MIH Summit Ponders Payer and Policy Issues

On March 25 more than 200 professionals gathered in Washington, DC, to hear healthcare leaders address payer and policy issues at the 2014 Mobile Integrated Healthcare Summit. The National Association of EMTs (NAEMT) partnered with EMS World to host the half-day summit prior NAEMT’s annual EMS on the Hill event.

The attendees heard from 13 speakers. “This is our time to help the rest of the healthcare industry understand how we can add more value to the entire transformation,” said Matt Zavadsky, MS-HSA, EMT, public affairs director for Ft. Worth’s MedStar Mobile Healthcare, who helped open the sessions. “We are driving the train.”

The presenters were clear about the challenges facing prehospital providers and their agencies. The current healthcare system is fragmented, expensive and poorly allocated across the country. Physician shortages are exacerbated by an increase in the number of Medicaid patients in the system. Despite healthcare reform, EMS is stuck responding much as it did when it was first founded in the 1970s.

“Eight percent of the U.S. calls 9-1-1 for assistance,” said Brent Myers, MD, MPH, FACEP, director and medical director of the Wake County (NC) EMS system. “We treat every one of them like they wrecked their care on the interstate.”

Worse yet, many of those outside the profession perceive EMS as an outrageously expensive transportation provider. Zavadsky referred to a recent report in the New York Times outlining the expense of ambulance transports.¹ The article said the Centers for Medicare and Medicaid Services (CMS) is alarmed at the significant growth in transport costs compared to 2002.

“Any time you see the largest payer of our services and the word alarmed in the same sentence, it’s not good for us,” Zavadsky said. He noted that without the input of EMS leaders, fee structures could be set based on a retrospective analysis of whether patients were admitted to hospitals or calculated based on the provider’s ability to meet response-time goals. Neither would be good for EMS.

What makes this time unique for EMS, said NAEMT President Don Lundy, NREMT-P, is that, unlike the past, “where we either waited for a book to tell us what to do or made it up as we went along, we’re writing our history.”

Show Me the Money

The good news for EMS is that MIH isn’t access reform, it’s payment reform. A number of EMS agencies are piloting programs that test the waters of alternative reimbursement models. For example, the community paramedic programs from Eagle County (CO), North Memorial Medical Center (MN), American Medical Response and MedStar are self-funded through direct payments from healthcare partners. By affiliating with hospitals, physician groups, accountable care organizations (ACOs) and others, these agencies are saving money, providing a needed resource to patients and enhancing prevention programs.

Government agencies are funding pilot programs. In Nevada, the Regional Emergency Medical Services Authority (REMSA) received a $9.9 million CMS Healthcare Innovation Award to respond to lower-acuity and chronic disease calls. Project director Brenda Staffan said that, despite the innovation grants, getting CMS to pay for patients to go somewhere other than the emergency room is difficult.

“Medicaid, on the other hand, has some flexibility,” Staffan said. She noted that, historically, private payers have not been leaders in reimbursement changes. However, it could be different if they see the value. “Self-pay is still there, if we have a value proposition to the individual consumer,” she added. By informing a consumer of the significant savings involved in going to a clinic for lower-acuity responses instead of an expensive hospital, they may make the choice for themselves.

The capitated model is gaining acceptance in several areas of the country, including St. Louis. This model involves a payer providing a per-member, per-month fee to cover a specific population of patients. Chris Cebollero, NREMT-P, chief of emergency medical services at Christian Hospital, said an insurance company found it was cheaper to pay into a capitated account for EMS to identify alternative destinations for emergency department “super-users” than to pay for each ED visit.

When these patients call 9-1-1, a community paramedic is sent to provide a full medical screening and determine if a medical emergency exists. “We can’t just close the door on these people. We are either going to treat them at home or give them a cab voucher,” Cebollero said. Patients with an actual medical emergency are transported via medic unit to the ED. So far the program has reduced both EMS calls and ED visits in the target population.

While grants are available, don’t dismiss waivers, said Dawn Zieger, community health project director for John Peter Smith Health Network in Ft. Worth. Her organization used a CMS Section 1115 Waiver through the Social Security Act to fund a demonstration project.

Tips From the Front Line

The MIH speakers offered a number of helpful tips for launching a program. All of the speakers agreed that the single surest way to torpedo a new program was to duplicate one from another area. A good deal of legwork is needed up front to assess an individual community’s needs and identify key players. The focus must be to augment, not replace current programs. Staffan recommended starting with a small project: Test it, learn from it and then expand it. She suggested targeting a specific patient population, such as those with congestive heart failure, frequent EMS users or hospice patients.

Many current programs do not involve expanding the current paramedic scope of practice. But you have to identify the right employees to participate. “In your organization, you know who shouldn’t do this kind of work,” said Dan Swayze, DrPH, MBA, MEMS, vice president and COO of the Center for Emergency Medicine of Western Pennsylvania, Inc. “But you have others who are perfect. They have the genetic mutation to help people.” He noted they are usually the ones you reprimand for taking too long on EMS calls.

Typically the geographic area an ACO or medical facility covers doesn’t match a single EMS organization’s service area. In those cases, EMS agencies will have to band together to collaborate.

At hospitals, talking to the appropriate people is critical. “The president and vice president aren’t the right people,” said Cebollero. He suggested going to the process improvement director. Reducing readmissions is nice, but if you can help affect the length of stay, you can increase revenue.

Home healthcare can be especially anxious about community paramedic programs. Get them involved early, said J. Daniel Bruce, LCSW, CCM, GCM, administrator at Klarus Home Health in Fort Worth. “You need to think in terms of what you can do for them,” he said—how can you augment the service they already provide?

Medical professionals need to see that EMS providers are appropriately credentialed, explained Gary Wingrove, director of government relations and strategic affairs for Mayo Clinic Medical Transport in Minneapolis. To them, credentials mean competence and credibility. Education is getting slightly easier. He cited a 2013 mobile integrated healthcare/community paramedicine survey that showed 35 colleges nationwide are teaching or will teach a community paramedic training program. He estimated that in five years, the number will jump to 167. Although not all community paramedic programs need a full, accredited course, “there are some principles that can be used and standards that can be established,” Wingrove said.

Some states are challenged by legislation that stymies efforts to establish MIH programs. It takes time, but flexibility for innovation can be incorporated while maintaining the government’s statutory responsibility of protecting the public.

MIH is still evolving, particularly as it applies to individual communities throughout the country. “We are opening a menu we never had [to offer] before,” Myers said. Common medical oversight, documentation and accredited programs will be necessary to promote confidence from both government officials and insurers to pay for it.

The goal of the MIH programs discussed at the summit is to provide better care to more people, more effectively and more efficiently. Finding ways to pay for these programs has been a challenge, but it is not impossible. “These programs are very sustainable,” Zavadsky said, “once you prove the value to the patient first, then to the system.”

Reference

1. Rosenthal E. Think the E.R. Is Expensive? Look at How Much It Costs to Get There. New York Times, 2013 Dec 4.