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  • 3 Oct 2018 8:54 AM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    Interesting continued coverage of activities related to balanced billing for air ambulance, including the perspective of the anonymous consultant regarding the payment amount vs. costs

    Congress angles for air ambulance cost transparency


    OCTOBER 2, 2018

    Last November, a fully insured North Dakotan was dispatched on an 84-mile medical air transport from Langdon, N.D., to Grand Forks. When the charges came in at more than $66,000, out-of-network insurance covered just $16,000.

    The patient was left with a $50,000 bill balance from Valley Med Flight. The tab far exceeded the $29,000 to $30,000 average price for a cross-country charter flight on a private midsize jet from Virginia to Oregon—according to an informal estimate by the charter company EvoJets.

    According to tallied complaints lodged with the state's insurance department and provided by Blue Cross and Blue Shield of North Dakota, surprise charges for various medical flights from the past four years ranged from $26,000 to nearly $534,000—although the latter number is a major outlier. Most charges fell between $30,000 and $88,000, with the average hovering around $60,000.

    One North Dakotan had a lien placed on their home. Another had wages garnished. Families have gone into bankruptcy.

    "They have health insurance, but no control over who picks them up," said Jeff Ubben, the state's deputy insurance commissioner.

    Like other states, North Dakota has tried to curb the unexpected bills. In 2015 the Legislature passed a law to split the medical air transport companies into two call lists. To make it on the primary call list, the company would have to be in-network with at least 75% of the state's health insurance contracts. All others would have dropped to a secondary call list and would only have been able to respond if none of the companies from the primary list picked up.

    In 2016, a federal judge struck down the law after Valley Med Flight sued, just as federal judges around the country have struck down similar state measures for violating the Airline Deregulation Act of 1978. This federal law bans states from regulating rates, routes or services of commercial airlines and continues to overrule state efforts to rein in air ambulance charges.

    Valley Med Flight is one of North Dakota's largest medical transportation companies, re-branded this year as Guardian Flight. As a subsidiary of Air Medical Group Holdings, which is owned by the global investment firm KKR, it is one of several sister air ambulance companies operating in the U.S.

    Air Medical Group Holdings did not respond to requests for comment.

    In 2017, North Dakota tried to tackle air ambulance billing again from a different angle, this time limiting out-of-network insurance reimbursements for these claims. If a person is transported by an out-of-network air ambulance, the transport company must accept the rate of an in-network carrier.

    Guardian Flight sued, but the case is still pending in federal court in Bismarck. Ubben told Modern Healthcare his office hasn't received consumer complaints since it went into effect in January of this year.

    But Congress would need to change the law to allow states to regulate the charges. Sen. Claire McCaskill (D-Mo.) pushed a bill this year to clarify that the 1978 statute could not prevent states from regulating the medical costs from air ambulances.

    Provisions from her proposal made it into the latest Federal Aviation Administration reauthorization bill expected to clear Congress this week, but ultimately lawmakers dropped the crucial measure that would allow states to address the consumer cost question.

    The final compromise provision requires the U.S. Transportation Department and HHS to convene an advisory committee of stakeholders to examine transparency measures, consumer education about insurance options for air transport and protections from excessive charges.

    Air ambulance companies would also need to list the Transportation Department's complaint hotline and website address on all bills. The Transportation secretary would have to set an industry oversight plan and write guidance for states on how to refer billing complaints.

    The provisions concur with some 2017 recommendations from the U.S. Government Accountability Office, which called for greater price transparency and better handling of consumer complaints.

    Insurers, insurance commissioners, patient advocates and the medical air transport industry herald the measure as "a step in the right direction," but it's unclear just how significant that step will be.

    The Transportation Department already oversees and handles consumer complaints on air transport, but close observers of the balance billing issue say the current process doesn't support patients stuck with tens of thousands of dollars of debt.

    "The Department of Transportation has regulatory authority and can determine whether the practices of any airline are fair or unfair, but they don't have expertise on medical billing practices," said Julie Mix McPeak, president of the National Association of Insurance Commissioners and Tennessee insurance commissioner. The association has been working on the issue for the past three years. "However, the department has yet to take action, and states are barred legally from doing so."

    The Association of Air Medical Services, or AAMS, the lobbying group for air ambulance companies, supports the final provision as a balanced approach.

    "We believe the formation of the advisory committee of stakeholders tasked with solving the complex issue of balance billing is a definite step in the right direction," the group said in a statement. "AAMS advocates for any effort to increase transparency to ensure our patients are not burdened by a bill that they did not expect and cannot afford."

    But ultimately the trade group blames the high balance bills on what they deem as inadequate Medicare reimbursements. The AAMS compares the air transport companies' net financial position with that of rural hospitals serving mostly government-insured or uninsured patients.

    The AAMS wants Congress to look at recalculating the air ambulance Medicare reimbursements, claiming it's "the only lasting solution" to protect air medical services, especially in rural areas.

    Both the House and Senate have introduced bills that would launch this effort, which are supported by the AAMS.

    Medicare's base pay for a single helicopter transport is $4,624, then an additional $31.67 per mile. According to data from the CMS, Medicare reimbursement for a typical 61-mile trip is about $6,556.

    The AAMS says that based on an independent study by the consulting firm Xcenda, Medicare covered 59% of actual costs in 2015.

    But one consultant, who spoke on condition of anonymity, pushed back on companies' claims that their charges correlate to their Medicare reimbursements. He said that the Medicare fee schedule, which moved reimbursements for air ambulances from Medicare Part A to Part B, favored the air ambulance industry when they were set in the early 2000s.

    He argued that the industry's claims about compensating for Medicare rates through high commercial and balance bill charges "are more related to underutilization and overcapacity."

    "In 1997 there were about 350 helicopters doing this," he said. "Today there are over 1,100."

    He estimated that Medicare pays for about one-third of these flights, commercial plans pay another one-third and Medicaid covers roughly 20% of the rest.

    "When two-thirds of customers paid at a rate that's favorable, the companies tripled the number of helicopters," he said, adding that the industry's ability to spread its fixed costs over a large number of transports is reduced because there are too many transports.

    "The problem is not that operating costs have dramatically increased; rather, companies cannot spread those costs over a reasonable number of flights," he said. "The industry then attempts to use this self-inflicted situation as justification for their extravagant billed charges."

    Aaron Todd, CEO of the operator Air Methods Corp., acknowledged in a 2015 investor earnings call that the number of transports may exceed market need.

    "And if you ask me personally, do we need 900 air medical helicopters to serve this country, I'd say probably not, maybe 500, 600 could do well, but it's an open market, these are—we don't have certificate-of-need restrictions," Todd said, according to the call transcript.

    One insurance lobbyist, who characterized the air ambulance market as "the wild West," complained of the sometimes aggressive ways companies find patients in the limited pool.

    "I've seen air ambulances following the police radio and showing up at the scene of an accident," the lobbyist said. "They have all sorts of tactics to get called."

    Analysis of one company's data shows the number of medical air transports per base has declined as those bases have proliferated. 

    According to numbers gleaned from past annual reports by Air Methods Corp.—one of the largest providers and publicly traded until a private equity firm bought the company last year—69 bases sent out about 39 transports each per month in 2005. In 2013, 179 bases each sent out about 25 transports per month. The company's annual number of total transports during that period increased from nearly 32,000 to just over 53,000.

    Rising operational costs for the air transport companies were the result of business decisions, the consultant said. "No one forced it; they just did it by themselves."

    He also said transport services develop relationships with the providers who dispatch patients from one facility to another for care. About 80% of transports send a patient from one facility to another, rather than airlifting a person from the scene of an accident.

    Even if they don't have a referral relationship with the air transport company, the consultant added, hospitals don't necessarily watch out for the patients' wallets since it isn't their money.

    "Again, you don't have a market where buyers or sellers are agreeing to buy some quality or quantity," he said. "None of this is a market situation."

  • 2 Oct 2018 9:26 AM | AIMHI Admin (Administrator)

    NYT Source Article | Comments Courtesy of Matt Zavadsky

    Another example of the ‘value’ challenge of traditional “EMS”. 

    Recall that Dr. Elisabeth Rosenthal (now the Editor in Chief of Kaiser Health News) also did an article in the NYT about the value of EMS, and she also did a video interview on the same topic…

    Contrast the message in recent media reports in publications, such as the NYT and Washington Post, extolling the value of “EMS 3.0” MIH services such as community paramedicine, alternate destinations and 9-1-1 nurse triage. 

    These vastly different perceptions of ‘value’ are likely why many EMS agencies are implementing MIH services, and many payers are moving quickly to pay for EMS patient navigation as opposed to being paid simply as a conveyance mechanism!

    Tip of the hat to Jonathan Washko from Northwell Health for sending along yesterday’s NYT article!

    Uber, Lyft and the Urgency of Saving Money on Ambulances

    ‘Don’t reflexively call an ambulance,’ a Harvard researcher says. In many cases, a cheaper way makes sense.


    By Austin Frakt

    Oct. 1, 2018

    An ambulance ride of just a few miles can cost thousands of dollars, and a lot of it may not be covered by insurance. With ride-hailing services like Uber or Lyft far cheaper and now available within minutes in many areas, would using one instead be a good idea?

    Perhaps surprisingly, the answer in many cases is yes.

    The high cost of an ambulance isn’t really for the ride. It comes with emergency medical staff and equipment, and those can be very important, of course, even lifesaving.  But they are not things you always need, although you (and your insurer) pay for them with every trip.

    “Don’t reflexively call an ambulance,” said Anupam Jena, a physician and researcher with the Harvard Medical School. “Ambulances are for emergencies. If you’re not having one, it’s reasonable to consider another form of transportation.”

    The cost of ambulance rides adds up. In 2011, the United States spent about $14 billion on ambulance services, $5.3 billion of which Medicare paid for. Many of those trips might not have required an ambulance. Estimates of inappropriate use vary, but most are around 30 percent.

    Although it’s not always clear when an ambulance is warranted, there is evidence of waste and fraud in the industry.

    Last year, ambulance companies collectively billed Medicare improperly for at least $700 million.

    In 2014, employees of a Philadelphia-area ambulance company received prison sentences for fraudulent bills. That same year, the owners of a Tennessee company were convicted of fraudulent ambulance billing. A 2015 O.I.G. report found that half of questionable billing of Medicare by ambulance companies is from four metropolitan areas: Philadelphia, Los Angeles, Houston and New York.

    Other recent evidence from New York suggests a substantial number of ambulance rides are taken for non-emergencies. Scholars from Georgia State University and the University of Colorado Denver studied ambulance rides in New York before and after the Affordable Care Act’s coverage expansion. After the expansion, dispatches for minor injuries rose considerably while those for more severe ones did not.

    By 18 months after the expansion, ambulance dispatches for minor injuries were up 150 percent.  An explanation for the results is that a person’s insurance coverage tends not to affect a decision about calling an ambulance in a real emergency. But for minor injuries, people are more likely to call an ambulance if they have coverage than if they do not, even if they don’t really require that level of care.

    Using an ambulance also diverts attention and resources from true emergencies. Response times are longer than they could otherwise be if ambulances were used only when needed. One study found that the Affordable Care Act, by expanding coverage and financial access to ambulance rides, slowed ambulance response times by 19 percent.

    Uber and Lyft can’t disobey traffic laws the way ambulances can to speed people to a hospital in urgent situations. But they can broaden transportation options for patients and could disrupt the ambulance market. Both have announced new services to provide rides to medical appointments. This kind of non-emergency medical transportation is something many health plans already provide, but Uber and Lyft may be able to do it more cheaply, with better customer service and less waste.

    Uber Health would allow health care providers to order rides for their patients. As of March, over 100 health care organizations were using the service. Lyft Concierge is similar and already being used by a number of organizations that arrange rides for people in need of care.

    Of course, patients can request Uber or Lyft rides on their own, instead of an ambulance. And these services could help patients avoid missing appointments because of lack of affordable transportation. They may also help patients receive care in more appropriate and lower-cost settings, like a doctor’s office instead of an emergency department. One study found that Uber’s entry into a city reduced ambulance use by 7 percent.

    An advantage of arranging your own ride is that you can direct it to a hospital or doctor’s office of your choosing. In contrast, ambulances take patients only to hospitals — and typically to the nearest one, whether the patient would prefer that or not.

    This can actually degrade care. Evidence suggests that patients who return to the hospital where they received major surgery have a lower risk of mortality than if they go to another hospital. With an ambulance, there is no guarantee you’ll return to the same hospital.

    Although lack of affordable transportation is one barrier to care, it isn’t the only one. A randomized study of Medicaid patients at two Philadelphia-area clinics found that offering Lyft rides did not change missed appointment rates. Patients may miss appointments for other reasons, such as being unable to get off work or to obtain child care.

    “We often use higher-intensity care more than necessary throughout our health system,” Dr. Jena said. “Ambulance rides in non-emergencies is just one example.”

    For some, the financial setback of an ambulance trip can be immense. An alternative choice for non-emergencies could save a person thousands of dollars and help reduce waste in a system rife with it.

    Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health.

  • 2 Oct 2018 9:14 AM | AIMHI Admin (Administrator)

    Health Affairs Source Article | Comments Courtesy of Matt Zavadsky

    Interesting counsel from the authors, and, interesting reference to the transport policies in Philly…

    When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply?

    Sara F. Jacoby  Elinore J. Kaufman  Therese S. Richmond  Daniel N. Holena

    OCTOBER 1, 2018

    At the University of Utah Hospital last October, a nurse was arrested when she refused to draw blood from an unconscious patient for a police officer who was lacking a legal warrant. Surveillance footage of her arrest and rough treatment drew national media attention. As a consequence, the police officer involved was fired from his job, and the hospital issued a policy that now bans law enforcement activities in patient care areas of its medical center. The Utah Legislature responded as well by passing a bill to outline conditions under which police can obtain blood samples from patients for investigative purposes. 

    This case may have been extreme, but conflicts between clinicians and police are not uncommon. Emergency departments are arguably an epicenter of opportunity for this kind of conflict. It is in these clinical settings that intersections between health care and law enforcement activities are most frequent, for example, when police respond to medical emergencies or seek information to inform emerging criminal investigations. The challenge of these interactions is that clinicians and police have distinct professional priorities, and there is notable ambiguity in how best to interpret guiding policy and ethics. 

    Clinicians And Police Have Intersecting But Potentially Conflicting Responsibilities 

    Traumatic injuries, such as gunshot wounds or motor vehicle crash injuries, are conditions that attract both health care and law enforcement responses. In these circumstances, clinicians and police share a mandate to protect injured people and public safety. However, the police mission to initiate an investigation and solve crimes may compete with the urgency of emergency health care, which is built on protocol-driven systems for rapid diagnosis, medical stabilization, and triage. 

    Injured people, themselves, are rarely in a position to advocate for their own medical and legal needs during emergency care. Traumatic injuries can cause physiologic and psychological alterations that limit the ability to fully consent to medical procedures and legal interrogation. Once a person is transported from the scene of an injury and into a health system, health care ethics and laws obligate clinicians to offer help and guardianship. This includes protection of privacy over health information and patients’ autonomy in decisions that affect health and well-being. 

    A Complex Policy Landscape With No Clear Oversight 

    To date, there are no universal cross-disciplinary policies from which to outline clear expectations for interactions among trauma patients, clinicians, and police in health care institutions. The American College of Emergency Physicians published a statement in 2010 that reinforces the primacy of patients’ rights, dignity, and interests when law enforcement activities take place in health care institutions. Members of the emergency medical community have subsequently advocated for the creation of explicit policy guidance for these activities and offer a sample policy for implementation. Enacting, operationalizing, and auditing compliance to these policies is/would become the responsibility of individual health care systems. This is not necessarily a simple pursuit. In doing so, health systems will need to consider and integrate their own institutional policies and practice norms with relevant but potentially inconsistent federal, state, and local policies. 

    The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 prohibits clinicians from releasing information about patients to police without consent or a court-ordered warrant. Exceptions are made when: required by law (that is, state-mandated reporting), where criminal conduct is suspected (as a cause of a patient’s death or during medical care), or to avert a serious threat to public health or safety.

    In addition, a 2003 US Supreme Court ruling affirmed the constitutionality of police seeking testimony for a criminal investigation during emergency medical care when an injured non-Mirandized patient was suspected of a crime. 

    State laws may actually necessitate interactions between clinicians and police after a traumatic injury, but the conditions for mandated interactions can vary from state to state. In most states, clinicians are required to report evidence of child and elder abuse. In several but not all states, clinicians are also required to report any suspicion of assault, domestic violence, or drunk driving associated with an injury. 

    At a local level, municipal policies can influence the ways that clinicians and police interact in response to injuries. In Philadelphia, Pennsylvania, for example, where the rate of violent injuries outpaces the resources available for emergency medical systems, the city permits police to provide direct transport to the nearest accredited trauma center. As a result, a substantial proportion (more than 50 percent in recent years) of patients with penetrating wounds such as gunshot injuries arrive at Philadelphia trauma centers in police vehicles. Across national trauma systems, police transport has been shown to be as effective as ambulance transport and is believed to be a lifesaving intervention for cities with high rates of injuries and proximity to the resources of trauma centers. At the same time, this practice creates opportunities for police to question patients en route to a hospital and offers a direct pathway for law enforcement activities within trauma center emergency departments. 

    Lack Of Clear Policies Can Put Patients And Clinicians In Vulnerable Positions 

    The danger of the current policy landscape is that any interpretive ambiguities can result in ad hoc negotiations for when, where, and how law enforcement activities take place in health care institutions. This may lead to unintended, informal, and even illegal access to patients and disclosures of their health information to police. It can also promote interprofessional conflict and negative clinical outcomes. If, for example, patients can’t differentiate between questioning in the service of law enforcement and questioning in the service of medical care, they may be reluctant to communicate essential information to their health care team. Our recent research describes how black patients in a Philadelphia trauma center express conflicted interpretations of their interaction with police during emergency injury care. Some perceived police to be acting in their best interest by offering security and expediting transport to the hospital. Others found police questioning as an added stressor and disruption to the medical interventions they felt were essential for their survival. Victims of gun violence in Chicago describe similar impressions of their interactions with police in the aftermath of their injuries. 

    The diversity of federal, state, and local polices make it difficult to imagine a singular rule of conduct for all law enforcement activities in health care settings. Professional trauma surgery and nursing societies, however, have the opportunity to articulate the need for boundaries and necessary considerations when law enforcement activities take place within US trauma centers. One pathway toward leadership in this area would be for entities such as the American College of Surgeons Committee on Trauma, which accredit US trauma systems, to mandate and audit compliance to individual institutional policies. Not only would this present the opportunity to better protect injured patients, clarify professional role expectations, and prevent conflict, it would also better prepare legal counsel and ethical consult teams to support clinicians in cases of difficulty in policy interpretation. 

    Balancing Patients’ Rights And Health With Clinicians’ Rights 

    As institutional policies are developed, the process should ideally integrate multiple stakeholders including community members, police, and a full range of health system actors. There may also be benefit to bringing multiple institutions and sectors together with the leadership of city or state health departments to consider policy interventions that guide intersections between emergency health care and law enforcement that can account for local needs, resources, and environments. Although institutional context may vary, we recommend three core policy goals: 

    1. Policies that guide law enforcement activity in health care institutions should make patient health the first priority. Except in extreme cases of public safety risk (active shooter threats, terrorist events, and so forth), law enforcement officers should not interview patients until they are medically stabilized as determined by treating clinicians. Health care institutions and law enforcement agencies should also work together to clearly define how patients who are under arrest or incarcerated are managed in the emergency department to permit clinicians the opportunity to provide the same standard of medical treatment as would be offered to any patient in their care.
    2. Patients’ rights are the next priority. Therefore, except as above, law enforcement officers should not interview patients until they are mentally ready to understand and participate (stable, not overly sedated or narcotized). Patients should also have access to appropriate legal counsel at all times, even if this delays questioning. Hospitals and local law enforcement and legal communities should set up systems to facilitate representation.  
    3. Although health care personnel are not legal experts, they have a responsibility to protect patients’ health and rights and should be educated about guiding policies and feel empowered to step in as needed. Following the example of University of Utah Hospital, health care institutions need to put into place structures and processes to accomplish these goals. 

    Programmatic crossroads between law enforcement and injury and emergency care will likely continue to increase in response to looming public health threats. The Stop the Bleed campaign to prevent death after trauma and Naloxone distribution to prevent the consequences of opioid overdoses are two prominent examples in which health care and law enforcement providers are interacting to promote public health priorities outside of the hospital. While challenging, developing policy to extend cross-disciplinary collaboration within emergency department settings in a way that protects the rights and well-being of patients, health care providers, and the public is an ethical imperative. 

    Authors’ Note

    All authors are senior fellows of the Leonard Davis Institute (LDI) of Health Economics at the University of Pennsylvania. Support for this work was provided by the LDI Policy Accelerator Program.

  • 1 Oct 2018 4:35 PM | AIMHI Admin (Administrator)

    Comments from Matt Zavadsky

    Governor Edmund "Jerry" Brown vetoed the California Community Paramedic legislation late yesterday…

    In his ‘veto message’ back to the stakeholders (attached), Governor Brown states:

    • His support for CP programs
    • His concerns with the restrictions in the Bill
    • Authorizes the continuance of the pilots, and
    • Urges the stakeholders to find a way to make CP permanent in California, without the restrictions contained in AB 3115

    Tip of the hat to Lou Meyer, the loaned executive from the California Healthcare Foundation to the California Emergency Medical Services Authority, for making us aware of this breaking news. 

    The CHCF is a major supporter of Community Paramedic program development in California.

    Please support Lou, Dr. Howard Backer and the State EMS Authority, and the numerous other stakeholders in supporting the further development of CP programs for California!

  • 1 Oct 2018 8:27 AM | AIMHI Admin (Administrator)
    JAMA Source Article | Highlights courtesy of Matt Zavadsky

    Original Investigation
    September 26, 2018

    Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies

    JAMA Cardiol. Published online September 26, 2018. doi:10.1001/jamacardio.2018.3037

    Masashi Okubo, MD, MS1Robert H. Schmicker, MS2David J. Wallace, MD, MPH1,3; et al Ahamed H. Idris, MD4,5Graham Nichol, MD, MPH6Michael A. Austin, MD7Brian Grunau, MD8Lynn K. Wittwer, MD9Neal Richmond, MD10Laurie J. Morrison, MD, MS11Michael C. Kurz, MD12Sheldon Cheskes, MD11Peter J. Kudenchuk, MD13Dana M. Zive, MPH14Tom P. Aufderheide, MD, MS15Henry E. Wang, MD, MS16Heather Herren, MPH2Christian Vaillancourt, MD7Daniel P. Davis, MD17Gary M. Vilke, MD17Frank X. Scheuermeyer, MD8Myron L. Weisfeldt, MD18Jonathan Elmer, MD, MS1,3Riccardo Colella, DO, MPH15Clifton W. Callaway, MD, PhD1; for the Resuscitation Outcomes Consortium Investigators

    Author Affiliations Article Information

    JAMA Cardiol. Published online September 26, 2018. doi:10.1001/jamacardio.2018.3037

    Key Points

    Question  What is the variation in survival after out-of-hospital cardiac arrest between emergency medical services (EMS) agencies?

    Findings  In this cohort study, among 43 656 adults treated for out-of-hospital cardiac arrest by any of 112 EMS agencies, there was a median difference of 56% in the odds of survival to hospital discharge for similar participants between any 2 randomly selected EMS agencies, after adjusting for known measured sources of variability and clustering of patients within agencies.

    Meaning  This study suggests there is substantial unexplained variation in survival after out-of-hospital cardiac arrest across treating EMS agencies in North America, despite controlling for documented patient and agency characteristics.


    Importance  Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood.

    Objective  To quantify variation in patient outcomes after OHCA across EMS agencies.

    Design, Setting, and Participants  This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018.

    Exposure  Treating EMS agency.

    Main Outcomes and Measures  The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies.

    Results  We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency–level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]).

    Conclusions and Relevance  We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency–level variables.

  • 28 Sep 2018 8:26 AM | Matt Zavadsky (Administrator)

    News Release


    Contact:             Mitzi Vince

    Phone:                 (304) 346-9864, ext. 3253


    CHARLESTON, WV (September 20, 2018) – Quality Insights has partnered with the Kanawha County Emergency Ambulance Authority (KCEAA), the Partners in Health Network and Jan Care to produce two educational videos on the impact of community paramedicine in West Virginia.

    Community paramedicine (CP) is a form of expanded care – often referred to as mobile integrated health care services – that is delivered by nationally-registered paramedics who have received additional training. CP has been shown to help lessen unnecessary hospital admissions and emergency department visits while enhancing access to quality care for the state’s most vulnerable and rural residents.

    “We teamed up with community paramedicine experts in our area to produce these videos as a way to help both patients and healthcare providers understand the positive impact of CP on people with Medicare who live in West Virginia,” Biddy Smith, Network Task Lead for Special Projects at Quality Insights, said.

    The videos, which are available on Quality Insights Quality Innovation Network’s YouTube channel (, include a patient-focused video titled “Community Paramedicine: Quality Health Care at Your Door” that explains the benefits of CP from the patient perspective. A provider- focused video, titled “Community Paramedicine: Enhancing Access to Quality Health Care,” examines the impact of CP on the healthcare industry.

    “Community paramedicine is filling a gap of needs within our communities,” Monica Mason, Director of Community Paramedicine at KCEAA, said. “Once patients are discharged from the hospital, our paramedics go out into the home and visit them to ensure that the plan of care from the hospital is continued to the home until they get back to their doctor’s office for follow-up and further recommendations.”

    Like Mason, fellow advocate Jerry Long believes community paramedicine can have a positive effect on decreasing overall healthcare costs by treating patients before they need to call 9-1-1.

    “I always felt like there was something more we could be doing,” Jerry Long, Director of Mobile Integrated Healthcare/Community Paramedicine at Jan Care, said. “We’re the second most rural state in the country. Our biggest healthcare crisis, in my opinion, is access. There are a lot of people still using emergency rooms as their primary care physician and that’s just a flawed system.”

    A community paramedic can address both medical and social needs. Community paramedics can provide home safety assessments, triage and referral services, chronic disease management education, support for family caregivers, medication compliance support, vaccinations and more.

    “It’s our hope that these videos can communicate the benefit of CP, not just for the patient, but also for the healthcare industry as a whole,” Smith said. “We want patients to understand how it can help improve their quality of life and we want providers to understand how CP is filling critical gaps in an effective and efficient way.”

    For more information about this project, contact Biddy Smith at, or call (304) 346- 9864 ext. 3252.

    About Quality Insights Quality Innovation Network

    Quality Insights is the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Delaware, Louisiana, New Jersey, Pennsylvania and West Virginia. Quality Insights collaborates with healthcare providers, patients and allied organizations across the network to bring about widespread, significant improvements in the quality of care they deliver. We are committed to reaching the Centers for Medicare & Medicaid Services' goals of better care, smarter spending and healthier people. To learn more about the network, visit

  • 27 Sep 2018 9:09 AM | AIMHI Admin (Administrator)

    San Diego Tribune Source Article | Comments Courtesy of Matt Zavadsky

    Nice to see a) the city and AMR attempting to revive the RAP prior to June 30th and b) San Diego including an MIH program in their RFP as a required component of a new ambulance contract! 

    Maybe a 1st in the nation to require a proposer implement an MIH program!

    Tip of the hat to Jeff Rollman from UCLA’s Fielding School of Public Health for the heads up on this story…

    San Diego will require new ambulance provider to weed out 911 abusers

    David Garrick

    September 25, 2018

    San Diego officials say the city’s new ambulance provider will be required to revive a program that targeted unnecessary 911 calls.

    The “request for proposals” for new ambulance providers that city officials plan to circulate this fall will require applying companies to agree to revive the program and cover the costs of potentially expanding it.

    The program, which ceased operations a year ago, used a software filter to identify and reroute the most frequent 911 callers: the homeless, the mentally ill and drug addicts.

    It drew national praise and saved the city money from 2010 through 2016 by allowing ambulances to focus on the most urgent emergency calls. But financial concerns prompted ambulance provider American Medical Response to stop providing the four paramedics required to operate the program.

    That company’s contract to provide San Diego ambulance services expires on June 30, giving the city an opportunity to require the program be revived after that.

    In June, the county grand jury issued a report criticizing the city for allowing the program, called the “resource access program,” to cease operations.

    City officials last week said they had little choice in the matter and that they are in ongoing discussions with American Medical Response about possibly reviving the program before June 30.

    The program’s software filter allowed city officials to build a history for each individual who was placing multiple calls to 911. It included the number of calls, length of time between the calls, the nature of the incidents and the treatment required.

    Paramedics contacted frequent callers to let them know about social services, mental health resources, shelters and other help. Some were also assigned case managers.

    Meanwhile, the city started to flag 911 calls from frequent callers and route them differently than an ordinary 911 call.

    Instead of sending those calls only to paramedics, they were sometimes routed to a wider network of service providers, including law enforcement, homeless outreach teams and social workers.

    In a response to the grand jury approved last week by the City Council’s Public Safety committee, city officials say the program was a success but that its elimination didn’t create the logistical strain described by the grand jury.

    The response says San Diego’s emergency call system can handle the extra volume of calls created by the city’s roughly 1,400 frequent callers, who generate 15 percent to 20 percent of all calls.

  • 26 Sep 2018 11:13 AM | AIMHI Admin (Administrator)

    NPR Source Article | Comments Courtesy of Matt Zavadsky

    No highlights on this one – the whole article is a must read – the audio is available at the link – compelling and personal story….  This aired on NPR national this evening – strongly recommend the audio…

    Taken For A Ride: M.D. Injured In ATV Crash Gets $56,603 Bill For Air Ambulance Trip

    September 25, 20182:59 PM ET

    Heard on All Things Considered

    It was the first — and only — time Dr. Naveed Khan, a 35-year-old radiologist, ever rode in an all-terrain vehicle.

    Khan took the wheel from his friend and drove circles in the sand, on a trail along the Red River in Texas.

    "As soon as I turned to the side where my body weight was, this two-seater vehicle ... just tilted toward the side and toppled," Khan recalled. It landed on his left arm.

    "I had about a 6-inch-wide exposed flesh gap that I could see below, on my forearm," he said. "And I could see muscle. I could see the fat. I could see the skin. The blood was pooling around it."

    Khan, feeling lightheaded, tied his jacket around his arm like a tourniquet. He and his friend managed to right the ATV, drive back toward the street and call 911.

    When an ambulance delivered him to the emergency room at United Regional Health Care System in Wichita Falls, Khan was surprised to hear a doctor murmur that it was the worst arm injury he'd ever seen.

    Khan needed immediate helicopter transport to a trauma center for surgery in Fort Worth, if there was any hope of saving the arm.

    Groggy from painkillers, Khan managed to ask the doctors how much the flight would cost and whether it would be covered by his insurer. "I think they told my friend, 'He needs to stop asking questions. He needs to get on that helicopter. He doesn't realize how serious this injury is,' " Khan recalled.

    Flown 108 miles to John Peter Smith Hospital in Fort Worth, the closest Level I trauma center, Khan was whisked into surgery to clean out the wound, repair his shattered bones and get blood flowing to the tissue.

    He had a total of eight operations to try to save his left forearm before he finally gave up. After weeks in the hospital, he asked the doctors to amputate, so he could get on with his life.

    And then the bill came.

    Patient: Naveed Khan, 35, a radiologist and married father of three young children in Southlake, Texas.

    Total bill: $56,603 for an air ambulance flight. Blue Cross Blue Shield of Texas, Khan's insurer, paid $11,972, after initially refusing altogether; the medevac company billed Khan for the remaining $44,631.

    Service provider: Air Evac Lifeteam, an air ambulance company that operates 130 bases in 15 states. It's owned by Air Medical Group Holdings, a holding company that owns four other air ambulance companies and one ground ambulance company. Air Medical, in turn, is owned by the giant private equity firm Kohlberg Kravis Roberts.

    Medical service: Khan was flown from the United Regional Health Care System in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.

    What gives: Khan got his first call from Air Evac Lifeteam just three days after the accident, while he was still lying in the hospital. A company representative told him the helicopter ride would most likely cost more than $50,000 and asked him how he planned to pay.

    For Khan, rapid transportation to the trauma center was essential since the blood supply to his arm had been cut off, said Dr. Rajesh Gandhi, the medical director for trauma services at JPS Hospital.

    "If there's no blood going that means there's no oxygen," he said. "It there's no oxygen, that means those cells are going to die." Minutes are precious and the helicopter can get from Wichita Falls to Fort Worth in an hour or less, half the time it takes by ground ambulance, he said.

    But complaints about sky-high bills to patients for air ambulance services are common. Since launching the "Bill of the Month" series in February, NPR and Kaiser Health News have received more than a dozen bills from patients like Khan who were charged tens of thousands of dollars for an air ambulance ride even after insurers' payments.

    Air ambulance companies defend their charges.

    Rick Sherlock, president of the Association of Air Medical Services, a trade group, said air ambulances require a more highly trained crew than a ground ambulance, because only the sickest or most seriously injured patients need air transport.

    AAMS commissioned a study to determine the actual cost of a medevac ride. The report found it takes about $2.9 million a year to run a single helicopter base. Each base handles about 300 transports a year, and the rides cost about $11,000 each, according to the report.

    A spokeswoman for Air Evac Lifeteam said the company bills people so much because it is trying to make up for what she said are meager payments from Medicare and Medicaid.

    "Our real cost per flight is the $10,200 plus the unreimbursed cost on each flight for Medicare, Medicaid and patients without any coverage," wrote Shelly Schneider, the company spokeswoman.

    The Centers for Medicare & Medicaid Services said it pays an average of $4,624 per ride, plus $31.67 a mile, which works out to an average Medicare reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in most states pays less.

    The industry has been advocating hard to get Medicare to boost its reimbursements, Sherlock said. There are bills pending in both the House and Senate that would do so, but there hasn't been much movement on them.

    But others say the industry's cost estimates are inflated by profit-driven expansion of a lucrative industry. Ground ambulances often carry critically ill patients, too.

    Too many air ambulances sit idle much of the time, said Dr. Ira Blumen, a professor of emergency medicine at the University of Chicago and medical director of the university's Aeromedical Network.

    Blumen said the industry — which is dominated by a few companies owned by private equity firms — expanded dramatically in 2002, the last time Medicare boosted its payments. And now there are too many helicopters — 908 as of last year — fighting for patients and profits at the same time.

    "The number of helicopters is outrageous for the continental United States," he said. In the 1990s, most helicopters ran more than 500 flights per year on average. At that rate, the cost per flight today would be less than $6,000.

    A BCBS of Texas spokesman said the insurer does have a contracted rate with an in-network air ambulance company, but it is not Air Evac Lifeteam. After initially refusing to pay anything for an out-of-network claim, it agreed to the $11,972 payment.

    But in some sense, the reason ambulance companies charge so much is simply that they can: Air ambulances are largely regulated not as health care but as part of the aviation industry. Federal laws prevent states from limiting aviation rates, routes and services.

    So many people have been hit with shockingly high air ambulance bills that members of Congress on both sides of the aisle are trying to do something about it. Legislation to reauthorize funding for the Federal Aviation Administration that is moving through Congress now would create a council of industry experts to address balance billing and other issues and set up a complaint line for consumers.

    Resolution: Khan has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the remaining $44,000 air ambulance bill. The company has asked him to appeal to the state's Department of Insurance, and though he first balked at the suggestion, he is now considering doing so. Khan says he doesn't understand why the helicopter flight, which was an integral part of the emergency medical care he received, is treated differently from his surgeries, nursing care and physical therapy.

    "I thought that this was another piece of that puzzle," he said. "It turns out that this was glaringly different."

    He is waiting for resolution as he gets accustomed to life with his disability. Holding his baby son, he asked in frustration:

    "How do I hold him while he's crying and at the same time heat up his bottle?"

    Khan, who has had to fight with his insurance company to get coverage for a prosthetic arm, is frustrated when he learns that the air ambulance company expects him to pay far more than the actual cost of his flight.

    "It's unfair," he says. "It's random; it's arbitrary. It's whatever price they want to set. And to put that onto a person who's already been through what I've been through, I hate to say it, but it's cruel."

    The takeaway: Most people with health problems serious enough to require a helicopter flight are in no position to ask whether the medevac company is in-network or there's a choice. But if you or a family member has time to ask, it could pay off.

    If you're faced with a huge bill for a medevac ride, there are a few steps you should take.

    First, let your insurer's process play out. BCBS of Texas first denied Khan's claim altogether. But he looked closely at his policy and saw that the threat of loss of limb was explicitly covered. He appealed, and that's when the insurer paid $11,972.

    Second, negotiate! The air ambulance company might be willing to negotiate a settlement for a fraction of the bill to avoid turning to debt collectors, who would pay them pennies on the dollar.

    Both Sherlock of the Association of Air Medical Services and Schneider of Air Evac Lifeteam said companies will try to determine what a patient can afford. So people with high incomes may find it hard to obtain a substantial reduction for their bill. Still, if patients know the true cost of the service they received, they may be better equipped to negotiate a discount.

    Many air ambulance companies offer membership plans that can cost less than $100 a year and guarantee that the company will accept whatever payment an insurance company makes without billing the patient for the rest. But buyer, beware: When people need an air ambulance, they are often not in a position to choose which company will respond to the call.

    Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

  • 26 Sep 2018 11:11 AM | AIMHI Admin (Administrator)

    Health Affairs Source Article | Comments Courtesy of Matt Zavadsky

    Interesting analysis of the proposed discussion draft of the balanced billing legislation – attached for your information….

    For our ambulance folks, note the last sections…

    Analyzing New Bipartisan Federal Legislation Limiting Surprise Medical Bills

    SEPTEMBER 25, 2018

    Surprise medical bills – those from out-of-network physicians that patients had no role in choosing – are not a new phenomenon, but national attention to the issue has grown tremendously in recent years, likely due to increased incidence and larger bills. Surprise bills arise most often during emergency care or during elective care involving ancillary physicians (such as radiologists, anesthesiologists, pathologists) who patients don’t actively choose and are not in the insurer’s provider network. Multiple studies have found that roughly one in five emergency department visits involved care from an out-of-network physician, as well as a not-insignificant share of elective inpatient admissions at in-network facilities. And these surprise bills can be quite large.

    Many states across the political spectrum have taken steps to mitigate this problem, including a handful in just the last two years: Arizona, Missouri, New Hampshire, New Jersey, and Oregon. However, current state laws do not apply to the roughly half of privately-insured Americans enrolled in so-called “self-insured” health plans that are common among large employers, because the Employee Retirement Income Security Act (ERISA) precludes states from regulating these plans. While there are policies states could pursue to mitigate surprise out-of-network billing for their residents in self-insured plans as well, which we will explore in a future paper, we do not know of any states that have taken such an approach.

    Federal action, therefore, may prove necessary to protect people enrolled in self-insured employer health plans, as well as all privately-insured individuals in the majority of states that have not enacted comprehensive surprise billing legislation. Such federal regulation of self-funded health plans has well-established precedent. For example, as we described previously in a Health Affairs Blog post: 

    Federal law currently requires all health plans, including self-funded ones, to: 1) cover mental health care on par with physical health care; 2) cover recommended evidence-based preventive care services without any cost sharing from patients; 3) avoid caps on total coverage amounts; 4) cover patient services provided through approved clinical trials; and 5) contribute to public funding of health services research. Preventing surprise medical billing under self-funded plans would only modestly modify the existing scope of federal requirements yet provide substantial protections that are needed to avoid systematic unfairness.

    On September 18, a bipartisan group of six Senators – Michael Bennet (D-CO), Tom Carper (D-DE), Bill Cassidy (R-LA), Chuck Grassley (R-IA), Claire McCaskill (D-MO), and Todd Young (R-IN) – took such action, releasing draft legislation to protect patients in both insured and self-insured plans from these surprise out-of-network bills. Titled the “Protecting Patients from Surprise Medical Bills Act,” the draft legislation represents only the second near-comprehensive Congressional bill to address the issue (Representative Michelle Lujan Grisham’s “Fair Billing Act of 2017” being the other).

    Protecting Patients from Surprise Medical Bills Act

    The bipartisan draft legislation includes three important components that would jointly protect consumers from surprise medical bills:

    • Limiting patient cost-sharing to the amount they would owe to an in-network provider;
    • Setting a payment standard regarding what insurers owe providers in these situations; and,
    • Prohibiting providers from balance billing patients.

    The legislation would address the two main situations in which surprise out-of-network bills frequently arise:

    • Out-of-network emergency care; and
    • Out-of-network care, typically from ancillary physicians, delivered at an in-network facility (e.g., a hospital or ambulatory surgical center).

    Additionally, once a patient is stabilized following emergency care at an out-of-network facility, the patient must be notified about the potential for higher cost-sharing if they remain at the current facility and provided the option to transfer to an in-network facility.

    Critically, the bill’s protections would automatically kick in when either of these two situations occur, without the patient having to take any action. The patient would be required only to pay the standard amount they would have owed if the service in question was performed by an in-network physician and balance billing would be prohibited. The patient’s health plan, then, would have to pay the provider an amount determined by the state (or locality) in which the service was performed. If a state does not elect a payment methodology, then the federal default would require the health plan to pay (less the patient cost-sharing) the greater of:

    • The median in-network contracted rate for the service in a specified geographic area (the draft legislation does not specify from which data this median rate would be calculated); or
    • 125 percent of the average allowed amount for the service in a specified geographic area, as determined by the most recent year of data available from a “statistically significant benchmarking database maintained by a nonprofit organization,” such as FAIR Health, Health Care Cost Institute, or a state’s all-payer claims database if administered by a nonprofit.

    The out-of-network physician, therefore, would have to accept this amount as payment in full. It is unclear why both of these options were included, as the second option will almost always be higher than the first.

    This approach is broadly similar in structure to surprise billing laws in California and Connecticut, which similarly combine a regulation on the health plan to treat the “surprise” out-of-network service as in-network, a prescribed rate that the health plan must pay to the provider, and a prohibition on the provider from balance billing the patient above their standard in-network cost-sharing amounts. Other states with near-comprehensive laws, such as Illinois, New Jersey, New Hampshire, and New York, and Representative Lujan Grisham’s “Fair Billing Act of 2017” take a similar approach, but instead of directly prescribing a payment rate from health plan to provider, leave that determination up to a binding arbitration process.

    Notably, this approach goes beyond what was included in the Affordable Care Act (and subsequent rulemaking), which, for emergency care, limited patient cost-sharing to in-network rates and required insurers to pay providers a minimum rate, but did not prohibit these providers from balance billing patients. 

    Because this current proposal would prohibit balance billing, it would effectively cap total payments to providers at a particular payment rate. Under this type of approach, then, a key question becomes how to determine the appropriate payment rate.

    Areas for Further Consideration

    The rest of this blog discusses changes that should be considered as Senators work on revising this discussion draft, specifically with respect to (1) determining the appropriate payment rate, (2) which types of physicians the bill’s protections should apply to, and (3) the possibility of expanding protections to ambulance services.

    Determining the “Appropriate” Payment Rate

    We believe that the option of “at least” 125 percent of average allowed amounts is unnecessarily high and would drive up insurance premiums and potentially have counterproductive impacts on contracting decisions. Emergency care and ancillary physicians, for whom the patient typically has little to no role in choosing, may have little incentive to join insurer networks if they are guaranteed payments of 125 percent of the average allowed amounts when they remain out-of-network.

    Additionally, to the extent any similar bill defines payment based on a percentile of average contracted rates or allowed amounts, unintended impacts on future contract negotiations can be minimized by tying the rate to a point in time before passage of the bill, inflated forward by the Consumer Price Index or something similar.

    Determining the “appropriate” rate, though, is difficult. It is clear that payment should not be tied in any way to providers’ billed charges, which are largely untethered by market forces and tend to be extremely high in relation to Medicare’s payment rates, especially for specialties most commonly involved in surprise out-of-network billing. That charges are particularly high for these specialties is not a coincidence, as billed charges are primarily only assessed to the uninsured and patients receiving out-of-network medical care (insurers negotiate lower contracted rates for their enrollees receiving in-network care). For specialties where the patient has little or no choice among physicians, there’s an incentive to charge high amounts both because the physician (or the physician’s employer) can assess these charges to unsuspecting out-of-network patients and because the threat of doing so helps them obtain higher in-network contracted rates from health plans. Indeed, using data from provider charges reported to Medicare, Ge Bai and Gerard Anderson find that median charges for emergency medicine, anesthesiology, radiology, and pathology are all at least 400 percent of Medicare rates.

    The two main options are to tie payment rates in “surprise” out-of-network situations to some percentage of Medicare rates or average (mean or median) in-network contracted rates (either specific to the patient’s health plan or averaged across all health plans in a region) for the service. Or, like in California, the rate could be set at the greater of two options.

    Medicare rates have the benefit of being tied to the government’s best attempt at determining the relative value of different services and can easily be scaled up or down depending on policymaker preferences. Average in-network payment rates notionally have the benefit of being tied to an existing market price, but that premise is flawed with respect to emergency care and ancillary physician services, where network rates are artificially high today because patients lack choice and hence the normal dynamics of negotiating lower rates in exchange for higher volume largely do not apply. While we do not know of concrete data on the question, two studies have found average in-network rates for emergency care in commercial plans to be at roughly 300 percent of Medicare rates. And at least for certain services, two studies have found average in-network rates for radiologists in commercial plans to be at roughly 200 percent of Medicare rates. Both of these are relatively high compared to average in-network rates negotiated by most physician specialties.

    Alternatively, as we discuss in more detail in a 2016 paper, policymakers could introduce a “baseball-style” binding arbitration process to determine the appropriate rate.  In this process, an arbitrator chooses the more reasonable of the parties’ final positions instead of specifying a compromise, which should promote settlement. Or this decision could be avoided altogether by placing the onus on the hospital to pay ED and ancillary physicians directly and build those costs into their facility rate negotiated with a health plan, similar to how nursing services are treated today. Yale Professors Zack Cooper and Fiona Scott Morton have recommended an approach along these lines, with the goal of using the market to determine rates in these situations.

    How Broadly Should Surprise Billing Protections Apply?

    The case for protecting patients in emergency situations who are seen by a physician outside of their insurer’s network is relatively straightforward—markets cannot work when the consumers have no choices. Similarly, when receiving elective care at an in-network facility from an in-network physician, the patient does not have any reasonable choice of the ancillary clinicians – or often the neonatologist or assistant surgeon – who might be involved in her care, and thus should not be held liable for higher cost-sharing if that clinician was outside of her health plan’s provider network. The draft legislation, however, would apply its protections to all out-of-network care delivered at an in-network facility without any exception for obtaining patient consent, which is likely too broad of a restriction. No patient consent exception is needed for out-of-network ancillary care at an in-network facility, but for other types of physicians, there are legitimate instances—for example, a surgeon – where, before admission, a patient proactively chooses to see an out-of-network physician at that facility.


    One notable omission from the discussion draft is any protection from out-of-network ambulance bills. In a study of large employer health plan claims, Christopher Garmon and Benjamin Chartock found that roughly half of all ambulance rides were billed out-of-network.  As the Senators work on revising this legislation, they should consider applying a similar approach as is used for out-of-network emergency care for ambulance rides.


    This bipartisan draft legislation marks an important step forward in putting an end to surprise out-of-network medical bills nationwide. As work proceeds on this issue, lawmakers should focus on:

    • Determining the appropriate payment rate from the health plan to the provider in these instances, specifically considering a lower rate than the 125 percent of average allowed amounts in a region currently in the draft (and if using any percentile of average allowed or contracted amounts, pegging this calculation to a point in time before passage of the bill, inflated forward);
    • Narrowing the protection for all out-of-network services at an in-network facility to those most likely to involve surprise bills; and
    • Adding a protection for out-of-network ambulance bills.

  • 24 Sep 2018 2:16 PM | AIMHI Admin (Administrator)

    Source Article from Washington Post | Comments Courtesy of Matt Zavadsky

    Interesting profile on the outcomes from D.C.’s system.  A 50% bounce back rate is not terribly different than start-ups in other EMS systems.


    Nurses in D.C.’s 911 center are helping cut some unnecessary ambulance runs, but not most

    By Clarence Williams

    September 23, 2018

    D.C. Fire and EMS officials found positive signs in the first 90 days of a $1 million nursing phone line at the 911 call center, but have yet to see big dividends in one of the program’s intended goals: reducing ambulance trips for patients who don’t need them.

    D.C. Fire Chief Gregory Dean sent a letter to the department this month highlighting early data from the “Right Care, Right Now” program that staffs a triage line at the 911 center with registered nurses. The nurses are there to diagnose callers who appear to have nonlife-threatening maladies or injuries and may not need medics or a fire crew and a trip to the emergency room.

    The fledgling program has been providing quick, private transportation for noncritical patients to clinics using a ride-share service, Dean’s letter said, and 911 callers who were processed through the nurse gave uniformly positive reviews about their experience in follow-up surveys.

    However, fire officials acknowledge that the program has not made a significant dent in the hundreds of calls they field daily that tie up EMTs, paramedics and ambulances with issues such as insect bites and toothaches.

    “There is a habit or pattern that we need to change. A lot of time people are not familiar with getting to a clinic. They are just used to calling 911. That’s not really what we wanted them to learn, but that’s what they’ve learned,” said Robert Holman, the D.C. Fire and EMS medical director. “We’re trying to establish a new pattern.”

    The changes are also intended to offer better health-care options than an emergency room visit provides.

    The triage program started in April, with nurses available on the 911 call line from 7 a.m. to 11 p.m. daily at a cost of $1 million for salaries and a technology build-out.

    In the first 90 days, Dean’s letter showed, nearly half of all calls routed from a 911 dispatcher to the nurses still resulted in a D.C. fire unit being sent out because nurses sent the call back after hearing a caller describe their medical need.

    As nurses grow more comfortable making decisions, the program could help redirect callers to less urgent but still appropriate medical options, Holman said.

    “We are happy with the modest impact, but we would like to see this grow a bit more. I don’t think our [department] members are feeling the effects of this just yet,” in relieving first responders from tending to low-priority calls, he said.

    Before the launch, officials had estimated that as many as 70 percent of their 911 medical runs involved patients with conditions that are not life-threatening emergencies.

    The city’s revitalization and expansion have not waned, which keeps emergency call volumes up and demands high on city emergency services even as the so-far-modest nurse triage program tries to relieve some of that pressure, said Dabney Hudson, president of the firefighter’s labor union. “We’ve gained more calls through growth than they’ve gotten rid of with this,” Hudson said. “We have a capacity issue.”

    Between the April 19 launch and late August, registered nurses fielded 1,103 calls to work through issues with 911 callers, who in their initial conversations described a seemingly not-urgent medical need.

    Nurses can bounce back patients to a dispatcher if they decide an EMS or ambulance crew should respond. For the callers who need non-emergency medical care, the nurses will book an appointment with a primary-care doctor or clinic in the caller’s neighborhood who can see them within two hours. The nurses will also send a Lyft driver to take Medicaid-covered patients to and from a doctor or clinic.

    Of the 1,103 calls routed to nurses for questioning known as triaging, officials said that 130 patients were sent to clinics, 289 calls were canceled, and 131 calls received “self care,” which includes nurses advising a caller to take prescribed medications to stabilize blood pressure or blood sugar levels or to buy over-the-counter ointments for other problems.

    In the opening weeks, nurses “were over-triaging back to 911 and they were doing so with an abundance of caution,” Holman said.

    “I give feedback on every one of these calls,” he added.

    His feedback to nurses included instructions not to send ambulances for strains and pulled muscles in the lower back or migraines and headaches that did not indicate any other serious disorder like a spike in blood pressure.

    Holman said that as nurses have gained experience and feedback, the calls resulting in emergency crews being dispatched has dropped from a weekly average of 33 in June to 15 by late August.

    Hudson said he applauds the attempt to deal with call volume that cripples the department’s efficiency and burdens the workforce. However, he said union officials warned the department that the nurse program might prove ineffective following interviews and research the union did about failed efforts in Philadelphia and Richmond.

    “It’s the same issue every other large city has run into that tried to implement this. The return on investment wasn’t there,” Hudson said. “They just sent a firetruck or an ambulance. Obviously that still doesn’t solve our problem.”

    Transportation has been a significant success early on, Holman said, as officials report that on average it took 37 minutes from the time a patient spoke with a nurse to arrive at a clinic for a walk-in appointment. A non-emergency ambulance trip to the hospital, which would include a patient evaluation and processing, can take 40 to 60 minutes officials said, depending on the time of day and traffic.

    Officials said nurses tried to call each patient to follow up on their treatment and to “review their customer service experience.” During the first 90 days, officials said they received zero complaints and all 55 patients nurses contacted “provided positive feedback,” the letter said.

    Only one complaint arrived after the initial 90-day period, Holman said, and after reviewing that call he believes a nurse rightly refused a transport in August for a man with a sore throat.

    “It’s early but we’re very pleased with our customer satisfaction,” Holman said. “We think we’ve built a good system.

    We just want to increase the volume so more people can take advantage.”

    Destiny Banks was one of the early users.

    A Lyft driver took her to the Unity clinic on Minnesota Avenue after she became lightheaded during a therapy session in the spring. Her therapist dialed 911 because Banks was pregnant, had a previous instance of passing out and suddenly could not finish sentences during the session.

    She expected to hear sirens and see lights from an ambulance, but within about 15 minutes a Lyft driver arrived to take her to a clinic, which was initially disorienting for Banks.

    “I was confused more than nervous. I was okay with it, it was just different,” she recalled.

    A clinic employee talked to her on site, and she was seen within about 20 minutes by medical personnel, much more quickly than in any previous emergency room situation, she said.

    She was diagnosed as being dehydrated and sent home with instructions to drink more water.  Her daughter Avay’e was born Aug. 24, without issue.

    The nurse triage and clinic referral “might be weird to other people, too. But I’m glad they put it into play. Not every time it’s a dire emergency that you need an ambulance,” Banks said. And getting to care “was really fast.”

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