (Figure 1). To initiate this process, each of the articles identified in the previously conducted literature review was analyzed, and a list of all the cost components used in those studies was generated (Table).31Lerner E.B. Maio R.F. Garrison H.G. et al.Economic value of prehospital emergency care: a structured literature review.Ann Emerg Med. 2006; 47: 515-524Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Using the information generated from this review and their experience, the authors generated a comprehensive list of all the components of EMS cost from a societal perspective. A consensus process was used to generate the initial cost framework, in which all of the panel members had to agree whether each candidate item was included or excluded from the list. In preparing this list, the authors also enumerated each of the assumptions that were required to generate the list.TableList of the costs considered in the 32 identified analyses of EMS cost.ArticleCost-effective AnalysisCost FactorsAltintas (1999)Cost descriptionCapital costs: building costs, ambulance vehicle, service car, fixtures, and equipmentRecurrent costs: personnel (physicians, nurses, drivers, and assistants), electricity, water, heating, cleaning, rental, insurance, tax, consumable medical materials, medications, radio repairs and maintenance, telephone fees and maintenance, ambulance engine oil, ambulance tire repairs, ambulance repairs and spare parts, ambulance gasoline, ambulance vehicle periodic controls, gasoline for service carsBrady (1996)Cost analysisUsed charges onlyBrazier (1996)Cost minimizationAircraft, pilots, medical personnel, maintenance, landing facilities, and ambulance control staff involved in deploymentBruhn (1993)Cost analysisOffice utilities and rent, medical supplies (new), medical supplies (disposable), nonmedical supplies, maintenance, unexpected costs, insurance, vehicle fuel, training, vehicle lease, staff (nurses, paramedics, driver/pilot, clinical operations director, medical director, and office staff) salary and benefitsBur (2001)Cost outcome descriptionHospital costs onlyCretin (1977)Cost benefitProvider salary and benefits, equipment, support personnel, maintenance and other costsDaberkow (1977)Cost descriptionDetermined the cost of having a staffed facility using a National Highway Traffic SafetyAdministration report; then used a general cost per call, cost per mile driven, and a cost for suppliesDe Wing (2000)Cost minimizationUsed charges by the agencyFischer (2000)Cost analysisMarginal cost for running an ambulance continually for a year; average number of crew per ambulance and the proportion that were paramedic; annual ambulance leasing costs, which included maintenance and equipment, fuel costs for idling, cost of uniforms, administrative consumables, and additional insuranceForrer (2002)Cost-effectivenessInstructor stipend, overtime for officer training time, equipment costs (defibrillator, battery, pads), equipment maintenance costsGearhart (1997)Cost outcome descriptionPersonnel (salaries, employee benefits, training expenses, Federal Aviation Administration–mandated physical examination, random drug and alcohol testing), capital, operations (fuel, maintenance contracts, spare parts, purchased services, and lease of a substitute aircraft during periods of major maintenance), medical supplies (liquid oxygen system, medications, and single-use patient care supplies), insurance (liability and aircraft hull), and administration (telephones, pagers, office supplies, advertising, computers, and interdepartmental hospital charges)Hallstrom (1981)Cost-effectivenessNo details providedHauswald (1997)Cost outcome descriptionPersonnel, ambulance purchase, maintenance, and minimal equipmentJakobsson (1987)Cost descriptionPrice of defibrillator divided by estimated working life of 5 years. Cost of training was salaries of EMT and nurses and physician lecture fees.Jermyn (2000)Cost-effectivenessDefibrillators, ancillary equipment, biomedical services for preventive maintenance on defibrillators, routine nonwarranty work, training equipment, trainer/provider certification, call review by medical control, attrition of providers and trainersKriegsman (1998)Cost descriptionFixed costs: salaries, benefits, overtime training, travel, training, administration, and equipment upgrade; Variable costs: expendable supplies, equipment wear and tear, and overtime responsesKurola (2002)Cost outcome descriptionNo details providedLammers (1995)Cost analysisMarginal cost of ambulance serviceLechleuthner (1994)Cost analysisPilot/driver, paramedic, physician, maintenance/technical (gas, inspection, leasing, depreciation, etc)Nichol (1996)Cost utility911 Service, ambulance communication center, ambulance bases, vehicles, equipment, wages, benefits, and educationNichol (2003)Cost-effectivenessDefibrillator, nontraditional responder training, instructor costs, retraining, drillsNicholl (1994)Cost analysisCapital, paramedic crew, training, helicopter hanger, landing sites, equipment, lease, vehicle fuel, repair, and depreciation, ambulance controllers, headquarters, and other overheadOrnato (1988)Cost-effectivenessEMT training, ambulance, radio equipment, medical equipment (eg, stretcher, oxygen, first aid supplies), defibrillator, ultrahigh frequency radio for telemetry, and drug boxPascarelli (1978)Cost descriptionMobile ICU, base station, defibrillation, salaries of personnel (supervisors and paramedics), expendable supplies (equipment and maintenance)Riediger (1990)Cost benefitNo details providedRosemurgy (1993)Cost descriptionCharges for out-of-hospital and hospital care obtainedSnooks (1996)Cost descriptionCrew, out-of-hospital capital, helicopter operating costs, and special landing and patient transfer facilitiesSuchard (1999)Cost descriptionAmount of reimbursement by MedicareTurner (2000)Cost minimizationConsumable equipment and cost per minute on callUrban (1981)Cost-effectivenessParamedic training, equipment, vehicle, salaries, benefits, relief pay, supplies, support services, equipment, maintenance, dispatching, management, vehicle operationValenzuela (1990)Cost-effectivenessPersonnel salary and benefits, training, equipment, maintenance, cost of adding one more unit to maintain response time Open table in a new tab Search for Existing LiteratureOnce a preliminary list of EMS cost components had been generated, the authors searched for and reviewed any additional available materials that described the cost of EMS. This secondary search was conducted to identify any non–peer-reviewed literature. The search included a general Internet-based method, as well as requests to selected experts for any relevant information. The secondary search for other types of published documents yielded few items for review. However, a methodology for evaluating cost within an EMS system, developed by the American Ambulance Association, was identified.33American Ambulance AssociationCommunity Guide to Ensure High Performance Emergency Ambulance Service. American Ambulance Association, McLean, VA2004Google Scholar Although this methodology was designed for use by a single EMS agency and was not comprehensive enough for determining EMS costs from a societal perspective, it was used to refine the comprehensive cost framework.External ReviewThe revised framework was sent to several outside reviewers from a variety of backgrounds (ie, EMS medical direction, EMS research, economics). The reviewers were asked to evaluate and comment on the framework, which included the list of cost components and a document describing related assumptions. The panel evaluated all outside reviewer comments and used the consensus process to finalize the framework.EMS Cost Framework AssumptionsThe components of the cost of EMS are illustrated in Figure 1. There is no hierarchic rank to the components; they are all necessary. The full EMS cost framework is shown in Figure 2. The framework lists each component of EMS cost plus the factors that make up the components. Each of the factors must be considered and assigned a value to calculate the cost of the EMS system to the community it serves. To fully use this framework, one must understand the assumptions that were made during its development.Figure 2EMS system cost framework.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Working Definition of an EMS SystemFor the purpose of this framework, our focus was on the EMS system as it responds to acute, unscheduled health care delivered outside the hospital within the setting of a system that deploys health resources in response to a request for emergency medical care, which includes lay responders, public safety, and EMS providers who participate in this response and the system within which they respond. All types of vehicles involved in response are included: air, water, and ground. Further, this definition would include any unscheduled acute request for aid, regardless of whether it is through a public safety answering point or not (eg, interfacility transport of a trauma patient from an outlying hospital to a Level I trauma center) but would not include scheduled interfacility transports (eg, transport of a nursing home patient to a dialysis appointment).Intended Audience for the FrameworkThe intended audience for this framework includes professionals involved in EMS operations, EMS policy, and EMS research, as well as the community, including government officials and policymakers. When costs are calculated, some items from this framework may not be included, depending on the perspective taken.This framework is intended to be comprehensive. In some locations, listed services may not be present and can be ignored when cost is calculated. However, if the service is provided by another agency within the community, the cost should be considered even if it is provided with no charge.PerspectiveIt is recommended that health economic evaluations be conducted from a societal prospective,32Gold M.R. Siegel J.E. Russell L.B. Cost-effectiveness in Health and Medicine. Oxford University Press, New York, NY1996Google Scholar which includes downstream health care costs, as well as other costs incurred by society. Here we report only considerations for calculating the cost of an EMS system providing out-of-hospital care to a community because the methodology for measuring the downstream costs of health care outside the EMS setting and societal costs such as lost wages are well described elsewhere (eg, Sloan,34Sloan F. Valuing Health Care. Cambridge University Press, New York, NY1995Crossref Google Scholar O'Brien et al,35O'Brien D.J. Price T.G. Adams P. The effectiveness of lights and siren use during ambulance transport by paramedics.Prehosp Emerg Care. 1999; 3: 127-130Crossref PubMed Scopus (34) Google Scholar and Gold et al32Gold M.R. Siegel J.E. Russell L.B. Cost-effectiveness in Health and Medicine. Oxford University Press, New York, NY1996Google Scholar). The cost of EMS and the cost and effects of health care outside the EMS setting are not entirely independent. For example, an intervention provided in the out-of-hospital setting may reduce the cost of subsequent hospitalization. Users of this framework can adopt any perspective desired. They simply need to determine which components are appropriate for their analysis.The cost of the EMS system to society is greater than the cost of maintaining a single EMS agency in a community (Figure 3). Not all of the items listed in this framework will be captured in an agency budget. Costs may be incurred by other sectors, with the benefit of some or all of those costs being reaped by the EMS sector. For example, use of radio infrastructure by a commercial ambulance service incurs costs, even if these are paid for by the municipality. The use of a societal perspective allows for comparisons across studies and communities and will help decisionmakers allocate limited resources within the EMS system, the general health system, or between the health system and other sectors of society.Figure 3From a societal perspective, the cost of EMS will be shared among sectors, including the EMS sector itself. Further, in some cases the benefit of some costs may be reaped by a sector different from the one that paid for it.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Costing Components of an EMS SystemOur primary focus was the description of methods of measuring EMS costs. These include the cost of readiness and actual service delivery. Readiness includes on-call staffing for coverage of the geographic service area. Service delivery includes staffing, durable and consumable equipment used to respond to the scene, provision of care on scene, and transportation to a receiving facility. The cost of training, retraining, quality management, medical direction, equipment, administration, housekeeping, and other expenses that are used to maintain the system are relevant. Once a community has calculated the cost of its system, it can attribute those costs to the cost of readiness versus the cost of patient care.Joint ProductionThis framework is intended to estimate the cost of the entire EMS system and, as such, may require consideration of 1 or more of the various types of agencies that are part of a system (eg, fire departments, police departments, first-tier EMS agencies, second-tier EMS agencies). When cost is evaluated, care provided by each of these agencies must be taken into account (Figure 2). Some of the agencies involved in an EMS system have other responsibilities. For example, a fire department may respond to both fire and medical requests for aid. Allocation of the cost of being available to provide either of these responses is necessary to estimate the cost of the system. How to allocate such joint costs (products) is an area of considerable debate that cannot be resolved in this article. The decision to allocate costs (eg, capital, equipment, human resources) as a proportion of resources used is common. However, this decision is relatively arbitrary and without foundation in economic theory.36Brouwer W.B. Koopmanshcap M.A. Rutten F.F. Response to recommendation of the Washington Panel.Health Econ. 1997; 6: 253-259Crossref PubMed Scopus (135) Google Scholar, 37Johannesson M. Karlsson G. The friction cost method: a comment.J Health Econ. 1997; 16: 249-255Crossref PubMed Scopus (131) Google Scholar, 38Koopmanschap M.A. Rutten F.F. van Ineveld B.M. et al.The friction cost method for measuring indirect costs of disease.J Health Econ. 1995; 14: 171-189Crossref PubMed Scopus (817) Google ScholarCharges versus CostsA cost reflects the actual resources consumed to produce a good or service. In contrast, a charge is the price paid for a good or service, which may or may not reflect the resources consumed.39Finkler S.A. The distinction between cost and charges.Ann Intern Med. 1982; 96: 102-109Crossref PubMed Scopus (964) Google Scholar A charge includes the cost, taxes, and any profit that might be earned for goods or a service.Often the charges the system pays for goods or services do not reflect the true cost. For example, a medical direction contract may be less than the actual cost of paying for the time that a physician spends performing medical director duties. Further, the opportunity cost of labor that is provided voluntarily must be accounted for by assigning the prevailing wage of the community, even if a nominal wage is being paid. Use of the prevailing wage in the community is usually the best method to calculate costs when the actual charges are not accurate. This information can be obtained from the United States Bureau of Labor Statistics (available at http://www.bls.gov/oes). This is an area of controversy in the economics field. There are other ways of dealing with this issue that depend on the perspective taken and whether workers must be replaced if they are not available.Type of CostThe cost framework includes broad components. Costs within these components may be fixed, variable, or quasifixed. Fixed costs are not responsive to production levels (eg, the cost of building a fire hall is static regardless of how much it is used). Variable costs grow with higher levels of production (eg, labor costs increase as more hours are worked). If there are only variable costs, at zero production the total cost will be zero. Quasifixed costs, or “sticky” costs, are a combination of fixed and variable costs, in which costs are flat in a certain range of production but jump to higher levels if certain thresholds are reached (eg, improving response intervals by adding a staffed EMS vehicle because one can acquire whole but not partial vehicles).Description of the EMS Cost Framework ComponentsHuman ResourcesThis component includes all personnel involved in the EMS system, whether they are involved in direct patient care or not. When considering human resources costs, one must consider salary, benefits, overtime pay, and the cost of training if it is paid for separately. These costs must be considered regardless of whether the position is paid or unpaid.Physical PlantThis component includes any buildings that are necessary to train, provide, maintain, or administer the EMS system. When considering physical plant costs, one must consider the cost of acquiring, operating (eg, utilities" @default.
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