Employee Dilemmas From Competing Organizational Goals: Insights from Emergency Medical Services

Abstract

The literature on multiple-goal organizations highlights the unique challenge of simultaneously meeting potentially conflicting profit and prosocial objectives. We study individual level performance effects on the delivery of a prosocial service in the presence of strong organization-level financial incentives. We examine these effects within the context of Emergency Medical Service (EMS) crews responding to 9-1-1 calls. Using data from 31 states reported to the US National Emergency Medical Services Information System, we find that even in the absence of direct individual benefits, EMS crews are responsive to the financial sustainability objective of their agencies by providing higher levels of service to patients with higher ability to pay. Specifically, we find that both private insurance and Medicare patients receive more procedures (4.6% and 1.5%) and have longer transport times (5.1% and 3.9%) than Medicaid patients controlling for time, call, patient, and condition characteristics. These differences reduce with call urgency and for agencies with a higher proportion of high ability to pay patients in the recent past but increase on busy days. The robustness of our findings derives from the quasi-random assignment of insurance across EMS units’ runs and the fixed effects specification in our models and is supported by several robustness checks including instrumental variable analyses.