News & Updates

  • 2 May 2022 7:00 PM | Matt Zavadsky (Administrator)

    Hats off to the FDCARES program developers, and all those who have ventured into the MIH/CP waters, proving the value of “EMS” in much different ways!

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    A Different Kind Of First Responder

    Brian Rinker

    MAY 2022

    https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00363

    Abstract

    A Washington State fire department dispatches nurses and social workers to address the underlying health and social needs of repeat 911 callers.

    Dana Bray remembered September 8, 2019, as the unforgettable day her seizures began. It started with what she thought was a bad reaction to a medication that left her unconscious and not breathing on her condo floor in Renton, a Seattle suburb in King County, Washington. Her downstairs neighbor found her purple and almost dead. The neighbor called 911, and Bray was admitted to the intensive care unit for ten days.

    Later, Bray, 65, was diagnosed with functional neurological disorder, a broad category of motion disorders caused by problems with how the brain functions.1 (After speaking with the author for this article, Bray died in March 2022.)

    After that first near-death experience, Bray’s neurological problems affected her ability to move around—she had to relearn how to walk, and getting around required a walker or wheelchair. More troubling, though, were the continued seizures, which snuck up without warning, randomly and frequently. Bray would go stiff, start shaking, and then fall.

    “The worst part about it was that I had no control where I fell,” Bray said.

    During the next two years, Bray estimated that she had fallen close to 150 times from the seizures. Sometimes she collapsed three times in a single day. There was hardly a spot in her modest condo where she hadn’t fallen and hurt herself. There was the time she knocked her chin on the nightstand, or when she rolled under the dresser, violently shaking, and got stuck; she also dislocated her ankle, severed a finger, and had countless blue and purple bruises all over her body. She must have called 911 at least once a month over the years, she said. On a particularly rough week, she remembered dialing 911 four days in a row.

    Had Bray lived in some other community across the United States, each of those of 911 calls likely would have resulted in a maximalist response: paramedics, ambulance with lights ablaze, and maybe even a million-dollar ladder truck from the local fire station. Fortunately, Bray said, her community is served by a fire department that instead sent a nonemergency unit known as FDCARES, which stands for Fire Department Community Assistance, Referrals, and Education Services.

    FDCARES is a specialized unit in which registered nurses and social workers work alongside firefighters to address the underlying causes contributing to repeat callers like Bray. It was created by Puget Sound Regional Fire Authority and is available in the southern region of King County.

    For Bray, from their first contact in 2019 until her death, FDCARES became a mainstay in her life. During that time, FDCARES connected her with a fall prevention program that installed grab bars and a shower seat in her bathroom. The unit stopped by her condo so many times, whether to drop off a new walker or a wheelchair or just to check in, that Bray considered one of the nurses a good friend.

    “I didn’t call and ask them to come see me, they just came and knocked on my door, you know, out of kindness,” she said. That meant a lot to Bray, who lived alone and didn’t have family nearby. “It was nice to have somebody with professional medical training visit me, and it was nice to know that somebody cared about me,” she said.

    ‘Costly And Overcrowded’

    Bray was what emergency service professionals refer to as a 911 high utilizer—a small subset of the population that uses a large portion of fire department, police, and emergency department resources. Every community has them. Many high utilizers have complex medical and psychosocial needs and call 911 for nonmedical emergencies. Cities and health systems across the country are incentivized to address these so-called high or “super” utilizers to divert them from costly and overcrowded emergency departments, drive down health costs, and free up limited resources for people experiencing true medical emergencies.

    Shifting trends during the past decades toward value-based and whole-person care—addressing an individual’s health, behavioral, and social services needs in concert—have led to a growing number of efforts nationwide to reduce hospital readmissions, divert nonemergency cases away from emergency departments, and provide resources to tackle any environmental conditions that may affect a person’s health. Although hospitals and accountable care organizations have a keen interest in coordinating care to improve health and wellness for high utilizers, some lack the resources and staff to meet this tough subset of patients.2

    Mobile integrated health programs such as FDCARES are well suited and strategically better positioned than hospitals or physician groups to provide care and social services to people in the community. These mobile health programs, also called community paramedicine, harness local emergency services, which have the existing infrastructure to respond to community members’ needs. One 2014 survey3 identified well over 100 EMS agencies in thirty-three states that are implementing some version of a mobile integrated model, with dozens more agencies in the process of launching their own units.

    With the COVID-19 pandemic, experts say that mobile integrated health units are now more important than ever before, as they have skill sets, resources, and infrastructure to quickly pivot and be flexible. When the pandemic hit and hospital systems were overwhelmed, the area’s public hospital district, UW Medicine Valley Medical Center, and the King County public health agency called on FDCARES to run community COVID-19 testing and vaccination efforts.

    FDCARES, however, is unlike other mobile integrated health units, as it is one of the only fire departments in the country to hire nurses and social workers to work alongside firefighters.

    ‘The Potential’

    The concept for FDCARES dates back to 2010 and was born out of the recognition that the King County fire departments were spending a lot of money, resources, and time to respond to repeat 911 callers.

    In general, fire departments assume the brunt of high utilizers’ impact, responding to upward of 80 percent of 911 calls for medical services. Of those calls, about 40 percent are considered nonemergencies, such as falls, complications arising from chronic health conditions, mental health episodes, and intoxication.

    For Puget Sound Regional Fire Authority, which serves several cities in southern King County, departmental estimates indicate that slightly more than 1 percent of the community accounts for roughly 40 percent of 911 calls.

    As envisioned, FDCARES not only helps people navigate the complicated world of health and mental health care but also connects them to social services, such as food banks, rental assistance, fall prevention, therapy, and substance use treatment. The idea is that by addressing the root causes of super utilizers’ super utilization, the program will save fire departments, hospitals, and taxpayers tons of money.

    Has that vision been fulfilled? As the public health field has learned, it’s hard to quantify prevention. However, a 2017 evaluation4 estimated that FDCARES had the potential for annual savings of $600,000 for the fire department, as well as $1 million a year for the area’s health care system, and that it could reduce emergency department visits by up to 200 a year.

    In the eyes of many regional officials, the program has been such a success that it has expanded to the nearby Renton Regional Fire Authority. At this time, FDCARES covers seven King County cities and receives roughly 2,600 calls a year. The program has continued to evolve since it formally launched in 2015 and is on track to grow bigger and take on more responsibilities.

    “I expect over the next fifteen to twenty years, mobile integrated health and…FDCARES-type units will be as common as fire suppression is at a fire station,” said Puget Sound Regional Fire Authority Deputy Chief Aaron Tyerman, who oversees FDCARES’s strategic direction.

    ‘It Doesn’t End There’

    The standard fire department model is straightforward. A 911 call for medical assistance comes in, and dispatch triggers a rapid response deployment of fire department emergency medical technicians (EMTs) and paramedics, who arrive on scene in four to seven minutes. The job of the first responders is to quickly assess the situation, deliver appropriate interventions, and then transport anyone who needs it to a hospital emergency department.

    But with close to half of all calls being nonemergency, said Captain Matthew Madlem, from Puget Sound, ten years ago they were essentially “sending very expensive ladder trucks to go help people who have just simply fallen.”

    A big chunk of 911 calls, according to Madlem, were from those who had fallen, in fact, and these callers didn’t need the emergency department, they needed someone to figure out why they were falling all the time. Perhaps it was a medication problem, an adverse consequence of a chronic health condition, intoxication, or a mental health issue. Yet back then the fire department, similar to many emergency medical services agencies, didn’t have a process for closing the loop on care or managing continuity of care for patients they saw repeatedly, Madlem noted.

    “Firefighters are trained to do a lot of things, from fighting fires to river rescues, confined space rescues, hazardous material responses, basic life support for people that have medical issues,” Madlem explained, “but we’re not trained to be social workers, and we’re not trained in transition care management or care coordination.”

    In fact, the department’s past approach to recording data was so arcane, it couldn’t even identify high utilizers. The first thing they had to do when implementing FDCARES was create a database that could identify repeat callers. The database also uses predictive analytics, a technique commonly called hot spotting, to identify areas and callers at higher risk for complex medical and psychosocial needs.

    Today, under the FDCARES model, when someone calls 911, dispatch uses updated criteria-based dispatch guidelines developed in house by King County Emergency Medical Services to identify nonemergency callers; in those cases, it’s the FDCARES unit that goes to the scene. Because the call is not an emergency, FDCARES has twenty-five minutes to get there, instead of only a few minutes. Nor does it need a large fire engine or state-of-the-art ladder truck.

    Instead, the firefighter and nurse duo drive a red pickup truck with “FD CARES” written on the side of the truck, which carries fall prevention equipment and lift devices. Altogether, their truck costs a fraction of the price of purchasing and maintaining a fully equipped fire engine. Once there, the responders can spend a much longer time working with the person to figure out what is going on and how they can help.

    But it doesn’t end there. The unit also proactively checks up on patients to make sure their needs are being met and whether the initial assistance is helping them navigate health care. This may include bringing a wheelchair or walker over, as they did in Bray’s case, or connecting them with a social worker.

    In 2015 the Puget Sound Regional Fire Authority launched FDCARES as an eighteen-month pilot program, hiring a social worker and three registered nurses. Reaching that point alone was a considerable lift for the department and local officials, as fire departments are funded with tax dollars and don’t have very much flexibility.

    To make sure FDCARES didn’t step on any toes, the program enlisted support from the Washington State Nurses Association and was able to obtain medical oversight from the medical director of the UW Valley Medical emergency department, Cameron Buck, who helped define the scope of practices.

    The partnerships supported the fire department’s case that it was in the community’s best interest to spend its tax dollars on nurses and a social worker. The buzz around FDCARES spread across the state and inspired the state legislature to pass a bill5 in 2013 allowing fire departments to hire nurses, social workers, and other nonfire personnel.

    ‘Worth The Risk’

    Back in November 2015, Sara Hardin was one of the first nurses hired. Hardin’s family thought it was odd that she left a stable job in the intensive care unit (ICU), taking a hefty pay cut, to join an experimental pilot program with the fire department. But for Hardin it was worth the risk. She said that it was “heartbreaking” to see the same people admitted to the ICU over and over again and not being able to prevent it.

    “Trying to offer a solution was really appealing,” she said about joining FDCARES.

    When FDCARES first went into action, the team got some pushback. The nurses didn’t exactly fit in at first. Initially, they weren’t a part of the firefighters’ union, which left them feeling that they were not on equal footing. Plus, they didn’t accrue any vacation or sick time, Hardin recalled.

    Some fire crews were concerned the nurses might replace firefighters, and their integration at the station went against decades of tradition. The county’s paramedic squad also complained, worried that the fire department was encroaching on their medical domain. When it eventually became clear that the nurses handled only nonemergency and high-utilizer calls, Madlem said, they agreed that FDCARES would make everyone’s jobs easier. Over time, the nurses blended in. Two years later the union accepted Hardin and her nurse colleagues into their ranks, further cementing their role as a core service of the fire department. Today, if the department canceled the FDCARES program, Hardin said, there would be an uproar.

    The other big challenge was getting nurses prepared to work in the station and up to speed on all the firehouse lingo and culture, as well as training them on the radio, computers, and operational procedures. Training them was Madlem’s job. Basically, the gist was “how to exist in the fire department culture as somebody who’s not a firefighter,” he said.

    Much of the learning is picked up over time by living with the crews, whether it’s working twenty-four- or forty-eight-hour shifts. They learn words such as “beanery,” firefighter talk for the living room, where there is always a pot of coffee ready, and “spike the bag,” meaning to start an intravenous drip. Then there are the little things, such as bringing doughnuts, making coffee, and racing to always be the first to answer the telephone.

    Hardin was surprised by just how much time the firefighters spend together, especially all of the group meals—wake up; drink coffee in the “beanery;” and eat breakfast, lunch, and dinner together. When bedtime arrived, they were all walking around with toothbrushes in hand. It was like a big family, Hardin said. And similar to what happens in big families, there was a lot of joshing around and poking fun at each other.

    “You have to be able to take a joke,” Hardin cautioned. “The fire department jokes a lot.”

    ‘Culture Shock’

    When Daniel Henriquez joined FDCARES, he didn’t know what he was getting himself into. Henriquez, similar to Hardin, was an ICU nurse. But he had longed to work in the community, helping vulnerable and marginalized people get better. In his decade of ICU experience, he had seen how often poorly managed chronic health conditions, such as hypertension, ended with preventable tragedies, such as a stroke or heart attack.

    In addition, coming from health care, Henriquez said, entering the fire department was a complete culture shock. Many firefighters have military or law enforcement backgrounds, and the fire department is structured with ranks similar to a military chain of command.

    Henriquez was roughly three months in with FDCARES when he went out on a 911 call that ended with him finally feeling like part of the team. It’s an unpleasant and terribly sad story, but it does have a happy ending.

    Henriquez and his firefighter partner got a call requesting help for a man who had been living in his car for several months. Approaching the vehicle, they were hit with a smell that Henriquez likened to the inside of a septic tank. The man told them to go and wouldn’t get out of the car, but after some cajoling, he rolled down the window.

    Henriquez started talking with the person—really talking, he said—and in that moment, “we were level, human-to-human,” he said.

    That’s when the man started bawling. He told them he had lost his job, been divorced, and was forced to live in his car, which was parked in front of his old home. He’d run out of money and gas. At some point, about six months prior, he lost the will to get out of the car. Henriquez looked inside the car and saw feces and urine piled all the way up to the man’s knees. Hoping to shield his legs from the mess, the man had wrapped plastic garbage bags around them, but the ties on the bags cut deep into the skin and muscle, all the way down to the bone; maggots covered the wounds.

    “If we try to move this patient out of here, his legs might fall off, and he will just bleed out and die,” Henriquez thought at the time.

    But they had to move him. They cut his clothes off and pulled him through the window and put him on a stretcher. His vital signs were OK, surprisingly. Paramedics transported the man to the hospital, and miraculously, they were able to save his legs.

    “Thank God for the maggots,” Henriquez said, noting their antimicrobial effects. “He had no infection whatsoever—those maggots saved his life.”

    Several months later the man walked into the fire station and left a message thanking the firefighter and Henriquez for taking care of him. He was grateful that they didn’t make fun of him, choosing compassion instead. Henriquez later heard that the man got an apartment and began volunteering at a homeless resource center.

    ‘It’s Evolving’

    Last year the fire chief asked Henriquez what he wanted for the FDCARES program. If you could have anything, the chief inquired, what would it be? “The first thing I said,” Henriquez recalled, was, “I need my partner to be a social worker instead of a firefighter.”

    During the four previous years, Henriquez had felt as if something was missing. Many of the calls he went on, although dispatch had classified them as nonemergency, still resulted in the patient being transported to the emergency department. When that happens, FDCARES units don’t have much of a role to play. Henriquez said that these calls are best handled by EMTs. In his view, having to spend all that time dealing with medical emergency calls prevented him and the other crews from doing the upstream work that FDCARES was created to do in the first place.

    Part of the challenge is that the county’s emergency dispatch service has a tough time understanding the severity of a call in that moment, said Nancy Valencia, FDCARES’s lone social worker. The call may come across as not that intense, but once first responders are on the scene, the patient may still need emergency medical care.

    Valencia, an army reservist, was deployed last year, and in her absence FDCARES turned to UW Valley Medical Center’s health facilitators to cover her social work duties, which did not entail going out on calls. With the pandemic strengthening their long-standing relationship, FDCARES is increasingly becoming UW Valley Medical Center’s boots on the ground in the community. The two organizations are currently ironing out the details on a project in which FDCARES will perform follow-up medical visits and welfare checks on patients recently released from the hospital.

    This summer Henriquez will get what he asked for: FDCARES has adjusted its model again. A nurse will team up with a social worker and go on calls only after a firefighter has determined them to be true nonemergency events. The department has a potential grant for $185,000 pending from the One Medic Foundation. If approved, the grant will go toward hiring three more social workers. As to an evaluation plan, Henriquez said that they don’t have one now. They are studying outcomes, such as how many patients get connected to resources, but with the pandemic and staffing shortages, they have struggled to keep up on these efforts.

    “We’ve been doing this for basically seven years, and it’s evolving,” Valencia said. “We’re continuing to try to meet the patients where we need to meet them and do that in the most efficient and effective way we can for our community.”

    Henriquez envisioned that working for FDCARES would be similar to providing home health care. Instead of the health care happening in the hospital, he’d address patients’ day-to-day health issues in their homes. It turned out to be kind of like home health care, but on steroids.

    FDCARES units are dispatched to multiple 911 calls each day—for example, responding to an intoxicated person experiencing homelessness, or an elderly person who has fallen—and they proactively follow up with past callers, helping them navigate the health care system and ensuring that they have been connected to the right resources, from medical equipment to rental assistance, and even assisting family caregivers struggling to care for a loved one.

    NOTES


  • 2 May 2022 6:59 PM | Matt Zavadsky (Administrator)

    Excellent article! 

    The 2nd linked study in the 4th to last paragraph has a fantastic compendium of all the research studies published around the world about MIH/CP programs (most of them from countries outside the U.S.), but GREAT info!

    The article references the benefits of EMS systems doing safety checks on scenes and referring patients for other follow-ups.  MedStar has been blessed to work with several Universities on HRSA and DOJ funded studies doing exactly that for things like fall risk assessments, elderly neglect and abuse and opioid overdose risks.  We strongly recommend agencies seek out those types of partnerships as a value-added role in your local community.

    Tip of the hat to MedStar’s Chris Cunningham for finding this article!

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    Beyond emergencies: Researchers rethink the role of paramedics in the health system

    April 26, 2022

    Alisa Kim

    https://www.utoronto.ca/news/beyond-emergencies-researchers-rethink-role-paramedics-health-system

    As a paramedic, University of Toronto alumnus Amir Allana routinely responds to a wide range of calls – from people suffering a heart attack or stroke to those experiencing mental health issues and addiction.

    “On a given day, I might go from acute trauma to someone who’s 70 and has just had a fall but is otherwise uninjured,” says Allana, who recently defended his master’s thesis in the health services research program offered by the Dalla Lana School of Public Health’s Institute of Health Policy, Management and Evaluation (IHPME).

    “The next call might be for someone who’s in a shelter system who has a number of chronic conditions that have gotten worse, or who just needs somewhere to go. You’re trying to navigate to what extent is this a health issue versus a social issue? Is this an addictions issue? You’re switching gears all the time, and a lot of it is case-finding, triage and navigation of the health system,”

    In fact, Allana says that traditional medical emergencies account for only a small fraction of the cases he sees.

    “It’s difficult for newer paramedics who spend all their schooling thinking about trauma and cardiac arrest, only to realize, ‘Oh, that’s just 10 per cent of what I do,’” he says. “Not enough education or cultural pieces are in place to tell them, ‘Actually, your role for the most part is diagnostics and care navigation. Your role is an extension of health services because you’re mobile in the community.’”

    Allana and his co-supervisor, Andrew Pinto, an associate professor at the Dalla Lana School of Public Health and a family physician at St. Michael’s Hospital, recently published a paper in Healthcare Policy, that explores how paramedics can address social determinants of health more effectively.

    Care could be improved, they argue, by equipping paramedics with tools for better social and environmental assessments. For example, questionnaires could be used to help paramedics assess patients for risks associated with housing, income and food insecurity. Paramedics could also address social factors linked to health by working directly with community-based organizations such as legal aid, shelters, detox centres, food banks and employment agencies.

    Allana says such an approach would require a shift in paramedic education, culture and governance.

    His research also looks at integrated care and how paramedics can extend primary and preventive care in home and community settings.

    Allana says the pandemic has exposed the vulnerability of the health system and provides an opportunity to think about how to restructure it in a way that leverages local agencies and services to improve outcomes.

    “There are approaches to care that can be provided in the community, but require a rethink of the role of primary care, community-based nursing and mobile care teams – including paramedics and mental health services – to address people’s needs in a way that doesn’t rely just on doctors and nurses in a hospital,” he says.

    In a study published in the International Journal of Integrated Care, Allana looked at 108 programs around the world that use paramedics in various care pathways in the community. He found paramedics bridged gaps in care by working across silos that exist between hospitals, social services, primary care and public health. For instance, paramedics in some jurisdictions work with primary care teams to address flare-ups of chronic diseases such as heart failure (when the heart is too weak to meet the body’s pumping needs) and chronic obstructive pulmonary disorder (a lung disease that causes breathing problems) by going into the community to address needs both reactively and proactively.

    “Even something simple like weight monitoring for people with congestive heart failure can catch deterioration early,” says Allana. “Systems can be put in place by family health teams and paramedics to follow care plans and adjust medications. There’s something in the middle of purely scheduled primary care and highly acute unscheduled emergency care – there’s a big gap in the middle that no one fills, and a lot of new [paramedicine] programs are filling that.”

    Allana says that, ultimately, a more expansive view of the profession is needed and that investing in the capacity of paramedics to provide urgent and preventive care will strengthen the health system for everyone.

    “The use of emergency departments and hospital services has outstripped population growth for several decades and that’s going to continue to happen. The reason for that is you’re not providing appropriate care options in the community. We don’t have capacity in the acute care system to appropriately care for people. If you invest in prevention and care co-ordination, it’ll pay off in the long term and curb the need for additional emergency coverage over time.”


  • 2 May 2022 6:57 PM | Matt Zavadsky (Administrator)

    This may be something for us to keep an eye on? 

    We’ve noticed denials from some MA programs for services covered by FFS Medicare, including some ambulance services coverage authorized under COVID-19 waivers…

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    Medicare Advantage debate rekindled by report on coverage denials

    Tina Reed

    Caitlin Owens

    4/29/22

    https://www.axios.com/medicare-advantage-debate-rekindled-by-report-on-coverage-denials-c76d3d57-df26-41be-8d7e-e8d1a5911514.html

    Thursday's federal watchdog report accusing Medicare Advantage of denying too many services that should have been paid for under Medicare coverage rules is inflaming Washington's debate over whether the program is helping seniors or simply padding insurers' pockets.

    Why it matters: Medicare Advantage enrollment has ballooned in recent years, making the question of its value — both in terms of quality and cost — increasingly important.

    Driving the news: The report from the HHS Office of the Inspector General says it found "widespread and persistent problems" of inappropriate denials of services and payment requests that met Medicare coverage rules.

    • Auditors found 15 Medicare Advantage organizations denied 12,273 previously authorized requests for medical care during the first week of June 2019.
    • Putting that into context, the Medicare Advantage plans would have denied 84,812 beneficiary requests for services that met Medicare coverage rules that year.

    Between the lines: Medicare Advantage has proved highly lucrative for insurers, turning Medicare into more of a private marketplace as enrollment swells.

    • Private insurers like Humana and UnitedHealth Group that administer Medicare Advantage plans can expect a 5% average increase in federal payments next year — half a percentage point above what the Biden administration proposed in February.
    • Humana recorded a $930 million first-quarter profit and projected its Medicare Advantage rolls will grow by 150,000 to 200,000 this year, according to Modern Healthcare.
    • More than 28 million seniors and people with disabilities were enrolled in a private Medicare Advantage plan at the beginning of this year, an 8.8% increase from the same time in 2021.

    Yes, but: Not everyone thinks the program's success is a good thing — particularly for taxpayers.

    • Whistleblowers have accused Medicare Advantage plans of inflating how sick their members are in order to bump up federal payments, Bloomberg recently reported.
    • A recent report from the Medicare Payment Advisory Commission concluded that plans collected $12 billion more caring for seniors in 2020 than it would have cost in traditional Medicare.

    The other side: "The OIG report validates that the vast majority of Medicare Advantage prior authorization requests are approved, and that the vast majority of denials that the OIG reviewed were appropriate," said Kristine Grow, a spokesperson for America's Health Insurance Plans, adding Medicare administrators noted plan performance is improving.

    What we're watching: The program generally isn't an attractive political target given its popularity with seniors and, for Republicans, its embrace of private-sector coverage.

    • Policymakers often turn a blind eye to exorbitant health care costs in response to health industry lobbying.
    • But denial of services could make the program an easier target for critics.
    • Democratic Reps. Katie Porter, Rosa DeLauro and Jan Schakowsky and Sen. Elizabeth Warren are pressing the Biden administration to put payments to Medicare Advantage plans on a par with traditional Medicare and increase transparency in the program.
    • Reps. Suzan DelBene, Mike Kelly, Ami Bera and Larry Bucshon seized on the inspector general's findings to call for reforms to the program.

    The bottom line: Medicare Advantage is unquestionably getting bigger. Thursday's report once again raised the question of whether that's a good thing.


  • 2 May 2022 6:56 PM | Matt Zavadsky (Administrator)

    An international challenge – Fundamental changes are need to how EMS is delivered….

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    Data shows ambulance unavailability getting worse in Winnipeg

    In January, there were 28 hours where zero ambulances were available, according to City of Winnipeg figures

    Sarah Petz · CBC News

    Apr 20, 2022

    https://www.cbc.ca/news/canada/manitoba/winnipeg-ambulance-unavailability-1.6425663

    There were 28 hours in January when there were zero ambulances available in the City of Winnipeg to respond to emergencies, according to data obtained by the Manitoba NDP. 

    That's four times longer than it was two years before in December 2019, which at the time was the longest monthly total in four years. 

    It also wasn't even the worst month for ambulance unavailability in Winnipeg in the last year.

    Figures from the City of Winnipeg show that in August 2021, there were nearly 31 hours where there were no ambulances available to respond to calls. 

    That works out to about 59.69 non-consecutive minutes per day, a City of Winnipeg spokesperson confirmed. 

    The data, obtained through a freedom of information request, was tabled in question period Wednesday by NDP Health Critic Uzoma Asagwara. 

    It also shows that in the same month, there were 588 instances where there were no EMS units available to respond to calls for service. 

    "The problems were known long before the pandemic, and the government did absolutely nothing to resolve it," Asagwara said. 

    Paramedics exhausted

    The figures for January also show that nearly two-thirds of the time that month the ambulances were in degraded mode — meaning there were six or fewer ambulances available for service.

    Six is the base number the Winnipeg Fire Paramedic Service uses to determine whether they can meet target response times.

    After working through the pandemic, paramedics are burned out, and numbers reflect that, said Ryan Woiden, a longtime paramedic who is the president of the paramedic union, Manitoba Government and General Employees' Union Local 911.

    "The days of trying to pick up the over time when the staffing levels are low, they're becoming fewer and far between because of the exhaustion," he said.

    Back in December 2019, Woiden told CBC News he had never seen it so busy for paramedics. 

    The fact that it's gotten even worse reflects that the entire system needs to be revamped, he said. 

    "Truly I think that you end up seeing those numbers increase because there hasn't been any major changes to the way we do business," he said. 

    "I'm not sitting here saying that we need ten more ambulances and 100 more paramedics. What I'm saying is, what if we were to think outside the box and do things a little bit differently?"

    Population growth, increased call volumes and call complexity, longer wait times for transferring patients, and the ongoing impact of the COVID-19 pandemic have put additional pressures on the city's transport ambulance availability, a spokesperson for the City of Winnipeg said via email.

    However, the Winnipeg Fire Paramedic Service and Shared Health are implementing measures to reduce strain on the system, such as serving lower acuity patients through the community paramedic when safe to do so, and establishing transfer of care procedures to minimize the time ambulances remain at a hospital, said Michelle Lancaster, communications officer for the Winnipeg Fire Paramedic Service.

    Health Minister Audrey Gordon said she hadn't seen the data yet, but will review it. 

    She added that her government's most recent budget includes money to hire 35 more paramedics across the province.

    In addition, the City of Winnipeg and Shared Health are currently working on a new deal over funding for ambulances and paramedics, she said. 

    "And it's my job to listen to Manitobans and ensure that, as part of the discussions around development of that agreement, we're looking at these concerns," she said.


  • 2 May 2022 6:55 PM | Matt Zavadsky (Administrator)

    A timely blog post, as some agencies are still facing this challenge – perhaps some kernels that folks can use?

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    Improving Flow: Addressing the Complexities of Emergency Department Overcrowding

    By Patricia Rutherford | Monday, April 11, 2022

    http://www.ihi.org/communities/blogs/improving-flow-addressing-the-complexities-of-emergency-department-overcrowding

    When patients have to wait for long periods in overcrowded emergency departments (EDs), it’s not just an inconvenience. Evidence shows that ED crowding leads to significant patient harm, resulting from delays in treatment and increases in preventable harm. systematic review in 2022 concluded that ED crowding was associated with higher mortality in 45 percent of the studies, worse quality of care in 75 percent, and a worse perception of care in 100 percent.

    ED Crowding Has Multiple Sources

    The problem of ED crowding is widely recognized. Too often, however, ED crowding is seen in isolation — as a matter of simply making ED operations more efficient. To be sure, there are ways that ED staff can improve their operations to ease crowding, but there are limits to how much those efforts can accomplish. Efficient, high-quality ED care is also dependent on factors outside the control of the ED — such as lack of sufficient and timely primary care and mental health services as well as timely availability of post-acute care services. To solve the problem of ED crowding and delays in admitting patients to the hospital, improvements in community-wide and hospital-wide patient flow are needed.

    Indeed, the situation is reminiscent of the metaphor about the people who are all looking at a different part of an elephant. The one who sees a tusk thinks it’s a spear, the one who sees the tail thinks it’s a rope, and so on. Something analogous occurs when clinicians and staff only see flow problems from their perspective in the ED and within other units or departments throughout the hospital. While the ED staff see long delays in admitting patients, the clinical staff on medical and surgical units see unnecessary bed days and long delays in discharging patients to homes and community-based care settings. To improve patient flow in the ED, we need to look at the whole “elephant” — the whole system that impacts hospital-wide patient flow.

    Efficiency Improvements in the ED

    There is certainly some potential for improvement in the ED itself. For example:

    • Separate flows in the ED (based on acuity) with dedicated clinical teams for each flow. Many EDs that have implemented these lean principles have significantly improved efficiencies and decreased the length of stay for patients discharged from the ED and for patients being admitted to the hospital.
    • Create a separate protocol-driven unit for short-stay patients with relatively straightforward diagnoses. These units are intended for patients who may not be sick enough to warrant a hospital admission but are not well enough to be discharged immediately. A 2013 article found that, compared to patients under observation elsewhere in the hospital, patients in dedicated observation units with defined protocols had 23 to 38 percent shorter length-of-stay, and their likelihood of subsequent inpatient admission was 17 to 44 percent lower.

    In addition, clinical teams in the ED can partner with community providers of care to shape demand for ED visits.

    • Provide end-of-life care in accordance with patients’ wishes. This step often prevents admissions to intensive care units.  
    • Utilize case managers. These team members can facilitate discharges to home and arrange home care and timely follow-up care after discharge from the ED.
    • Support patients with low-acuity needs in community-based care settings. Extend the hours of primary care offices and offer more virtual office visits for primary care, specialists, and mental health care.

    Addressing Common Bottlenecks in the Hospital

    Often, beds are not available in the hospital, leaving patients to wait for inexcusably long periods in the ED. A commentary in NEJM Catalyst suggests the problem is, in fact, getting worse.

    Common bottlenecks and system constraints include:

    • Discharge delays — Difficulty finding the right settings and needed services for patients who are otherwise ready to be discharged from the hospital causes delays. Address this bottleneck by focusing on efficient discharge planning and collaborations with family caregivers and community providers of care. In other words, focus on the “back door” in addition to the “front door” of the hospital.
    • Unnecessary bed days — Unnecessary bed days occur when patients remain in the hospital for extra days or weeks after they are medically ready for discharge. Comprehensive assessments for post-acute care needs, interdisciplinary planning with a patient and their family, and decision-making can all take time and extend a patient’s stay. In addition, the lack of availability of post-acute facility beds and home care services often leads to long-term hospital occupancy. Inpatient units lose functional capacity as patients await placement in post-discharge health care settings (rehabilitation centers, skilled nursing facilities, or nursing homes).
    • Uneven elective surgical scheduling — It is common for surgeons to schedule elective surgery in an uneven manner throughout the week, which can contribute significantly to hospital-wide flow problems. Efforts to “smooth” the flow of elective surgical patients throughout the week can have multiple benefits: more predictable flows of patients from the operating room to intensive care units and other inpatient units, less competition between ED and elective admissions, and more predictable and appropriate nurse staffing on units.

    NEJM Catalyst article identified essential steps to mitigate crowding in the ED, including acknowledging it as a serious problem and threat to patient safety, and urging visible, committed leadership buy-in as an essential part of the solution.

    It is crucial to address hospital-wide patient flow, not just to pursue isolated improvement projects that may not have an impact on timely patient progression throughout the hospital. In addition, community-wide efforts to create timely access to care can prevent overutilization of ED services and lengthy hospital admissions. We need to see the “whole elephant” to address both system-wide hospital flow issues and the availability of community-based health care services which impact overutilization in hospitals.


  • 2 May 2022 6:54 PM | Matt Zavadsky (Administrator)

    The Pandemic Exacerbates the 'Paramedic Paradox' in Rural America

    Katheryn Houghton Kaiser Health News

    April 07, 2022

    https://khn.org/news/article/rural-paramedic-pandemic-shortage-montana/

    Even after she's clocked out, Sarah Lewin keeps a Ford Explorer outfitted with medical gear parked outside her house. As one of just four paramedics covering five counties across vast, sprawling eastern Montana, she knows a call that someone had a heart attack, was in a serious car crash, or needs life support and is 100-plus miles away from the nearest hospital can come at any time.

    "I've had as much as 100 hours of overtime in a two-week period," said Lewin, the battalion chief for the Miles City Fire and Rescue department. "Other people have had more."

    Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

    But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

    Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don't have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

    Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn't have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn't balance the intense program with their day jobs. Others didn't want the added workload that comes with being a paramedic.

    "If you're the only paramedic on, you end up taking more calls," Lewin said.

    What's happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

    "The patients who need the paramedics the most are in the more rural areas," said Dia Gainor, executive director of the National Association of State EMS Officials. But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

    "Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education," Gainor said. "The list goes on."

    The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage "a full-blown emergency" and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

    At the beginning of this year, Colorado reactivated its crisis standard of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in covid cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school to pique students' interest.

    In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state's five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state's 147,000 square miles. Meanwhile, 21 of Montana's 56 counties don't have a single licensed EMS paramedic.

    The Pandemic Exacerbates the "Paramedic Paradox" in Rural America

    Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

    If those rural groups do find or train paramedics in-house, they're often poached by larger stations. "Paramedics get siphoned off because as soon as they have those skills, they're marketable," Gienapp said.

    Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

    But action at the state level doesn't always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a "minimum level" of ambulance services. But legislators didn't appropriate any money to go with the law, leaving the added cost — estimated to be up to $41 per resident each year — for local governments to figure out.

    Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn't contribute to the department's costs. The team's territory includes 6,000 miles of roads and trails, and Smith said it's a constant struggle to find and retain the staffers to cover that ground.

    Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven't attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can't match.

    "The public has this expectation that if something happens, we always have an ambulance available, we're there in a couple of minutes, and we have the highest-trained people," Smith said. "The reality is that's not always the case when the money is rare and it's hard to find and retain people."

    Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic health care in rural areas. Montana is among the states trying to expand EMS work to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

    A private ambulance provider in Montana's Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic health care is on the back burner. The top priority is hiring a paramedic.

    Advancing the care that EMT crews can do without paramedics is possible. Montana's EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

    "Realistically, you're just not going to have paramedics in those rural areas where there's no income available," Graham said.

    Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she's not sure she'll be able to fill the spots. She has a few new EMT hires, but they won't be ready for paramedic certification by then.

    "I don't have any people interested," Lewin said. For now, she'll keep that emergency care rig in her driveway, ready to go.


  • 2 May 2022 6:51 PM | Matt Zavadsky (Administrator)

    Interesting case…  The amounts billed do seem odd….

    ----------------------

    The Case of the $489,000 Air Ambulance Ride

    By Julie Appleby

    MARCH 25, 2022

    https://khn.org/news/article/the-case-of-the-489000-air-ambulance-ride/

    Sean Deines and his wife, Rebekah, were road-tripping after he lost his job as a bartender when the pandemic hit. But while visiting his grandfather in a remote part of Wyoming, Sean started to feel very ill.

    Rebekah insisted he go to an urgent care center in Laramie.

    “‘Your white blood count is through the roof. You need to get to an ER right now,’” Deines, 32, recalls a staffer saying. The North Carolina couple initially drove to a hospital in Casper but were quickly airlifted to the University of Colorado Hospital near Denver, where he was admitted on Nov. 28, 2020.

    There, specialists confirmed his diagnosis: acute lymphoblastic leukemia, a fast-growing blood cancer.

    “Literally within 12 hours, I needed to figure out what to do with the next step of my life,” said Deines.

    So, after he was started on intravenous treatments, including steroids and antibiotics, in Colorado to stabilize him, the couple decided it was prudent to return to North Carolina, where they could get help from his mother and mother-in-law. They selected Duke University Medical Center in Durham, which was in his insurance network.

    His family called Angel MedFlight, part of Aviation West Charters of Scottsdale, Arizona, which told Rebekah Deines that it would accept whatever the couple’s insurer would pay and that they would not be held responsible for any remaining balance.

    Sean Deines was flown to North Carolina on Dec. 1, 2020, and taken by ground ambulance to Duke, where he spent the next 28 days as an inpatient.

    By his discharge, he felt better and things were looking up.

    Then the bills came.

    The Patient: Sean Deines, 32, who purchased coverage through the Affordable Care Act marketplace with Blue Cross Blue Shield of North Carolina.

    Medical Service: A 1,468-mile air ambulance flight from Colorado to North Carolina, along with ground transportation between the hospitals and airports.

    Service Provider: Aviation West Charters, doing business as Angel MedFlight, a medical transport company.

    Total Bill: $489,000, most of which was for the flight from Denver, with approximately $70,000 for the ground ambulance service to and from the Denver and Raleigh-Durham airports.

    What Gives: Insurers generally get to decide what care is “medically necessary” and therefore covered. And that is often in the eye of the beholder. In this case, the debate revolved first around whether Deines was stable enough to safely take a three-plus-hour commercial flight to North Carolina during a pandemic or required the intensive care the air ambulance provided. Second, there was the question of whether Deines should have stayed in Denver for his 28-day treatment to get him into remission. Insurers tend not to consider patient stress or family convenience in their decisions.

    Also, both air and ground ambulance services have been center stage in the national fight over huge surprise bills, since the for-profit companies that run them frequently do not participate in insurance networks.

    Angel MedFlight, which was not in Deines’ insurance network, sought prior authorization from Blue Cross Blue Shield of North Carolina. The request was dated Nov. 30, but the insurer said the fax arrived in the predawn hours the same day as the flight, Dec. 1, 2020.

    On that day, Angel MedFlight flew Deines to North Carolina in an airplane, along with a nurse to oversee his IV medications and oxygen levels.

    Angel MedFlight spokesperson Kimberly Halloran did not answer a specific written question from KHN about why the flight went ahead without prior approval; often medical interventions are postponed until it has been obtained. But in an emailed statement, she said the company “satisfied each step in the health insurance process and transported Sean to his long-term health care providers in good faith.”

    According to the review of the case done months later by an independent evaluator, Blue Cross on Dec. 3 denied coverage for the air ambulance services because medical records did not support that it was an emergency and Deines was already in an appropriate medical facility.

    At the end of December, an appeal was filed against that decision on behalf of Deines by Angel MedFlight.

    Then, in March 2021, Blue Cross sent Deines a check for $72,000 to cover part of the $489,000 bill, which he forwarded to the air ambulance company. The explanation of benefits showed the majority of the charges were ruled “not medically necessary.”

    Angel MedFlight, through a revenue management firm it hires called MedHealth Partners, continued to appeal to Blue Cross to overturn the denial of the flight portion of the bill.

    Then, three months after Blue Cross sent the check that Deines then sent on to Angel MedFlight, the insurer demanded Deines pay back the $72,000.

    “The initial thought was ‘I can’t believe this is happening,’” said Deines.

    Medical necessity criteria are set by insurers, with North Carolina Blue Cross covering air ambulances in “exceptional circumstances,” such as when needed treatment isn’t available locally.

    When Deines, who was still unemployed and undergoing treatment, couldn’t pay, the debt was sent to collections.

    In late June, Deines’ representatives at Angel MedFlight took the next step allowed under the Affordable Care Act, appealing the insurer’s internal determination that the flight wasn’t medically necessary to an independent third party through the state.

    On July 29, the evaluator ruled in favor of Blue Cross.

    Normally, such a flight would be appropriate because the patient was “medically unfit to travel via commercial airflight,” the review noted. But, it went on to say, there was actually no need to travel, as the University of Colorado Hospital — a member of the National Comprehensive Cancer Network — could have managed Deines’ treatment.

    His health plan “clearly stipulates their indications for medical flight coverage and, unfortunately, this case does not meet that criteria,” the review concluded.

    Resolution: The bill disappeared only after the press got involved. Shortly after a KHN reporter contacted the communications representatives for both the insurer and Angel MedFlight, Deines heard from both of them.

    The $72,000 payment was made in error, said Blue Cross spokesperson Jami Sowers.

    “We apologize for putting the member in the middle of this complicated situation,” she said in an email that also noted “the air ambulance company billed more than $70,000 just for ground transportation to and from the airport — more than 30 times the average cost of medical ground transport.”

    Such a situation would “typically” be flagged by internal systems but for some reason was not, Sowers said.

    “I have never heard of a ground transport that costs that much. That’s shocking,” said Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University College of Law, who studies patient billing and air ambulance costs.

    Still, there’s good news for Deines: Both the insurer and the air ambulance company told KHN he will not be held responsible for any of the charges. (None of the charges stemmed from his first air ambulance flight from Casper to Denver, which was covered by the insurer.)

    “Once North Carolina Blue engages in our formal inquiries about its refund request, the status of the funds will be resolved,” the ambulance spokesperson wrote in her email. “One thing is certain, Sean will not have to pay for North Carolina’s wavering coverage decision.”

    In an email, Sowers said Blue Cross had “ceased all recoupment efforts” related to Sean’s case.

    The Takeaway: If the flight had happened this year, the couple might have received more price information before they took the flight.

    A law called the No Surprises Act took effect Jan. 1. Its main thrust is to protect insured patients from “balance bills” for the difference between what their insurance pays and what an out-of-network provider charges in emergencies.

    It also covers nonemergency situations in which an insured patient is treated in an in-network facility by an out-of-network provider. In those cases, the patient would pay only what they would owe had the service been fully in-network.

    Another part of the law, called a good faith estimate, might have provided Deines with more transparency into the costs.

    That portion says medical providers, including air ambulances, must give upfront cost estimates in nonemergency situations to patients. Had the law been in effect, Deines might have learned before the flight that it could be billed at $489,000.

    Insured patients in similar situations today should always check first with their insurer, if they are able, to see if an air transport would be covered, experts said.

    Even if the law had been in effect, it likely would not have helped with the big hang-up in Deines’ case: the disagreement over “medical necessity.” Insurers still have leeway to define it.

    For his part, Deines said he’s glad he took the flight to be closer to home and family, despite the later financial shock.

    “I would not change it, because it provided support for myself and my wife, who needed to take care of me; she was keeping my sanity,” he said.


  • 16 Mar 2022 9:11 AM | Matt Zavadsky (Administrator)

    'It’s been a nightmare': EMS leaders warn industry on verge of collapse

    They say underfunding, staffing shortages to blame

    By Clay LePard

    Mar 14, 2022

    https://www.news5cleveland.com/news/local-news/oh-ashtabula/its-been-a-nightmare-ems-leaders-warn-industry-on-verge-of-collapse

    GENEVA, Ohio — During a recent Ohio EMS Chiefs Association meeting, board members pointed to the mix of staffing and supply shortages, as well as funding issues, as the driving forces behind major issues eroding their industry.

    “The state of the EMS industry is on the verge of collapse,” Eric Burns, vice president of Tri-Village Joint Ambulance District in Darke County said. “If we don’t do something quickly, I think EMS as we know it is going to fall apart.”

    When a 911 call is made, you expect an ambulance to show up. But what happens when it doesn’t?

    It's a question Cody Buskirk knows well. His mother passed away last month, after he says she waited for two hours for an ambulance to arrive at her rehabilitation center.

    "I was furious," he said. "Two hours of her waiting there for someone to get her, that was a death penalty right there."

    Buskirk told News 5 his mother passed away as crews were loading her into an ambulance when it finally showed up. The ambulance was supposed to transport her to a hospital a mile and a half away.

    "I don’t want people to brush this under the rug," Buskirk added. "We should be confident that we can call an ambulance and they’ll be there for us when we need them."

    On top of Buskirk's situation, Vince Gildone also wonders more often nowadays about the idea of ambulances not being able to show up when called.

    When the pandemic began, Gildone’s staff at Northwest Ambulance in Geneva consisted of 10 full-time EMTs and around 30 on call. Today, that on-call auxiliary staff is about half and Gildone told News 5 there’s no new names at his doorstep waiting to join.

    “I think EMS is in trouble,” Gildone said. “It’s been a nightmare. It was a career path before and now it’s not being looked at as a career path by most people.”

    It’s an industry that nowadays pays about the same as some fast-food restaurants, and on top of people not liking the pay, Gildone said the earlier days of uncertainty surrounding COVID-19 scared away quite a few staffers.

    To make matters worse, Gildone said supply chain issues have made it harder to repair or replace aging equipment.

    “To get a new truck used to take three months, now it’s 18 months,” he added. “[This industry has] been ignored and it's been shoestring-funded for many years, and I think COVID-19 was the thing that pushed us over the edge.”

    The board members told News 5 the issue starts first and foremost with funding, with much of theirs coming from reimbursements from programs such as Medicaid.

    “When I'm only getting $98 per call, it’s hard to maintain a budget and maintain good equipment and staffing relying on those types of reimbursements,” Burns added. “I worry about who is taking the place of us older ones getting ready to retire.”

    And keep in mind, those reimbursements, they say, only come through if someone is transported to a hospital; meaning if care is declined when an ambulance shows up, the ambulance company doesn’t get paid.

    “We’re almost treated as a trucking company,” Todd Shroyer, Coshocton County EMS, said. “If a trucking company isn’t hauling freight, they’re not making money. As EMS, if we’re not hauling patients, we’re not making money. Everything we do that doesn’t involve transport, there’s no reimbursement.”

    Right now, all 50 states classify police and fire departments as essential services, which means they are required by the government and as a result, those departments can gain access to additional funding.

    However, when it comes to EMS, only 11 states classify EMS as an essential service, with Ohio as one of the 39 states that does not.

    States that classify EMS as an essential service include Oregon, Washington, Utah, Iowa, Pennsylvania, Indiana, Tennessee, North Carolina, Delaware, Connecticut, and West Virginia according to the National Association of State EMS Officials.

    “To think EMS is not considered essential, I can't even imagine how that slipped through the cracks at some point,” Eric Burgess, president of the Ohio EMS Chiefs Association, said.

    Burgess, who oversees Delaware County EMS, estimates local EMS budgets only amount to about one-fourth of the budgets of fire and police departments.

    This coalition plans to lobby in Columbus later this year in hopes that lawmakers will put them closer to a level playing field with other first responders when it comes to attracting new talent.

    “We are having people retire, we have people who say, ‘it’s enough, I'm getting out of the business and I'm doing something else,’ and we’re not bringing new people in fast enough to replace the people as they’re leaving,” Burgess said.

    A cycle of problems with the power to pummel a profession.

    “Until we fix the reimbursement issue, we can't really get our wages where they need to be,” Shroyer explained. “And until we can get our wages where they need to be, I'm not sure how we’re going to attract people into the business.”

    “We frequently talk about when you call an ambulance and there isn't one to send,” Gildone said. “That's clearly something we need to think about and could happen. I think COVID-19 has forever changed how we do business and we don’t know what the outcome is going to be.”


  • 16 Mar 2022 6:46 AM | Matt Zavadsky (Administrator)


    The telehealth extension includes coverage for telehealth services provided in the patient’s residence.  This may help many EMS agencies.

    ‘‘(iii) EXPANDING ACCESS TO TELEHEALTH SERVICES.—With respect to telehealth services identified in subparagraph (F)(i) as of the date of the enactment of this clause that are furnished during the 151-day period beginning on the first day after the end of the emergency period described in section 1135(g)(1)(B), the term ‘originating site’ means any site in the United States at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system, including the home of an individual.’’

    ------------------ 

    Congress to temporarily extend Medicare telehealth coverage in funding package

    March 08, 2022

    JESSIE HELLMANN

    https://www.modernhealthcare.com/politics-policy/congress-temporarily-extend-medicare-telehealth-coverage

    Congress will include a months-long extension of telehealth flexibilities in a package to fund the government, fulfilling a key ask made by providers and advocates.

    Under a draft of the provisions obtained by Modern Healthcare, Medicare will cover an array of telehealth services for at least 151 days after the end of the public health emergency, allowing beneficiaries to continue accessing care from their homes, at least temporarily.

    That will allow Congress more time to study the impacts of expanding telehealth access under Medicare and to decide whether lawmakers want to make those changes permanent.

    Before the pandemic, Medicare coverage of telehealth was fairly limited. But with the pandemic came an explosion of telehealth usage as people became afraid to seek care. It forced Medicare to update its coverage policies, and stakeholders have argued those changes should be made permanent.

    Under the public health emergency, Medicare has temporarily waived several restrictions on coverage, including a requirement that beneficiaries be at a rural healthcare facility to receive telehealth services. Many of those waivers expire at the end of the public health emergency, which could end as soon as July 15.

    Congress has been pushed by providers and telehealth advocates to permanently repeal those restrictions, but due to concerns about fraud and abuse, lawmakers decided to extend the flexibilities temporarily to allow for more time to collect data on costs and utilization.

    The package directs the Medicare Payment Advisory Commission to release a report by June 15, 2023 detailing telehealth utilization in Medicare and costs. Congress will also direct the Office of the Inspector General to submit a report by the same date on program integrity risks associated with Medicare coverage of telehealth.

    Under the temporary extension, federally qualified health centers and rural health clinics will be allowed to offer telehealth for 151 days after the public health emergency.

    Medicare will continue to cover occupational and physical therapy as well as speech-language pathology delivered through telehealth during the 151-day period.

    The package will also delay requirements that Medicare beneficiaries using telehealth for mental health services be examined in person by the provider within six months of starting treatment, and every year after.

    The requirement, which was included in the government funding bill passed in 2020, was criticized by healthcare providers as a barrier to mental healthcare, especially for people in rural areas.

    The package would also temporarily extend Medicare coverage of audio-only telehealth services.


  • 22 Feb 2022 7:57 AM | AIMHI Admin (Administrator)

    Axios Source Article | Comments Courtesy of Matt Zavadsky

    Lots to unpack here…

    Interesting findings from a reputable and widely respected non-profit, which is often cited by governmental leaders as a basis for fee and payment analysis.  The hyperlinks to related commentary are also interesting reads.

    It may be a good idea for a coalition of EMS experts from the AAA, NAEMT, IAFC, AIMHI, etc., form a task force to digest this report, compare ambulance fee changes compared to other emergency/safety-net medical care services, and do some localized research (i.e.: ground truth) on things like cost of service delivery trends, trends in payer mix and payment practices, impact of performance expectations that have little correlation to patient outcomes (response times, staffing), etc., to prepare and publish an analysis of this report, with recommendations for things like alternate deployment models, clinically relevant performance standards, alternate dispositions, etc.

    Some of the most interesting findings and charts from the report included below.

    Strongly recommend that interested folks download the full report here.

    ---------------------------

    Ambulance rides are getting a lot more expensive

    Tina Reed, 2/22/22


    https://www.axios.com/ambulance-rides-are-getting-a-lot-more-expensive-cee897fe-63b7-4412-aa67-718109773e79.html

    The cost of an ambulance ride has soared over the past five years, according to a report from FAIR Health, shared first with Axios.

    Why it matters: Patients typically have little ability to choose their ambulance provider, and often find themselves on the hook for hundreds, if not thousands of dollars.

    The details: Most ambulance trips billed insurers for "advanced life support," according to FAIR Health's analysis.

    • Private insurers' average payment for those rides jumped by 56% between 2017 and 2020 — from $486 to $758.
    • Ambulance operators' sticker prices, before accounting for discounts negotiated with insurers, have risen 22% over the same period, and are now over $1,200.

    Medicare, however, kept its payments in check: Its average reimbursement for advanced life support ambulance rides increased by just 5%, from $441 to $463.

    Between the lines: Ambulances aren't covered by the new law that bans most surprise medical bills, meaning patients are still on the hook in payment disputes between insurers and ambulance operators.

    State of play: Ground ambulances are operated by local fire departments, private companies, hospitals and other providers and paid for in a variety of ways, which makes this a tricky issue to address, according to the Commonwealth Fund.

    • Some states — such as Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia — have protections against surprise ground ambulance billing, a columnist in the Deseret News pointed out earlier this year.
    • But in California, Florida, Colorado, Texas, Illinois, Washington state and Wisconsin, more than two-thirds of emergency ambulance rides included an out-of-network charge for ambulance-related services that posed a surprise bill risk in 2018, according to a Peterson-KFF Health System Tracker brief.
    • The Biden administration has said it's working on the problem.

    The bottom line: Costs for ground ambulance care are on the rise and, with few balance billing protections, that means patients could still be hit with some big surprises if they wind up needing a ride in an ambulance.


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