An EMS Introduction to Accountable Care Organizations

Policy: Traditional EMS organization and reimbursement models haven’t changed much over time or with changing healthcare landscapes.

Strategy: New models like EMS consortia and organizations like ACOs may provide financial advantages in this new healthcare era.

Vision: Systems should consider new possibilities and arrangements to provide greater efficiencies and sustainability into the future.

What do we in EMS need to know about accountable care organizations and their role in our new healthcare systems? EMS World posed some basic questions to mobile integrated healthcare expert Matt Zavadsky, MS-HSA, EMT, director of public affairs for Ft. Worth’s MedStar Mobile Healthcare, about his organization’s experience and ACOs in general.

What groups are involved in your local ACO, and what kinds of programs has it sparked to cut costs?

In Fort Worth a local large independent practice association (IPA), North Texas Specialty Physicians, joined with one of our large hospital systems, Texas Health Resources, to form one of the original Pioneer ACOs, Medicare Plus. 

This group approached us with an opportunity they saw to reduce the incidence of observational admissions in emergency departments by using our community health program (CHP). Observational admissions occur when patients are held temporarily in an ED but not admitted as inpatients. In many cases, the patient has a follow-up appointment with a care provider within 24 hours, but the ED physician may be uncomfortable discharging them home, not knowing what the support system may be in that environment. Observation status typically lasts less than 48 hours.

Here’s a typical example: A 70-year-old woman comes to the ED for evaluation after a fall at home. Her examination and diagnostics in the ED are generally negative, but neither the patient nor the ED physician is sure why she fell. She has an appointment with her primary-care physician tomorrow, but due to the uncertainty of the home environment, the ED physician decides to keep her overnight in the ED for observation, then discharge her in the morning, closer to her follow-up appointment.

Under this program, the patient is discharged from the ED into our CHP, receives one or two in-home visits by one of our mobile healthcare practitioners (MHPs) and is safely transitioned to her follow-up appointment the next day. We also conduct an extensive home environment assessment to determine if there are any issues that need to be addressed to enhance safety. If so, we can connect the patient with community resources to help resolve any issues. We participate in a health information exchange to share these assessments with the patient’s primary care provider. The patient is also provided a 10-digit nonemergency access number in case she needs any episodic care.

So far, 51 patients have been referred to the program, and only one needed to be seen again in the ED prior to their follow-up appointment. According to IPA data, each avoided observational admission saves them $7,800.

In July Medicare Plus was one the ACOs that withdrew from the CMS program. However, the IPA still has 20,000 Medicare-covered lives in a shared-risk Medicare Advantage program with a large insurer in a program called Secure Horizons. They have kept our program in place for the patients enrolled in the shared-risk population.

How did MedStar initially get involved?

The medical control authority for MedStar is provided by an external medical oversight board, the Emergency Physicians Advisory Board (EPAB). EPAB consists of the physician medical directors for all the EDs in our service area and representatives from the county medical society. This board contracts for the medical director and associate medical director for the system. Our associate medical director is part of the IPA that partnered in the ACO. He suggested to the IPA that we meet to discuss the possibility of helping with the observation admit challenges the ACO faced.

The initial meeting to discuss the possibility was with the IPA’s medical management committee, composed of healthcare system stakeholders including hospital case management directors, payers, physicians and hospital administrators. At the meeting we simply introduced the concept, and most of the other committee members began sharing their experiences with our community health program. Needless to say, the committee unanimously recommended the program.

What other MedStar programs are part of this? What might be in the future?

In addition to the observation admission avoidance program, we conduct several other mobile healthcare programs for other payers and healthcare partners.

High utilizer/“EMS Loyalty” program—Patients who activate the 9-1-1 system a certain number of times are asked to enroll in the program. If they consent, we work with the patient to help them access healthcare in a way that is more patient-centric than using the ED. These patients also get a 10-digit nonemergency number to contact our call center for a visit by one of our MHPs. The patients are also flagged in our 9-1-1 CAD system. In the event of a 9-1-1 call, we add the MHP to the response to potentially navigate the patient to the best resource.

CHF readmission reduction program—Patients at high risk for a 30-day CHF readmission are referred to the program for voluntary enrollment. Through a series of home visits that decrease in frequency over the 30 days, the patients receive specific education to help manage their condition. They also get logs to track their weights and medication compliance. We continually provide feedback to the patient’s PCP and teach the patient how to regularly access their primary care network.

In the event of decomposition or fluid retention, point-of-care testing for relevant lab values can be analyzed in the home and the assessment provided to the patient’s PCP. If needed, a diuretic protocol developed and approved by our medical director and system cardiologists can be used to help the patient at home, with a follow-up PCP appointment.

Hospice revocation avoidance program—Patients and patient families at risk for hospice disenrollment are referred to this program. We conduct a joint home visit with the patient’s hospice nurse. The family is reminded that the hospice nurse is their primary point of contact, but in the unusual event that the hospice nurse cannot be readily accessed, the family can contact us for a home visit by our MHPs. These patients are also registered in our CAD, with contact numbers for their assigned hospice nurses. In the event a patient or family calls 9-1-1, we send the regular response, add the MHP to the call, and contact the hospice nurse to respond to the scene. The MHP typically arrives prior to the nurse and, if the medical request is hospice-related, reminds the family of the patient’s desire for hospice status and that we’ve arranged direct admission to an inpatient hospice unit.

Is there data yet to demonstrate patient benefit or cost savings?

Yes. The biggest improvement in these patients is the change in their overall health status. When patients are enrolled, we use the EuroQol survey to assess their health status. The patients self-report things like their mobility status, limitations on daily activities and overall health status. They repeat the survey upon graduation from the program. The CHF patients report a 32% improvement in overall health status. High-utilizer group patients report a 98% improvement.

We also track and report data related to the patients’ utilization of 9-1-1, ED use and admissions. For the high-utilizer population, we have seen a reduction of 9-1-1 use by 48% during the 30–90-day enrollment with a sustained reduction of 86% post-graduation. Tracking 50 patients with 12 months of pre- and 12 months of post-enrollment data, a total of 989 ambulance trips to the ED have been averted in the past 12 months. When you apply the typical health system expenditures of $421 for an ambulance trip and $774 for just the ED facility charge, you have a savings of more than $1 million.

Tracking the 24 referred and enrolled CHF patients in the program, every one of them was referred due to the risk of a 30-day readmission. This population had three readmissions, resulting in a readmission rate of 8.6%, compared to 24.7% rate in the community. In terms of actual utilization, we have prevented 21 30-day readmissions in the enrolled patients. Applying the same $421 ambulance expenditure and adding the CMS-reported $17,500 expenditure for a CHF admission, we’ve saved $377,000 in that population.

How would you characterize your ACO involvement to date (pros, cons, surprises, wisdom to share)?

The primary thing we’ve learned is how to operate in their world, speak their language and learn what is important to them. We’ve also learned that they suffer the same challenges we do, such as sharing information in the HIPAA environment and tracking data. One of our programs didn’t see its first referral for months because the IPA case manager working in the ED wasn’t granted access to the hospital’s EMR. That seemed silly, since they were part of the same ACO.

We also learned how they apply the value equation. We initially undervalued our price for services because we used our typical cost-based pricing model where they were using the cost-reduction model. We have now learned to apply the same value matrix in a shared-savings model as opposed to the cost-based model.

We also learned to be patient. ACOs and other payers are still learning how to navigate their own systems, let alone the new role of a provider they typically viewed as a cost, not a cost-saver. Sometimes that took some time to evolve; however, once it did, they had numerous other programs they want us to consider working on with them. Overall, it has been exceptionally positive.

What are the different/other types of ACOs relevant to EMS organizations? Are other services participating in different ways?

They all look and act a little different. We partnered with an ACO that involved a large IPA with a large hospital system. There are ACOs composed of payers and hospitals, hospitals and outpatient providers, and physicians and payers. They also operate under different structures within CMS. Some are shared-savings models, some have capitated rates for defined populations.

What we need to understand is that the concept of financial incentives for accountable care does not have to be in a strict ACO model. Since our ACO bowed out of the ACO model, we have continued to be paid by the IPA for the patients they have in a shared-risk arrangement with a large payer. Interestingly, the hospital that was part of the ACO has asked us to contract with them to help manage their high-ED-utilizer population. So regardless of the term ACO, there are payers out there who see the value of mobile integrated healthcare services and are willing to invest in them.

How can EMS agencies get the process of ACO involvement started? Is it right for everyone?

EMS agencies need to start the dialogue with ACOs and other payers. They have problems, and we have logical solutions to their problems that they don’t know about. That starts with the realization that we are healthcare providers who deliver care in the mobile environment. Once we come to grips with that reality, we can engage our internal and external stakeholders in an infectious dialogue that opens doors to multiple opportunities. If you don’t bring your proposed solutions to the stakeholders, they will find their own.

Some form of mobile integrated healthcare is right for everyone. Be sure your programs meet defined needs in your community. We function most effectively in the “transitional” setting, not the replacement setting. Every community is different. An urban area may need patient navigation services, not a substitute for primary care already available. A rural community may need primary care providers. Involve multiple stakeholders in a community assessment to see if there are gaps you can fill. If so, determine the value of filling each gap and collaboratively start providing the service.

Start small and work out the issues on a small program. Once you’ve refined the process and built trust, the sky’s the limit.

Matt Zavadsky, MS-HSA, EMT, is director of public affairs for MedStar Mobile Healthcare, the public utility model system in Fort Worth and 14 surrounding cities in North Texas.