News & Updates

  • 23 Jul 2019 9:57 AM | AIMHI Admin (Administrator)

    FierceHealthcare source article | Comments courtesy of Matt Zavadsky

    Interesting brief from UnitedHealthcare – this is likely a driver for payers discussing in earnest alternate payment models for EMS, models that add value to the payer through appropriate navigation of beneficiaries who access 911 for their healthcare needs.

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    UnitedHealth: Healthcare could save $32B annually by diverting avoidable ED visits

    by Jacqueline Renfrow

    Jul 22, 2019

    UnitedHealth Group says 27 million annual trips to the ED are unnecessary.

    https://www.fiercehealthcare.com/payer/two-thirds-ed-visits-avoidable 

    One of the biggest contributors to the rising costs of healthcare is avoidable visits to hospital emergency departments (EDs). In fact, up to two-thirds of the annual 27 million ED visits by privately insured people in the U.S. are avoidable, according to a new brief (PDF) from UnitedHealth Group.

    The average costs of treating these conditions in an ED is $2,032, which is 12 times higher than the $167 it would cost in a physician’s office. The cost is even 10 times higher than visiting urgent care—on average $193.

    Overall, UnitedHealth Group says the healthcare system could save $32 billion a year by diverting these ED visits to primary care or urgent care.

    UnitedHealth Group defines an “avoidable trip” as one that could be treated in a primary care setting. In other words: not an actual emergency. Some of the conditions seen in EDs that could be handled by a primary care physician include bronchitis, cough, dizziness, flu, headache, low back pain, nausea, sore throat, strep throat and upper respiratory infection.

    “The high number of avoidable hospital ED visits is neither a surprise nor a new problem,” L.D. Platt, UnitedHealth Group vice president of external affairs communications told FierceHealthcare in an email. “Uneven access to timely, consumer-friendly and convenient primary care options is a longstanding problem, and there is a need to bolster and expand primary care capacity through urgent care centers, physician offices and nurse practitioners.”

    Platt notes, however, that until there are better options, consumers will continue to visit EDs for primary-care-treatable conditions.

    What are the main contributors that make ED visits so much more expensive?

    First, hospital facility fees, which cost an average of $1,069 per patient visit. And second, lab, pathology and radiology services cost around $335 per visit at a hospital and $31 at a doctor’s office.

    “Increasing primary care capacity and making primary care options more available and accessible to consumers beyond normal business hours will help consumers avoid unnecessary and costly visits to hospital EDs,” Platt said.

    Of course, taking direct action to curb avoidable visits under control has proved to be a trickier proposition as insurers' attempts to target non-emergency use of the ED have faced heavy criticism and lawsuits.

    For instance, Anthem’s Blue Cross Blue Shield of Georgia was sued last year after instituting a policy to retrospectively deny payments for emergency department encounters it deemed “non-emergent." UnitedHealth also announced it was adopting a new policy for emergency services last year, saying that if it decided a coding— denoting intensity of emergency services provided in an ED—was not justified, they could downcode provider reimbursement or reject it completely. It has faced some pushback from some providers over its claims denial policies.


  • 10 Jul 2019 1:16 PM | AIMHI Admin (Administrator)

    Health Affairs source article | Comments courtesy of Matt Zavadsky

    Interesting data report in this month’s Health Affairs.

    Original and highlighted versions of the published study attached.  Highlighted sections replicated below for your convenience.

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    Air Ambulances With Sky-High Charges

    Ge Bai, Arjun Chanmugam, Valerie Y. Suslow, and Gerard F. Anderson

    JULY 2019

    https://doi.org/10.1377/hlthaff.2018.05375

    ABSTRACT

    Charges for air ambulance services were 4.1–9.5 times higher than what Medicare paid for the same services in 2016. The median charge ratios (the charge divided by the Medicare rate) for the services increased by 46–61 percent in 2012–16. Air ambulance charges varied substantially across the US, and some of the largest providers had among the highest charges.

    In 2017 two-thirds of air ambulance services with available billing information on network status for privately insured patients were out of network.4 In 2016 the national median charges for air ambulance services were 4.1–9.5 times the Medicare rates; in contrast, the national median charges for ground ambulance services were 2.8 times what Medicare paid (exhibit 1).

    STUDY RESULTS

    As shown in exhibits 1 and 2, the national median charges for initial fees and mileage rates for air ambulances for rotary-wing air ambulances were 5.3 and 7.3 times the Medicare rate, respectively, compared to 4.1 and 9.5 times that rate for fixed-wing air ambulances. In contrast, the national median charges for initial fees and mileage rates for ground ambulances were 1.7–2.8 times the Medicare rate.

    Charges increased substantially over this time. The median charge increased by approximately 60 percent, from $24,000 to $39,000, for both types of air ambulances (appendix exhibit A2).6In the same period, the median charge ratios for the mileage rate increased for rotary (55 percent, from 4.7 to 7.3) and fixed wing (46 percent, from 6.5 to 9.5) (exhibit 4). The median ratios for the initial fee also increased, by 61 percent (from 3.3 to 5.3) for rotary and 46 percent (from 2.8 to 4.1) for fixed wing.

    The high charges might be the result not of lack of entrants or limited supply, but of a market failure.

    Encouraging the market entry of new air ambulance providers could spur competition and reduce charges, but since many incumbent providers possess underused capacity, the market may already be saturated.8 The high charges, therefore, might be the result not of lack of entrants or limited supply, but of a market failure. Patients lack control over which air ambulance provider transports them, nor can they check provider network status or conduct price comparisons in the midst of an emergency serious enough to require air ambulance service.

  • 4 Jul 2019 11:00 AM | AIMHI Admin (Administrator)

    Modern Healthcare source article | Comments courtesy of Matt Zavadsky HCA has been investing heavily in the Urgent Care model – as referenced in the article, they acquired 24 of them back in October 2016, and they are part of our current ambulance transport alternatives program for a capitated payment agreement we have with a commercial payer.

    They have been very willing to partner on data and outcome sharing, as well as making it easy for us to refer patients to them, both through our 9-1-1 Nurse Triage program, as well as part of a 9-1-1 response.  HCA/CareNow have already reached out with interest in being part of ET3 models as a non-participating partner.

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    HCA buys two dozen urgent-care centers from Fresenius Medical Care

    July 2, 2019

    HCA Healthcare purchased 24 MedSpring urgent-care centers from Fresenius Medical Care, the investor-owned hospital chain announced Tuesday.

    The urgent-care centers will operate under HCA's Medical City Healthcare division and be rebranded as CareNow Urgent Care. The acquisition adds eight centers to CareNow's 37 North Texas locations. In 2018, CareNow and Medical City Children's Urgent Care clinics served about 10% of the Dallas-Fort Worth population, with more than 770,000 patient visits, HCA said.

    "Like many of our communities across the country, Austin, Dallas and Houston are experiencing significant growth, and increasingly people want to be able to access healthcare services closer to where they live and work," HCA CEO Sam Hazen said in prepared remarks. "The addition of these urgent-care centers will complement our already robust healthcare networks and help us provide more convenient access for our patients."

    Medical City Healthcare has invested more than $1.7 billion over four years in access points, including CareNow urgent-care locations, infrastructure and new technology, HCA said.

    With the addition, CareNow will operate 160 urgent-care centers across the country. Terms of the deal were not disclosed.

    Investors have targeted urgent care and medical offices, particularly in rapidly growing markets, as the industry pushes for more convenient, affordable care.

    The number of U.S. urgent-care centers swelled to 8,774 as of November 2018, up 8% from 8,125 in 2017, according to the Urgent Care Association's annual report. The number of Medicare and Medicaid patients seeking services at urgent-care centers continues to grow, accounting for nearly 27% of all visits in 2018.

    "This acquisition creates more access to the quality healthcare services our community needs, when and where they need them," Erol Akdamar, president of Medical City Healthcare, said in prepared remarks.

    HCA Healthcare reported net income of $3.79 billion on revenue of $46.68 billion in 2018, up from $2.22 billion in net income on revenue of $43.61 billion in 2017.

    Same-facility inpatient admissions increased 2.5% during 2018 while same-facility outpatient surgeries rose 1.8%.

    Outpatient revenue as a percentage of patient revenue remained relatively flat at 38.2%.

    The gap between U.S. hospitals' outpatient and inpatient revenue continued to shrink in 2017, according to the American Hospital Association.


  • 30 Jun 2019 7:02 AM | AIMHI Admin (Administrator)

    AIMHI is deeply saddened to share the passing of longtime leader and friend Patrick Smith.

    Patrick Wells Smith, age 65, passed away unexpectedly on June 21, 2019, at his home in Reno, Nev.  He was well-known as a nationally-respected innovator and icon in the Emergency Medical Services (EMS) industry. Most recently he was the President and CEO of REMSA (Regional Emergency Medical Services Authority) and Care Flight, based in Reno, from January 1990 through March 2013 and then President of SEMSA (Sierra Emergency Medical Services Authority) also based in Reno,  from April 2013 to June 2018.

    He was born on November 17, 1953 in Minneapolis, Minnesota, to parents Ted Arvel Smith and Margaret Wells Smith. He was the second of three children. He attended Minnetonka High School, got his start as an EMT in 1973 as a college student in Minnesota, and soon began taking on supervisory roles for EMS agencies in Minnesota and Oregon. In 1980 he was hired as an assistant director of Metropolitan Ambulance Services Trust in Kansas City where he consulted to establish EMS systems in Fort Wayne, IN.; Pinellas County, FL; Fort Worth, TX; and Little Rock, AK. He worked as Vice President of Eastern Ambulance in Syracuse New York after that before moving to Reno. 

    He was well known for his innovation and leadership in EMS systems design and medical 911 communications systems. One of his most fascinating stories was his role as a first responder at the 1981 collapse of the walkway at the Hyatt Regency in Kansas City where he was one of the initial responders on site. It killed 114 people and injured 216. That experience inspired the ways he help REMSA to prepare for many crises in which the team needed to respond with speed and outstanding systems, but still compassion.

    During his time at REMSA he created and fostered programs such as the special events coverage team, community and professional education teams, and the TEMS program which attaches specially-trained paramedics from REMSA to the SWAT teams of local law enforcement. He received numerous local and national awards, including the Secretary of Defense Employer Support Freedom Award for small businesses in 2008 where he was awarded the opportunity to meet the President of the United States.

    He was proudest in his professional life when talking about his REMSA/Care Flight team. “It’s about the people,” he would often say. He was a proud and loving father and grandfather who passed on his devotion to Disney and instilled a deep loyalty to the Minnesota Vikings in his family. 

    He was very active at the leadership level volunteering in the American Ambulance Association, and also NAPUM, National Association of Public Utility Model, which was a group of EMS organizations across the nation, each with the unique structure of a Public Utility Model, which provided guaranteed quality of care, response times and coverage without tax subsidies. REMSA had been one of those PUMs since its creation in 1986.

    He is survived by his five children: Michelle Bergren (Matt), Aaron Smith (Divya), Danielle Sanford (Michael), Theodore Smith (Hailey), and Allison Hahn (Mark), his seven grandchildren: Blake, Sage, Bode, Rishi, Rohan, Hadley, and Cole, his nephews Jason  and Jeremy Smith, and the mother of his children and ex-wife, Linda Smith, who remained his good friend and co-parent/grandparent, as well as his many other friends and EMS and medical profession colleagues.

    He was preceded in death by his parents, his sister Diana Smith and his brother James Smith. 

    A celebration of life will be held on Tuesday July 2, from 4 to 7pm at 10379 Dixon Lane in Reno. 

    In lieu of flowers, the family requests donations to Truckee Meadows Community College to the Patrick Smith Memorial Scholarship, which will be for students who want to study to become an Emergency Medical Technician, or a Paramedic. 

    Please send donations to:

    TMCC Foundation
    7000 Dandini Blvd, RDMT 200 
    Reno, Nevada 89512-3999 

    You can also donate online at: https://www.tmcc.edu/foundation/support-tmcc/make-gift. In the “Leave a Comment” box just note your donation is for the Patrick Smith Memorial Scholarship.


  • 28 Jun 2019 8:48 AM | AIMHI Admin (Administrator)

    EMSWorld Source Article | Comments courtesy of Matt Zavadsky

    Outstanding initiative by the folks in Ohio!  The most recent NAEMT MIH-CP Survey revealed multiple EMS agencies in OH doing MIH-CP programs – coupling those proactive service lines with navigation of patients requesting episodic care through the 911 access point may demonstrate significant value!

    Ohio Health System Launches EMS-Based Accountable Care Network

    06/25/2019

    John Erich

    Responding to real time-critical emergencies isn’t a big part of EMS providers’ jobs. Most of what we do, truth be told, is provide access to the healthcare system, primarily through transport to an emergency department. 

    That gives EMS a unique ethical burden. Callers to 9-1-1 don’t have a choice of ambulance providers; rarely can the direly hurt or ill offer informed consent. This means EMS bears much of the responsibility for ensuring its care is appropriate. In turn, that has obviously large implications for the use of health systems’ finite resources. 

    While the latter hasn’t historically been their purview, emergency medical services are well positioned to shape stewardship of those limited dollars. At the junction of planned and unplanned care, hospital and out-of-hospital, EMS is optimally suited to reach patients early, establish directions for further care, and impact much that happens downstream. 

    CONTINUE READING►


  • 25 Jun 2019 8:43 AM | AIMHI Admin (Administrator)

    HealthAffairs Source Article | Comments courtesy of Matt Zavadsky

    Nice summary from the Health Affairs on yesterday’s Executive Order…  Much to unpack in the near future as the rules are proposed….

    Unpacking The Executive Order On Health Care Price Transparency And Quality

    Katie Keith

    JUNE 25, 2019

    On January [June] 24, 2019, President Donald Trump issued a highly anticipated executive order on health care price and quality transparency. The White House also posted a fact sheet alongside the order. The goal of the executive order is to help consumers know the prices and quality of a good or service and to make informed decisions about their health care. The executive order is consistent with recent rules to, for instance, require drug manufacturers to disclose list prices in their advertisements or require hospitals to publish list prices on their websites.

    Generally speaking, the executive order directs an array of federal agencies to adopt rules, issue guidance, or develop reports with the goal of increasing the transparency of health care price and quality information.

    CONTINUE READING►


  • 24 Jun 2019 6:08 PM | AIMHI Admin (Administrator)

    JAMA Network source article | Comments courtesy of Matt Zavadsky

    Special thanks to Dr. Munjal, Dr. Margolis and Dr. Kellerman for this editorial in the JAMA Network!

    Tip of the hat to Dr. Margolis for sharing this link!

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    Realignment of EMS Reimbursement Policy

    New Hope for Patient-Centered Out-of-Hospital Care

    Kevin G. Munjal, MD, MPH, MSCR1Gregg S. Margolis, PhD, NRP2Arthur L. Kellermann, MD, MPH3

    Viewpoint

    June 21, 2019

    doi:10.1001/jama.2019.7488

    Substantial efforts have been made over the past decade to move the US health care system away from fee-for-service reimbursement toward alternative payment models, with the goals of expanding access, improving quality, and reducing medical costs. However, financing for emergency medical services (EMS) continues to incentivize transport to the emergency department (ED), regardless of the needs or desires of patients. In 2016, EMS agencies in the United States responded to an estimated 22.0 million 911 calls and transported an estimated 14.6 million patients to a hospital. Of those transports with complete billing information, 33% were billed to Medicare, 31% to private insurers, 20% to Medicaid, and 15% were self-pay.1

    Experts have long called for realigning reimbursement policy to support a more patient-centered approach to out-of-hospital emergency care. On February 14, 2019, the Center for Medicare & Medicaid Innovation (CMMI) announced the Emergency Triage, Treat, and Transport (ET3) model.2 This voluntary, 5-year payment model will allow EMS agencies to be reimbursed for handling 911 calls with dispositions other than transportation to an ED, including nurse triage, treatment by a qualified health care practitioner either on scene or via telehealth, or transporting patients to an urgent care center, or primary care physician office.

    The decoupling of EMS assessment and treatment from ED transport is a major development for out-of-hospital care. This approach is consistent with a 2007 Institute of Medicine recommendation “to evaluate the reimbursement of emergency medical services” and follows the recent release of the EMS Agenda 2050 document, commissioned by the National Highway Traffic Safety Administration, which articulated a future in which EMS is safe, reliable, efficient, equitable, innovative, and seamlessly integrated into health care.3 Together, these developments have the potential to promote significant innovation within the EMS community.

    Moving Beyond Transport

    EMS services are generally underfunded and have historically lacked financial motivation to invest in approaches that could help determine the most appropriate level of care. The CMMI announcement does not indicate an intended reduction in Medicare’s annual ambulance expenditures of $5.5 billion, but rather cites a projected $560 million in annual savings from reduced ED expenditures if 15.6% of Medicare ambulance transports could be managed outside a hospital ED.4

    With the ET3 model, incentives are now better aligned for EMS to pursue new communications technologies, decision-support applications, and point-of-care laboratory testing that could enable more patient-centered care to help avoid transport. The ET3 model is also likely to promote new collaborations between EMS and various community resources, including federally qualified health centers, dialysis centers, and substance abuse treatment programs. Other partnerships, such as with traditional taxi services or app-based ride services, may develop and could give patients more affordable transportation options.

    In rural and remote areas, EMS services could potentially manage an array of problems on scene with telehealth support, rather than transporting every patient (often requiring a lengthy ambulance ride) to a hospital ED. Likewise, patients receiving hospice care or palliative care may be treated more humanely in their home rather than in the hospital ED.

    EMS systems participating in the ET3 model also may be able to expand their efforts to promote injury and disease prevention. Because EMS personnel already make “house calls” and regularly encounter vulnerable populations, they are ideally positioned to identify health hazards and connect patients to community-based resources such as home health, housing assistance, and food delivery programs.

    Remaining Barriers

    Despite the potential for the ET3 model to transform EMS, several issues must be addressed to ensure that the concept moves from demonstration project to established policy.

    Patient Safety

    While the ET3 model is designed to unlock potential savings opportunities through reduced ED utilization, EMS agencies must ensure that patients who require ED care receive that service. It will, therefore, be important to demonstrate that EMS professionals can safely and consistently identify patients with nonemergency conditions. A 2009 meta-analysis of paramedic accuracy in determining medical necessity from 13 studies calculated negative predictive values of 91% for ambulance transport and 68% for ED evaluation.5 A more recent analysis involving 503 patients and 45 paramedics found a similar under-triage rate of 19.3%.6

    With additional education, greater use of evidence-based algorithms, clinical decision support, and online medical control, it should be possible to improve paramedics’ decision-making. A study performed by Wake County EMS demonstrated that a validated clinical protocol avoided transport for 65.8% of 840 low-acuity falls among older adults and achieved a negative predictive value of 98% for a time-sensitive condition.7 This same group created another protocol that triaged 226 patients with minor behavioral health symptoms, such as substance use disorders and depression, to a specialty center, with only 5% requiring secondary transport from the specialty center to the ED.8

    In another study, Houston EMS demonstrated safer decision-making using physicians via telehealth. Based on an analysis of 5570 patients treated by EMS in 2015, the project achieved a mean 44-minute reduction in EMS call time (from 83 to 39 minutes), and 75% of patients were safely transported by taxi (3751 patients) or treated on scene without transport (419 patients).9

    Measuring and Ensuring Quality

    Within the ET3 model, the Centers for Medicare & Medicaid Services includes a 5% upside-only incentive based on as-yet unannounced quality metrics. This represents one of the first pay-for-performance initiatives for EMS and will hopefully help to ensure safety of the new initiative. Measures will be needed to assess 911 call handling, nurse triage, treat-and-release policies, alternative destination management, and telehealth. However, quality measurement in EMS remains underdeveloped. With the exception of a few well-funded disease-specific registries, it has proven difficult for EMS services to obtain data on patient outcomes.

    EMS agencies will more likely succeed in the ET3 model if they can access and send electronic health information to other health care entities. This could serve to improve triage, treatment, and transport decisions, and could enable notification of the patient’s primary care physician, care manager, or both of the EMS encounter and needed follow-up.

    States, Municipalities, and Other Payers

    EMS is primarily state-regulated with substantial variation in system design and clinical protocols. As a result, the ET3 model may prove more feasible in some jurisdictions than others. In highly restrictive regulatory environments, this model may provide political impetus for reform. However, some hospitals and EDs may oppose giving EMS the flexibility to manage patients in less costly ways.

    Medicare officials are encouraging multi-payer arrangements so that EMS agencies can service all patients in a region. While most patients will benefit from more coordinated, patient-centered out-of-hospital care, Medicaid beneficiaries have particularly high EMS utilization rates, thus giving state governments the greatest opportunity to benefit from reduced health care spending.

    Local governments often operate local 911 centers, making them eligible to apply for ET3 model funding to support a medical triage function. Despite having substantial influence over the provision of EMS, many communities currently do little more than monitor EMS response times. The 5% quality incentive may encourage more meaningful priorities, such as improving patient experience and measuring clinical outcomes.

    Unintended Consequences

    The ET3 program only applies to patients who access the 911 system, as opposed to directly contacting a health system call center. As a consequence, innovative programs that are virtually identical to the ET3 model will be ineligible for reimbursement despite having demonstrated substantial savings. A future refinement of the ET3 program might reimburse all EMS systems providing care, regardless of how the call for out-of-hospital emergency care is first placed.

    Another concern is the potential for abuse of 911 services to secure convenient treatment at home, taxi vouchers to an ED or urgent care center, or quicker appointments. EMS systems will need to monitor call volumes to determine if the ET3 program incentivizes increased utilization of 911 for low-acuity conditions. If this proves to be problematic, additional measures may be required to deter misuse of the system. However, recognizing human behavior, some increase in call volume may need to be accepted, if offset by increased efficiency and therefore increased availability of 911 resources for life-threatening emergencies.

    Conclusions

    The recent CMMI announcement represents an important development for EMS. This is a first step toward the financial and delivery system reforms needed to allow out-of-hospital care systems to deliver higher-quality, patient-centered, coordinated health care that could lower costs. If CMMI and the EMS community can successfully address patient safety, quality, and local and state regulation and mitigate unintended consequences, the ET3 model experiment could help EMS realize its full potential.


  • 24 Jun 2019 6:01 PM | AIMHI Admin (Administrator)

    Modern Healthcare source article | Comments courtesy of Matt Zavadsky

    Interesting perspective…

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    Conservative legal expert calls surprise bill proposals unconstitutional

    June 21, 2019

    HARRIS MEYER  

    A prominent conservative legal expert is warning that congressional moves to regulate surprise out-of-network billing by physicians are unconstitutional and could be challenged in court.

    In a new legal brief, Paul Clement, a former Republican solicitor general who led the unsuccessful effort to overturn the Affordable Care Act in 2012, said bipartisan congressional proposals to cap out-of-network rates would violate the takings clause of the Fifth Amendment as well as the First Amendment right to freely associate.

    Other legal experts said Clement's arguments are dubious but could convince lawmakers to back off or water down legislation.

    "These are extremely weak constitutional claims—the sorts of claims that, if accepted, would threaten the constitutionality of any kind of legislative price controls," said Nicholas Bagley, a health law professor at University of Michigan.

    Nevertheless, Clement's brief may foreshadow a court challenge by provider groups or conservative legal groups if Congress passes legislation to protect consumers from surprise out-of-network bills and cap the rates insurers pay for out-of-network services.

    The Senate health committee is planning to vote next week on a bipartisan bill that would cap payment for out-of-network care at a regional insurer's typical negotiated rate. House Energy and Commerce Committee leaders have offered a similar proposal.

    With public outrage growing over surprise bills, President Donald Trump and lawmakers of both parties have called for protecting patients from these bills. "A very unpleasant surprise," Trump said last month. "So this must end."

    Clement, a partner at Kirkland & Ellis who has argued nearly 100 cases before the U.S. Supreme Court, said the proposed legislation "threatens to take property from healthcare providers without just compensation" and "threatens to infringe on providers' associational activity."

    He argued that any legislation should at least ensure that out-of-network providers who treat patients during an emergency or at an in-network facility receive the prevailing market rate as soon as possible after providing the service. In addition, he said Congress also should require a baseball-style arbitration process as an alternative.

    Clement's office did not respond to a question about whether he wrote the brief on behalf of a particular client.

    Physician and hospital groups strongly oppose the Senate health committee's "benchmarked cap" proposal as well as proposals to require hospitals to bring all their physicians into their insurance networks.

    Provider groups didn't immediately indicate whether they agreed with Clement's legal analysis or would sue to block legislation. But the American College of Emergency Physicians echoed his arguments.

    "While we can't speak to the legal or constitutional implications of the benchmarking approach of the Senate (health committee) bill, we have very strong concerns about the damaging impact that capping out-of-network reimbursement at the median in-network rate would have on patient access to care," said Laura Wooster, the association's associate executive director for public affairs.

    Clement wrote that capping or eliminating balance billing would rob providers of the negotiating leverage they have with health plans, forcing them to accept unreasonable network rates. Over time, he said, rates would decline and physician practices would become economically non-viable for both network and out-of-network providers.

    But those arguments are unlikely to hold up in court, said Tim Jost, an emeritus health law professor at Washington and Lee University.

    "It seems to me a real stretch to say that requiring providers to accept a median in-network rate would be a taking prohibited by the Constitution or a violation of freedom of association," he said. "Government action has to be pretty extreme to constitute a taking."

    Still, Clement's arguments "may give cover to politicians who are otherwise opposed to addressing surprise medical billing," he added.


  • 18 Jun 2019 1:15 PM | AIMHI Admin (Administrator)

    Kaiser Health News source article |Comments courtesy of Matt Zavadsky

    This article was produced by Kaiser Health News and published in Governing Magazine…

    In Fight Against Surprise Medical Bills, Lawmakers Miss High Air Ambulance Costs

    BY KAISER HEALTH NEWS

    JUNE 18, 2019

    In April 2018, 9-year-old Christian Bolling was hiking with his parents and sister in Virginia’s Blue Ridge Mountains, near their home in Roanoke. While climbing some boulders, he lost his footing and fell down a rocky 20-foot drop, fracturing both bones in his lower left leg, his wrist, both sides of his nose and his skull.

    A rescue squad carried him out of the woods, and a helicopter flew him to a pediatric hospital trauma unit in Roanoke.

    Most of Christian’s care was covered by his parents’ insurance. But one bill stood out. Med-Trans, the air ambulance company, was not part of the family’s health plan network and billed $36,000 for the 34-mile trip from the mountain to the hospital. It was greater than the cost of his two-day hospitalization, scans and cast combined.

    “When you’re in that moment, you’re only thinking about the life of your child,” said Christian’s mother, Cynthia Bolling, an occupational therapist. “I know that I am being taken advantage of. It’s just wrong.”

    The rising number of complaints about surprise medical bills is spurring efforts on Capitol Hill and at the White House to help consumers. Over and over again, the high cost associated with air ambulance service gives patients the biggest sticker shock — the subject has come up at nearly every Capitol Hill hearing and press conference on surprise medical bills.

    Yet air ambulance costs are not addressed in any of the proposals introduced or circulating in Congress. Even a congressional decision last year to set up a panel that would study air ambulance billing hasn’t gotten off the ground.

    “We’re doing a disservice to patients if we protect them from hospital bills but bankrupt them on the way there,” said James Gelfand, senior vice president for health policy for the ERISA Industry Committee, known as ERIC, a trade association for large employers.

    The issue came up again Wednesday at a House Energy and Commerce subcommittee hearing where Rick Sherlock, president and CEO of the Association of Air Medical Services, the industry group for air ambulances, was among eight witnesses.

    Rep. Ben Ray Luján (D-N.M.) sharply questioned Sherlock why costs for air ambulance services have risen by 300 percent in his state since 2006.

    “I’m trying to get my hands around why this is costing so much and why so many of my constituents are being hit by surprise bills,” Luján said.

    Sherlock said that reimbursements from Medicare and Medicaid do not cover the cost of providing services, so charges to private patients must make up that difference.

    Air ambulances serve more than 550,000 patients a year, according to industry data, and in many rural areas air ambulances are the only speedy way to get patients to trauma centers and burn units. As more than 100 rural hospitals have closed around the country since 2010, the need has increased for air services.

    More than 80 million people can get to a Level 1 or 2 trauma center within an hour only if they’re flown by helicopter, according to Sherlock.

    The service, though, comes at a cost. According to a recent report from the Government Accountability Office, two-thirds of the more than 34,000 air ambulance transports examined were not in the patients’ insurance networks. That can leave patients on the hook for the charges their insurers don’t cover, a practice known as “balance billing.”

    In 2017, GAO found that the median price charged nationally by air ambulance providers was around $36,400 for helicopter rides and even higher for other aircraft. The total generally includes the costs for both the transportation and the medical care aboard the aircraft.

    Additionally, the ongoing “Bill of the Month” investigative series by Kaiser Health News and NPR has received more than a dozen such bills, ranging from $28,000 to $97,000.

    Cynthia Bolling said her insurance company paid about a third of Christian’s air ambulance bill and the family settled this week with Med Trans by agreeing to pay $4,400 out-of-pocket.

    Reid Vogel, director of marketing and communications for Med Trans, said the company cannot talk about a private patient because of privacy rules. But he added that the company works with patients to find “equitable solutions” when their bills are not covered by insurance.

    Since nearly three-quarters of flights are for patients insured by low-paying Medicare, Tricare and Medicaid, he said, “providers must shift costs to insured patients.”

    Private insurers usually will pay only an amount close to what Medicare reimburses, which is around $6,500. That gives air ambulance companies an incentive to remain out-of-network, according to a 2017 GAO report.

    “A representative from a large independent provider noted that being out of network with insurance is advantageous to the provider because a patient receiving a balance bill will ask for a higher payment from the insurance company, which often results in higher payment to the air ambulance provider than having a pre-negotiated payment rate with the insurer,” the GAO said.

    In an interview, Sherlock, of the trade association, disputed the report’s findings, saying his members are actively trying to be in-network in more places, although he couldn’t provide any specific numbers.

    “I think that everywhere they can, they’re incentivized to be in-network,” he said.

    States are hampered in their efforts to ease the strain for residents.

    The Airline Deregulation Act of 1978, which was intended to encourage more competition, forbids states to regulate prices for any air carrier, which applies to air ambulances. What’s more, many large employers’ health insurance is not governed by states but regulated by the federal labor law, known as ERISA.

    So a remedy likely has to come from Congress. And it’s proven to be a heavy lift.

    For example, the committees that deal with regulation of the air industry — the Commerce Committee in the Senate and the Transportation Committee in the House — don’t make health policy or regulate health insurance.

    Last year, some lawmakers sought to let states regulate air ambulances with a provision in the bill reauthorizing the Federal Aviation Administration.

    But that measure was ultimately eliminated. Instead, the bill called for the creation of an advisory committee to study air ambulance prices and surprise bills.

    “The air ambulance lobby did a very good job playing defense during FAA authorization,” said ERIC’s Gelfand.

    The panel, which was supposed to be formed within 60 days of the law’s enactment date — Oct. 5 — still has not been created.

    Representatives from the air ambulance industry don’t think congressional action is necessary, although they are calling for higher reimbursements from Medicare.

    Chris Eastlee, vice president for government relations for the Association of Air Medical Services, said his group does not favor more congressional regulation of prices but would support mandatory disclosure of costs to the secretary of Health and Human Services. The organization argues that greater transparency will help companies negotiate more in-network contracts.

    A fix for surprise bills supported by some researchers and advocates would require every provider within a medical facility to accept any insurance plan that contracts with that hospital. It might also help bring down air ambulance bills, said Loren Adler, associate director of USC-Brookings Schaeffer Initiative for Health Policy.

    It would avoid the situation where someone picks an in-network hospital only to find out that a surgeon or anesthesiologist at that hospital doesn’t take their insurance. Air transport should also be included in the rule, he said.

    “It’s the exact same situation as with the out-of-network emergency facility rates,” Adler said. “The same solutions should apply.”

    Gelfand suggested also that the House Ways and Means Committee mandate that air ambulance companies seeking to participate in Medicare must charge in-network rates.

    That would require only a small tweak of the legislative language, as he sees it. “Every proposal that includes something to address surprise bills for emergency care, all you have to do is add in the words ‘air ambulances,’” Gelfand said.

    Right now, the closest any surprise billing proposal has come to addressing air ambulances is a draft legislative plan on medical costs from Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.). They would require bills for air ambulance trips to be itemized to show both medical charges and the transportation charges so patients and health plans can understand them better.


  • 18 Jun 2019 7:35 AM | AIMHI Admin (Administrator)

    Axios Source Article | Comments Courtesy of Matt Zavadsky

    Interesting – From Axios

    Surprise billing proposals don't address ambulances

    Caitlin Owens

    6/16/2019

    None of Congress' proposals to rein in surprise medical bills address ambulances — which are expensive and often aren't covered by insurance.

    Why it matters: More than half of ambulance rides, and two-thirds of air ambulance transports, aren't covered by private insurance. Patients are often billed more than $10,000 for what insurance won't cover.

    What we're watching: Energy and Commerce Committee Chairman Frank Pallone has said that the committee plans to address air ambulances in its final bill. But it's less clear what will happen with ground ambulances.

    What they're saying: "Ground ambulances are arguably the screwiest market of any that comes up in this context," said Brooking's Loren Adler.

    • "Neither side has much incentive to contract because the insurer knows the ambulance has to pick up anyone who calls 911 and the ambulance doesn’t want to take less money from the insurer than they could get balance billing people," he added.

    The other side: Air ambulances say that the government reimburses below the cost of the service. That means that they have to charge privately insured patients higher rates, but insurers often refuse to cover their services.


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