News & Updates

  • 12 Jun 2019 10:20 PM | Matt Zavadsky (Administrator)

    Top 7 Reasons That Mobile Integrated Healthcare-Community Paramedicine Programs Benefit Everyone

    Kevin Amell

    May 30, 2019

    A new model of healthcare has arrived in the form of mobile integrated healthcare community paramedicine (MIH-CP).

    You’ve heard all the buzz about these programs and partnerships with local EMS and ambulance companies. You’ve heard about how specially-trained paramedics can visit the homes of selected residents. You’ve heard about how it’s supposed to help EMS agencies to create patient-centered, mobile resources in an out-of-hospital environment. Do MIH-CP programs live up to the hype? In today’s post, we’ll look into seven reasons that MIH-CP programs benefit everyone.

    1. Lowering super-utilizers

    In Milwaukee, Wisconsin, a 2015 review of more than 60,000 annual 911 calls found that 7 percent, or 4288 calls, came from the same 100 people. California’s Alameda County has a list of the top 25 “frequent fliers” who call 911 regularly; in just two years, 25 people had collectively called the 911 line 4,291 times. A 2009 MedStar study found that in the Fort Worth, Texas area, 21 patients had been transported to local EDs a total of 800 times over a 12-month period, generating over $950,000 in ambulance charges and even more significant ED expenses. Most of these individuals did not have health insurance and relied on EMS and local EDs for health services. The Tucson Fire Department had been able to identify 50 individuals who accounted for more than 300 non-emergency 911 calls over a 12-month period.

    This is no surprise. All EMS workers know this: super-utilizers and “frequent flyers” are prevalent everywhere across the country.

    This certainly isn’t ideal. It’s a waste of EMS services, time, effort, and money, especially when most of the problems that these frequent flyers have, and this system abuse seems only to be getting worse. How can communities combat this?

    The answer is not to limit people’s access to 911, of course. Instead, MIH community paramedicine is an answer. MIH-CP programs aim to solve this by attacking the underlying causes of these many 911 frequent flyers, or at least mitigate the load and give these patients the proper care. MIH-CP can improve the health and wellness of underserved populations — especially those with chronic conditions who use the ER as their primary source of healthcare. People needing mental health care can be directed to the proper facilities through proper transportation. Slowly, they’ll learn to better take care of themselves instead of using 911 as their catch-all. By helping patients in the community improve mental and physical health, the frequent flyer and super-utilizer phenomenon decreases.

    2. Relieve the EMS system in 911 Calls

    The community paramedicine program in North Memorial, Minnesota, is seeing a decline in 911 calls after implementing an MIH-CP program. For the first half of 2018, North Memorial found no cost savings during that time period, but in the second half of 2018, the costs of patients who had received those visits declined by $1,969 per member per month.

    Fort Worth, Texas, saw similar results as well. Between July 2009 and August 2011, the Texan community saw the volume of 911 calls fall by 58 percent, from an average of 342.3 monthly calls during the 6-month period before enrollment to 143.3 monthly calls afterward. Unsurprisingly, the decline in calls corresponded to a drop in wasted money; the annualized EMS transport costs for these patients decreased by over $900,000 (from $1,577,472 to $660,128) and charges falling by over $2.8 million ($4,929,600 to $2,062,899).

    An EMS1 article wrote that “81 percent of [MIH-CP] programs in operation for two or more years reported success in lowering costs by reducing 911-call use and emergency department visits for defined groups of patients.”

    Give the EMS and emergency room workers a break — and let them focus on the emergencies they need to focus on.

    3. Educate and help the underserved populations

    When community paramedics can visit underserved populations, it saves time for everyone. MIH-CP programs allow paramedics and emergency medical technicians (EMTs) to operate in expanded roles by assisting with public health and primary healthcare and preventive services to underserved populations in the community. Ultimately, allowing EMS workers to do this helps improve access to care, as many populations currently don’t know how to access that care. Instead, community paramedicine brings that care to them.

    By focusing on medically or socially underserved populations, which are the ones who tend to have a higher risk of using emergency departments, MIH-CP programs become first responders with community health worker skills.

    Healthy Hennepin, a publication managed by Minnesota’s Hennepin County Public Health Department reported the following story: “A community paramedic was on-site when an asthmatic shelter resident, who had recently been discharged from the hospital, began wheezing. ‘Normally someone would have called 911 about him,’ the paramedic remembers. ‘Instead, they called me.’ After showing the resident how to properly use his nebulizer and inhaler, his wheezing subsided. Crisis averted. Calm achieved. Costs contained.”

    In a California study of MIH-CP in over five counties, patient self-assessments after receiving community paramedic visits showed several improvements: a 16% increase in their rating of overall health, 11% in their understanding of discharge instructions, 4% in their understanding of when to take medications, and 9.5% in their understanding of medication side effects.

    4. Provide the proper care for the caller

    The point of community paramedicine is to outgrow the outdated system currently in place. Anyone working in EMS knows that the 911 calls they receive are often for non-urgent needs or those that a hospital emergency room is not equipped to handle. Research has shown that 11 to 52 percent of 911 calls aren’t from people in serious health emergencies.

    Additionally, many visits are made for patients with conditions that are better treated in a primary care setting. Going to an emergency room for acute upper respiratory infections, viral infections, otitis media, and acute pharyngitis is often worse off for the patient because the emergency room is already so busy that the doctors and nurses don’t have enough time to explain the patient’s condition to them adequately, nor how to properly take care of themselves during the recovery process.

    Importantly, the real underlying problems of many 911 callers, especially for frequent flyers, are psychosocial problems that cannot be effectively treated in the emergency room. An emergency room doctor or surgeon cannot fix someone’s alcohol or drug dependency problem, nor can they do much to help a patient with depression. With community paramedicine programs, paramedics will be allowed to transport a person experiencing a behavioral health problem directly to a crisis care center instead of the emergency room first, which will enable patients to get the help they need much faster. Inebriated individuals can be sent to sobering centers.

    Although some might argue that this could lead to the under-triaging of patients, but it’s already been well established that a hefty portion of 911 calls don’t require emergency room treatment. It makes more sense to paramedics to transport patients to the most appropriate location for their condition instead of trying to funnel all patients through a more-likely-than-not costly and crowded emergency department.

    Many callers use 911 because they don’t know where else to go for healthcare-related problems. By allowing paramedics to transport them (or suggest that idea to the patient), patients can slowly learn about the available solutions to their problems.

    5. Reducing hospital readmissions

    One specific subset of also routinely call 911 and visit the emergency room with exacerbations of chronic conditions that could be avoided with proper condition management. Community paramedics aim to help those with complex chronic conditions improve their health and wellness at home. Through home visits, community paramedics teach patients how to use and why they should use their medication. Additionally, these paramedics can assist in filling prescriptions, sorting medications, and explaining how to take them as prescribed. They can supplement information by providing counseling on hospital and clinic discharge instructions.

    Community paramedics can assess the patient’s lifestyle — often the culprit of hospital readmissions, especially in those with chronic conditions — and educate them on how or why they should change certain things. This allows healthcare providers insight into a part of the patient’s life that even doctors don’t get to see and has had proven benefits in reducing the number of hospital admissions.

    In a 2017 California MIH-CP study in the Alameda, Glendale, San Bernardino, Solano counties, hospital readmissions rates decreased by about 10%. Other studies have shown up to a 50% decrease in readmissions

    6. Build more trust with the community

    Since MIH-CP programs aim to solve everyone’s problems, having an effective MIH-CP helps people have more confidence in their EMS and network of healthcare providers in the area. By making routine visits to patients’ homes, paramedics not only help improve patients’ physical health but also feel more cared-for and supported. Relations between all network healthcare providers would be improved, especially given the logistical and financial benefits for everyone involved. When people know that their community healthcare providers can provide them with the support that they need, the community inherently will learn to trust them more.

    Additionally, everyone in the community will be in better shape. Emergency room doctors see fewer non-emergency cases, and hospital charges decrease, urgent care centers get better access to the people who need them, and the patients get the care they need.

    7. It’s easier than ever to do this

    The good news is that the technology is finally where it needs to be. Implementing an MIH-CP program is easier than ever because software and systems that bring entire local healthcare provider workforces together to effectively collaborate finally exist. With Julota, for example, a community’s health systems, EMS, law enforcement, social services, mental health, and all other community care organizations can benefit from more collaboration, better health, and lower overall costs. As comprehensive HIPAA-/mental health (42 CFR part 2)-/Criminal Justice Information System-compliant solution that manages secure multidirectional sharing of consented information, Julota helps patients get better and more appropriate treatments that they would otherwise lack.

  • 12 Jun 2019 10:17 PM | Matt Zavadsky (Administrator)

    Kudos to the folks in Lexington, Kentucky for this program!!

    Tip of the hat to NAEMT’s Melissa Trumbull for the heads up on this news story…


    Community Paramedicine Program helps hundreds in Lexington, saving taxpayers millions

    By Miranda Combs

    May 29, 2019


    LEXINGTON, Ky. (WKYT) - At last count, the number of homeless people living in shelters and on the street had dropped drastically in the past few years -- by almost half.

    In the last couple of years, a new program in Lexington called the Community Paramedicine Program has helped connect the homeless and the people who regularly visit Lexington's emergency rooms with resources in the community to keep them off the streets and out of the ER.

    Cecil Brown was a man who did both. He was homeless, and he'd show up at UK Good Samaritan emergency room regularly. So often, that Physician Assistant Julie Stumbo took an interest in his life.

    "He had told me a lot about his family. Just bits and pieces through the time that I saw him," Stumbo said.

    Stumbo said she'd see him so much, that if time went a few months without showing up, she'd worry.

    "He was respectful and never rude and was grateful for everything we gave him," she said.

    Cecil's visits with Stumbo went on for seven and a half years. He'd been hit by three cars over his lifetime. The last time landed him in the hospital for 22 days.

    "I'm so grateful for the car that hit him," Stumbo said of what would be a life-altering moment.

    "I just said, 'I'll never drink again God, for the mercy that you've shown me," Cecil said.

    He headed to rehab after the hospital, and when he got out, the community paramedicine program hooked him up with a group that provided housing for free.

    Cecil said his friends from UK Good Samaritan Hospital showed up to make the apartment home.

    "When they found out I had an apartment, I didn't ask for nothing. They come with this stuff," Cecil said.

    "We never set out to furnish his apartment. I just wanted him to have a bed. There's truly more good in the world than evil," Stumbo said.

    The Community Paramedicine Program director said the program has had at least 290 unique individual cases since July 2018.

  • 12 Jun 2019 10:05 PM | Matt Zavadsky (Administrator)

    Source Study | Comments courtesy of Matt Zavadsky


    Concerning report on NPR’s Morning Edition… 

    MedStar crews, in cooperation with UT Health, have been making a HUGE difference in finding solutions to this problem by our participation in the DETECT project! 

    The results of DETECT Phase I have recently been published.

    In cooperation with UT Health, MedStar will begin Phase II of DETECT this summer. 


    Reports Find Health Workers Still Aren't Alerting Police Regarding Likely Elder Abuse

    June 12, 2019

    By Ina Jaffe

    Correspondent, National Desk

    Heard on Morning Edition

    Two reports from the federal government have determined that many cases of abuse or neglect of elderly patients that are severe enough to require medical attention are not being reported to enforcement agencies by nursing homes or health workers — even though such reporting is required by law.

    It can be hard to quantify the problem of elder abuse. Experts believe that many cases go unreported. And Wednesday morning, their belief was confirmed by two new government studies.

    The research, conducted and published by the Office of Inspector General of the U.S. Department of Health and Human Services, finds that in many cases of abuse or neglect severe enough to require medical attention, the incidents have not been reported to enforcement agencies, though that's required by law.

    One of the studies focuses solely on the possible abuse of nursing home residents who end up in emergency rooms. The report looks at claims sent to Medicare in 2016 for treatment of head injuries, body bruises, bed sores and other diagnoses that might indicate physical abuse, sexual abuse or severe neglect.

    Gloria Jarmon, deputy inspector general for audit services, says her team found that nursing homes failed to report nearly 1 in 5 of these potential cases to the state inspection agencies charged with investigating them.

    "Some of the cases we saw, a person is treated in an emergency room [and] they're sent back to the same facility where they were potentially abused and neglected," Jarmon says.

    But the failure to record and follow up on possible cases of elder abuse is not just the fault of the nursing homes. Jarmon says that in five states where nursing home inspectors did investigate and substantiate cases of abuse, "97 percent of those had not been reported to local law enforcement as required."

    State inspectors of nursing homes who participated in the study appeared to be confused about when they were required to refer cases to law enforcement, Jarmon notes. One state agency said that it only contacted the police for what it called "the most serious abuse cases."

    Elder abuse occurs in many settings — not just nursing homes. The second study looked at Medicare claims for the treatment of potential abuse or neglect of older adults, regardless of where it took place. The data was collected on incidents occurring between January of 2015 and June of 2017.

  • 30 May 2019 8:54 AM | AIMHI Admin (Administrator)

    Source Study | Comments courtesy of Matt Zavadsky

    Interesting study recently conducted on the EMS professional’s perspectives of Community Paramedicine:

    Emergency Medical Services Professionals’ Attitudes About Community Paramedic Programs


    Introduction: The number of community paramedic (CP) programs has expanded to mitigate the impact of increased patient usage on emergency services. However, it has not been determined to what extent emergency medical services (EMS) professionals would be willing to participate in this model of care. With this project, we sought to evaluate the perceptions of EMS professionals toward the concept of a CP program.

    Methods: We used a cross-sectional study method to evaluate the perceptions of participating EMS professionals with regard to their understanding of and willingness to participate in a CP program. Approximately 350 licensed EMS professionals currently working for an EMS service that provides coverage to four states (Missouri, Arkansas, Kansas, and Oklahoma) were invited to participate in an electronic survey regarding their perceptions toward a CP program. We analyzed interval data using the Mann-Whitney U test, Kruskal-Wallis one-way analysis of variance, and Pearson correlation as appropriate. Multivariate logistic regression was performed to examine the impact of participant characteristics on their willingness to perform CP duties. Statistical significance was established at p ≤ 0.05.

    Results: Of the 350 EMS professionals receiving an invitation, 283 (81%) participated. Of those participants, 165 (70%) indicated that they understood what a CP program entails. One hundred thirty-five (58%) stated they were likely to attend additional education in order to become a CP, 152 (66%) were willing to perform CP duties, and 175 (75%) felt that their respective communities would be in favor of a local CP program. Using logistic regression with regard to willingness to perform CP duties, we found that females were more willing than males (OR = 4.65; p = 0.03) and that those participants without any perceived time on shift to commit to CP duties were less willing than those who believed their work shifts could accommodate additional duties (OR = 0.20; p < 0.001).

    Conclusion: The majority of EMS professionals in this study believe they understand CP programs and perceive that their communities want them to provide CP-level care. While fewer in number, most are willing to attend additional CP education and/or are willing to perform CP duties. [West J Emerg Med. 2017;18(4)630-639.]

  • 30 May 2019 8:42 AM | AIMHI Admin (Administrator)

    WFAA Source Article | Comments Courtesy of Matt Zavadsky

    Excellent news story by Teresa Woodard on the plight of high ER utilizer patients, and the expense to the community in caring for them. 

    Community collaborations, often including an EMS-Based Mobile Integrated Healthcare (MIH) program like the one here at MedStar, have demonstrated significant improvements in care coordination (including addressing the important social determinants of health), enhancing patient experience of care, improved health status, and significant reduction in acute care utilization, including EMS resources (and the cost associated avoiding preventable utilization).

    Note that Parkland estimates the cost to the community for caring for high utilizer patients at $14 million!


    80 people went to Dallas emergency rooms 5,139 times in a year — usually because they were lonely

    Parkland Hospital officials say the cost of taking care of repeat ER patients is “absolutely passed on to you.”

    Teresa Woodard

    May 28, 2019

    DALLAS — Michael Johnson is 57. He’s from Dallas. He’s diabetic. He has a job in fast food. He rents a home. He gets by.

    Until recently, no one ever explained to him how hospitals, doctors and emergency rooms work.

    “My momma always told me when something’s wrong with you, go see the doctor,” Johnson said.

    The only way he knew to see a doctor was go to the emergency room at Parkland Hospital, which is why he racked up 31 ER visits in 24 months.

    Johnson’s numbers are not at all surprising for administrators at Parkland, which has one of the busiest emergency rooms in the country.

    “It’s not unusual for us to see in excess of 700 people in a 24-hour period in our emergency room,” said Dr. Esmail Porsa, executive vice president and chief strategy and integration officer for Parkland Health and Hospital System.

    Parkland’s ER is busy for countless reasons, but chief among them is repeat patients like Johnson. He’s considered a high emergency department utilizer because of those repeated visits.

    High ER utilizers often take up valuable space which can lead to long waits, Porsa said. Because Parkland is a public hospital, these frequent patients cost Dallas County taxpayers money.

    The hospital wanted to determine why these high utilizers keep coming in. But to do that, they needed to identify who they are.

    “We looked at the data every which way. We looked at zip codes, gender, race, education, income. One day we sorted the data by medical record and realized — lo and behold — there were three patients on the top of the list,” Porsa said.

    Those three patients visited the hospital 500 times in one year.

    "Five hundred times," Porsa repeated.

    Porsa and his team expanded their research to include data from other health systems in Dallas County, which led to a revelation.

    They identified 80 patients who, collectively, went to four Dallas County emergency rooms 5,139 times in a 12-month period.

    “The same people are basically going from emergency room to emergency room,” Porsa said.

    Parkland estimates those visits cost more than $14 million.

    “It is absolutely passed on to you,” Porsa said of the cost to taxpayers.

    Once they determined who those high utilizers were, it was time to get back to why they keep coming in.

    That research led to a painful reality: the cause for most of the repeat visits is loneliness.

    “It’s a lack of relationships and support structure,” Porsa said.

    Poverty and food shortage are factors for the frequent visits, but they aren't the main reason.

    "The No. 1 determinant of high emergency department utilization is relationships," Porsa said.

    Dr. Jeffery Metzger, chief of emergency services at Parkland Health and Hospital System, calls the challenges some of these patients face heartbreaking.

    “In medical school, we get taught how to take care of medical illnesses, but there’s a group of patients who come in who are here for some other reason,” he said. “If we just throw medicines at them when they keep coming in, they’re not going to get better.”

    Parkland began intense case management with the high ER users. Teams of administrators, doctors, nurses, social workers and chaplains meet regularly to track them. 

    Every 90 days, Parkland re-evaluates the data to identify new high users.

    Freedom McAdoo, chaplain at Parkland Health and Hospital System, is also leading a new DFW Faith Health Collaborative.

    Baylor Scott and White Health, Methodist Health System and Children’s Health are working together on the effort, to partner church and community organizations with patients who need companions, “so they’re not alone,” McAdoo said.

    “If you are isolated and lonely, but you have someone that you remember, like nurse April, nurse Tina, or nurse John, and they’re like, ‘Hey, how are you doing?’ And you’re greeted with warmth and love, well yeah, I’m gonna come back,” she said, explaining why patients keep returning.

    Michael Johnson didn’t know community clinics, like Parkland’s Bluitt-Flowers Health Center, even existed. The clinic on Overton Road is near the fast food restaurant where he works.

    After social worker Jo Black began managing his case and educating him, his ER visits fell by 70 percent.

    “We just look at what constitutes an emergency, what (the ER) is there for and what we can do here,” Black said. “A lot of times, patients just really do not know.”

    Black shows tough love with patients like Johnson, holding them accountable for missed appointments and follow up visits.

    “Now I know,” Johnson said. “And I’m glad I know.”

    Johnson is a success story, but he’s just one patient among many.

    He’s proof that human connections matter. Widespread change depends on all of Dallas realizing that and then living it.

  • 28 May 2019 7:50 AM | AIMHI Admin (Administrator)

    Washington Post Source Article | Comments Courtesy of Matt Zavadsky

    This is one of the most amazing articles about the plight of healthcare and hospitals in rural America.  Yes, it’s very long, but exceptionally well written.

    Strongly encourage you to read this, and click on the link to see some of the photos – it wrench your gut, and likely bring tears to your eyes.

    EMS agencies in these areas, often volunteers, face immense struggles as they become the default healthcare in areas where hospitals have closed – and have to transport patients great distances, taking resources away from the community for longer periods of time.


    ‘Who’s going to take care of these people?’

    As emergencies rise across rural America, a hospital fights for its life

    By Eli Saslow 

    MAY 11, 2019 

    Fairfax, Okla. - The hospital had already transferred out most of its patients and lost half its staff when the CEO called a meeting to take inventory of what was left. Employees crammed into Tina Steele’s office at Fairfax Community Hospital, where the air conditioning was no longer working and the computer software had just been shut off for nonpayment.

    “I want to start with good news,” Steele said, and she told them a food bank would make deliveries to the hospital and Dollar General would donate office supplies.

    “So how desperate are we?” one employee asked. “How much money do we have in the bank?”

    “Somewhere around $12,000,” Steele said.

    “And how long will that last us?”

    “Under normal circumstances?” Steele asked. She looked down at a chart on her desk and ran calculations in her head. “Probably a few hours,” she said. “Maybe a day at most.”

    Continue Reading at The Washington Post►

  • 28 May 2019 7:47 AM | Amanda Riordan (Administrator)

    CBS News Source Article | Comments Courtesy of Matt Zavadsky

    Scary statistics from the National Safety Council:

    • 71% of drivers admitted to taking photos and texting while driving by emergency workers.
    • Sixteen percent of drivers say they've struck or nearly struck an emergency vehicle or first responder on the side of the road.
    • Forty first responders were killed on the side of the road last year, up 60% from 2017.
    • So far this year, 21 have died, including 10 police officers; 14 officers were hit and killed in all of 2018.

    Please help keep our First Responders safe as they try to keep others safe!


    Distracted drivers an increasing threat to first responders

    CBS NEWS May 27, 2019, 7:40 AM

    New research shows that many drivers are profoundly distracted by their phones when they're going past first responders working accidents on the roadways.

    New research from the National Safety Council found 71% of drivers admitted to taking photos and texting while driving by emergency workers; that's nearly triple the 24% who admitted to doing it under normal driving conditions. Sixty percent admitted to posting to social media; two-thirds have emailed about what they're driving by.

    And the results are increasingly deadly. Sixteen percent of drivers say they've struck or nearly struck an emergency vehicle or first responder on the side of the road. Forty first responders were killed on the side of the road last year, up 60% from 2017. And so far this year, 21 have died, including 10 police officers; 14 officers were hit and killed in all of 2018.

    "What surprised us most about this study was the magnitude of people who are really exercising very dangerous behavior," said Kelly Nantel of the National Safety Council. "They're adding another level of exposure to these first responders."

    Last December, Florida Highway Patrol Trooper Mithil Patel was on the shoulder of interstate 95 working an accident when, despite a traffic lane being closed as a safety buffer, a suspected distracted driver was the cause of a car losing control and swerving towards him.

    Video captured Patel throwing another man to safety right before being hit by the car himself.

    "It's a different feeling definitely, seeing where I almost got killed – definitely a weird feeling,' Patel said.

    "Do you feel lucky to have survived that?" Van Cleave asked.

    "I feel extremely lucky," Patel replied. "I have seen people, you know, pretty much die from this."

    Patel admitted to some nerves as he hit the road in his patrol car for the first time since the accident. "I still have the butterfly in my belly," he told Van Cleave. "Whenever you see the brakes squeeze really hard, you're always going to be back to be, like, is he coming toward my way or not?"

    Patel hopes to be back to full duty and working calls on the side of the road in the coming months.

    In Miami, Fire Captain Steve Perez, heading to a traffic accident, said as soon as they flip on the lights and sirens, drivers behave differently.

    Van Cleave asked, "Every call you see people paying more attention to their phones than the road? Is it that common?"

    "Sure, I'll venture to say it's very common to see somebody either on their phone or taking their phone out to try to videotape or get a snap of what's going on," said Captain Perez.

    Patel said, "I have seen it where they pull out the phone outside the window and take start taking pictures, not paying attention to the road."

    All 50 states have a "move over" law that requires drivers to give first responders room to work, but police say it's about 50-50 if people actually do it.

    Trooper Patel says, bottom line, put down the phone.

  • 28 May 2019 7:20 AM | AIMHI Admin (Administrator)

    While many excellent nominations were received, the following were selected by the AIMHI Board and Education Committee as the 2019 Excellence in EMS Integration Award winners.

    2019 Winners List

    Click each winner for a comprehensive look at their programs.

    Excellence in EMS Integration Award (Tie)

    Excellence in Public Information or Education Award

    Excellence in Value Demonstration or Research

    Leadership in Integrated Healthcare Award

  • 15 May 2019 5:35 PM | AIMHI Admin (Administrator)

    TimesUnion source article | Comments courtesy of Matt Zavadsky

    Congrats to our Montana team, especially Justin Grohs of Great Falls Emergency Services and Jim DeTienne, EMS lead for Montana in getting this legislation passed.

    Legislation text►

    New law allows emergency care providers to offer other aid

    By AMY BETH HANSON, Associated Press

    May 2, 2019

    HELENA, Mont. (AP) — Montana Gov. Steve Bullock has signed a bill allowing emergency care providers to offer non-emergency medical assistance in their communities to reduce noncritical calls to 911, especially in rural areas.

    The providers could fill gaps in the current medical system by helping people manage their medicine or chronic illnesses, giving them a ride to their doctor's office or home from a hospital, or connecting them with other medical or mental health services, supporters said.

    The bill, sponsored by Democratic Sen. Margie MacDonald, allows the Board of Medical Examiners to create rules detailing changes and a training program for paramedics and emergency medical technicians. It does not require volunteer emergency agencies to offer the services.

    Supporters said the measure, which Bullock signed Wednesday, will reduce the number of 911 calls from people who could have been helped earlier and less expensively.

    Hundreds of programs around the country are using emergency care providers to fill similar community medical needs. Montana has successful pilot programs in Cut Bank and Red Lodge, said Jim DeTienne, supervisor of the state health department's Emergency Medical Services and Trauma Systems section.

    Medicaid pays for similar programs in other states, and the department is talking with health insurers about covering the service. However, insurers wanted to see it credentialed and regulated, DeTienne said.

    Supporters said the program may draw volunteers who don't want to be on-call for emergency situations but would be willing to help with scheduled visits.

    The state has funding for six pilot projects that would gather data about the effectiveness of the programs, said Jon Ebelt, spokesman for the Department of Public Health and Human Services.

    Officials with fire and rescue services told lawmakers about 911 calls that could have been avoided if the callers had someone to help them manage their medication or give them a ride to a doctor instead of an emergency room if that would better serve them.

    The legislation gives emergency responders the ability to sit down with patients and get to the reason for repeated 911 calls, said Bob Drake, chief of the Tri-Lakes Volunteer Fire Department, northeast of Helena.

    Drake told lawmakers a resident, despite being in a wheelchair, kept falling and calling 911. He said he finally asked the man why he was falling so much and the man said the brakes on his wheelchair were broken and it kept rolling out from under him as he moved in or out of the chair.

    Drake said the man was a patient of the Department of Veterans Affairs, so he called the VA, but they said it would take a few weeks to get him a new wheelchair.

    Drake said he went home and got his late father's wheelchair and took it to the man.

    "The 911 calls stopped for three weeks," he said.

  • 15 May 2019 8:28 AM | AIMHI Admin (Administrator)

    HealthAffairs Source Article | Comments Courtesy of Matt Zavadsky

    There has been much discussion about surprise medical bills over the past few years.  The House Energy and Commerce committee released a discussion draft of a proposed Bill and today, requested formal feedback from industry stakeholders.

    The email to stakeholders and the supporting documents to the email are below and attached.

    Here is an interesting analysis of the Bill released by the Energy and Commerce Committee.

    Analyzing The House E&C Committee’s Bipartisan Surprise Out-Of-Network Billing Proposal

    Loren Adler, Paul B. Ginsburg, Mark Hall, Erin Trish

    MAY 14, 2019


    A new bipartisan discussion draft to address surprise out-of-network billing was released today, introduced by the Chairman and Ranking Member of the House Energy and Commerce Committee. This bill follows two Senate proposals released late last year, one from a bipartisan group composed of Senators Bennet, Carper, Cassidy, Grassley, McCaskill, and Young, and another from Senator Hassan.

    Surprise out-of-network bills can occur when a patient receives care from an out-of-network provider in situations they cannot reasonably avoid, typically when there is no real choice of provider. These surprise bills can arise both from emergency care (whether the facility itself is out-of-network, the ambulance that transports the patient is out-of-network, or a physician providing emergency treatment is out-of-network) and out-of-network nonemergency care received at an in-network facility (typically a hospital or ambulatory surgery center).

    Energy And Commerce Draft Approach

    The Energy and Commerce draft would eliminate surprise out-of-network billing for both emergency and non-emergency services (with the notable exception of ambulance services) and across different sites of care (e.g., hospitals, ambulatory surgery centers (ASCs), freestanding emergency departments). Importantly, the legislation would do so for all commercial insurance plan types, including self-insured health plans that can only be regulated by the federal government. The legislation achieves this objective by combining the following three components:

    • Require the health plan to treat the out-of-network service as if it were in-network for purposes of enrollee cost-sharing, deductibles, and out-of-pocket limits;
    • Set a minimum payment amount that the health plan must pay to the out-of-network provider; and
    • Prohibit out-of-network providers from “balance billing” patients -- that is, from billing the patient any amount above the patient’s in-network cost-sharing.

    These protections would apply to all out-of-network emergency services and to all out-of-network nonemergency services received at an in-network facility from “facility-based providers,” which the bill defines to include anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, intensivists, and any additional provider types specified by the Secretary of Health and Human Services (HHS). Other provider types would still be allowed to treat patients on an out-of-network basis in nonemergency situations if they met the strong notice and consent requirements detailed in the discussion draft. Limiting notice and consent exceptions to physician specialties that patients typically actively choose strikes a sensible balance. It preserves patients’ ability to seek out-of-network care in circumstances where it is appropriate, while mitigating the risk that the flood of paperwork involved in seeking medical care will result in some patients consenting to out-of-network billing without understanding what they are consenting to or whether they have a reasonable alternative.

    Payment Standard

    By prohibiting balance billing by out-of-network emergency and facility-based providers, the Energy and Commerce draft addresses the market failure that allows these specialties to receive what appear to be very high in-network payment rates, relative to what specialties facing more typical market forces earn. In addition, to help providers, the draft requires health plans to pay out-of-network emergency and facility-based providers their plan-specific median contracted rate for the relevant service in that geographic area. Existing state laws that provide methods for determining out-of-network payment for surprise bills would remain for fully insured plans and would not be pre-empted.

    Notably, given that the threat of surprise billing allows emergency and ancillary physicians such as anesthesiologists to garner very high in-network rates today, tying a payment standard to current median contracted rates may fail to bring rates down to what normal market rates would be in the absence of the market failure. However, because median contracted rates for the specialties most commonly associated with surprise billing are typically considerably below the mean (due to the typical presence of a minority of physician groups garnering especially high rates), this bill represents a clear improvement over the status quo. For example, in one study of commercial claims data, mean reimbursement for the highest-level emergency physician service was 306 percent of Medicare’s payment for the same service, whereas median reimbursement was 257 percent of the Medicare rate.

    Therefore, the Energy and Commerce draft likely would result in lower insurance premiums in most markets and hence reduced federal deficits (from reducing loss of revenue from tax subsidies to health insurance), in addition to eliminating the scourge of surprise bills to patients. We also believe that a decision by Congress on an out-of-network payment standard is preferred to arbitration, which could be unpredictable, lacks transparency, and could involve significant administrative costs. While it may fall short of fully unwinding the increase in health care spending stemming from today’s market failure, the Energy and Commerce draft legislation represents the strongest proposal to date on the dual fronts of protecting consumers and reducing health care costs. The bill’s structure is most similar to state laws in California and Oregon.

    Areas For Further Consideration

    The Energy and Commerce Committee should be applauded for a serious bipartisan proposal to address surprise out-of-network billing. As is, the proposal would reduce system wide health costs and provide valuable protection from surprise bills to patients.

    The rest of this post discusses a few areas that Members should consider as they revise this discussion draft.

    How To Determine The Median Contracted Rate

    There are important considerations relating to the payment standard being tied to an insurer’s own median in-network rate for the relevant service in a geographic area. First, this approach gets around the technical challenge of setting different payment standards by geography from the federal perch, without sufficient data available to calculate median contracted rates by geographic market. Second, it leaves in place insurer-specific dynamics based on the rates they have negotiated for emergency services and “facility-based providers,” which may not be desirable to the extent that those rates largely reflect a plan’s current willingness to shield their enrollees from surprise bills.

    Third, over time this approach may allow health plans to drive down in-network payment rates toward normal market rates if the plan is able to undo contracts with physician groups earning especially exorbitant rates today and rachet down their plan-specific median contracted rate to more reasonable levels. And because the draft legislation requires the plan to make this payment directly to the provider and prohibits the provider from billing the patient any more than their in-network cost-sharing amounts, the distinction between these provider types technically being in- or out-of-network becomes meaningless from the patient’s perspective.

    Still, relying on insurer’s own median rates may lead to out-of-network payment rates being unpredictable for providers, although the HHS Secretary is tasked with determining a methodology for guaranteeing accurate and fair reporting by insurers, which may address this concern. States with all-payer claims databases could also be allowed to use those to determine a market-wide median rate.

    In the context of a relatively high payment standard such as median contracted rates, the insurer-specific median approach may be preferable. However, there would be value to pursuing a more transparent approach utilizing a payment standard tied to a lower rate set across a market or tied to a percentage of Medicare rates, which vary by geography.

    Lower Payment Standard

    For emergency physicians and ancillary clinicians (anesthesiologists, certified nurse anesthetists, radiologists, and pathologists), the natural market negotiation is between them and the facility at which they practice (that’s where the price-volume trade-off exists). To fully ameliorate the current market failure, an out-of-network payment standard would need to be set at or below the normal market rate for that specialist (that is, the rate that would be negotiated with the hospital in the absence of the ability to surprise bill patients).

    Fortunately, there is little risk to setting the payment standard below market rates because facilities would then have to step in to demand market rate payment from insurers in order to ensure adequate staffing – or, alternatively, pay these specialists more money directly. (See here for a more detailed discussion of the considerations in setting an out-of-network payment standard.) Given the difficulty of determining this normal market rate, we recommend setting an out-of-network payment standard at a percentage of the relevant Medicare payment rate equal to the ratio of average contracted rates to Medicare rates for other specialists (ones that patients do choose) in the same geographic region.


    Similar to the two Senate bills last year, today’s draft does nothing to prevent surprise out-of-network bills from ground or air ambulances, despite ambulance services frequently being delivered out-of-network. Very similar market dynamics characterize ambulance services, and federal law prevents states from addressing this market failure for air ambulances in particular.  Federal legislation addressing surprise billing should incorporate ambulance services within the emergency service protections. The same approach, including a payment standard, could apply.

    Non-Physician Providers

    Non-physician providers often involved in surprise billing, such as certified nurse anesthetists (CRNAs), should be included in the draft’s list of “facility-based providers” that are subject to the law. Lab services are also a common source of surprise bills. While the draft includes laboratories in its list of health care facilities, it’s not clear that a patient would be protected from a surprise bill if their labs are sent to a non-participating facility.

    State Preemption

    As drafted, the Energy and Commerce bill appears to allow all existing state surprise billing laws that include a payment standard or arbitration process to supersede the new federal law, for the fully insured plans that states can regulate. This approach, however, allows for state laws that are worse for consumers to continue. One option to address this risk while still allowing for state flexibility would be to rely on the approach already built into the Public Health Service Act -- to allow states to maintain laws that are at least as protective as the federal one. The federal legislation could then include language clarifying that to be considered at least as protective, state protections must not increase premiums or include a payment standard tied to amounts greater than median contracted rates (or an arbitration process in which arbiters are, on average, selecting rates above the relevant median contracted rate).

    There is also a narrower question to be resolved regarding how preemption would function for state laws that have a method for determining out-of-network payment but exempt surprise bills below a certain dollar amount, such as in New York or Arizona. A federal law should at least serve as the default for the surprise bills currently not protected against by such state laws. Similarly, certain state surprise billing laws only apply to specific physician specialties, and it should be clarified that the federal default would then apply to other specialties providing out-of-network services for enrollees in state-regulated, fully insured plans.

    Post-Stabilization Protections

    While the draft legislation clearly protects consumers from surprise out-of-network bills for emergency services, there may remain a risk of patients receiving surprise bills for post-stabilization services performed at an out-of-network facility. One approach to ameliorate this concern is to extend protections from surprise out-of-network facility bills to 24 hours after stabilization from an emergency and require that the facility offer transfer to an in-network facility for continued care.


    Body of email from E & C:

    Dear Stakeholder:


    Last week, Energy and Commerce Committee Chairman Pallone and Ranking Member Walden announced their commitment to crafting a bipartisan solution to address the problem of surprise medical bills that are leaving families across the country with crippling amounts of financial debt.  As the Committee leaders said last week, no family should be left in financial ruin through no fault of their own.


    Today, Chairman Pallone and Ranking Member Walden are releasing a bipartisan discussion draft, the No Surprises Act, which would protect consumers from surprise medical bills and increase transparency in our health care system.  Attached you will find legislative text and a summary of the discussion draft, which the Chairman and Ranking Member are requesting your constructive feedback on.  Specifically, the Committee requests feedback on the following areas:


    ·        Increasing Transparency for Consumers.  Our health care system is confusing for even the most educated consumers.  The Committee is interested in feedback on ways to help consumers better understand their health plans and which providers are in their network.    

    ·        Ensuring Network Adequacy.  Consumers deserve adequate networks that offer the right care at the right time.  The Committee seeks feedback on ensuring that networks are sufficiently meeting the needs of individuals.    

    ·        Encouraging the Development of State All-Payer Claims Databases.  All-payer claims databases have the potential to bring greater transparency to health care costs and spur innovative policy solutions.  The Committee requests feedback on how to aide states in developing robust all-payer claims databases. 

    ·        Protecting Consumers from Surprise Bills from Air and Ground Ambulances.  While the No Surprises Act does not address the issue of surprise medical bills from ground or air ambulances, the Committee recognizes the need for solutions in these areas and seeks feedback on how to provide relief to consumers burdened with unexpected ambulance bills. 

    ·        Establishing a market-based benchmark to resolve out-of-network payment disputes between providers and insurers.  Payment disputes between providers and insurers must be resolved in a manner that takes the patient out of the middle, is transparent and does not increase federal healthcare expenditures.  The Committee requests feedback on how to adequately provide payment in these situations through a transparent, non-inflationary mechanism.


    The Committee requests your written feedback by May 28th and upon receiving your feedback welcomes the opportunity for further discussion.  We look forward to working with you to solve this critical issue for consumers.


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