News & Updates

JEMS Source Article | Comments Courtesy of Matt Zavadsky

Interesting commentary from Dr. Bledsoe…

Many of us, when asked if there is a paramedic ‘shortage’ have difficulty answering the question.  The reason? By definition, to express a shortage of anything, we first need to know the answer to the question “How many do we need?”  Once we have the answer to that question, then we might be able to determine if there is a shortage.

Some systems have an overabundance of paramedics, while others struggle to recruit and retain paramedics.  So, you could say we have a paramedic mal-distribution?

Dr. Bledsoe asks the tough questions…

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The Paramedic Shortage — Opportunity or Crisis?

By Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P | 9.24.19

There has been a great deal discussion, of late, related to a shortage of paramedics in the United States. It is often debated, and there are deniers, as well as believers. However, the data are clear in that fewer people are entering EMS when compared to a decade or two ago. The reasons are debatable but include such things as poor pay, working conditions, schedules, work type, and cultural changes in younger individuals and their belief systems. Many lament this but it may actually be the opportunity needed to drive EMS to the next level.

At a most fundamental level, the term “shortage” refers to a state or condition where something needed cannot be attained in sufficient amounts. From a business standpoint, it is the difference between supply and demand. A shortage can be rectified by increasing the supply of the necessary product. It can also be rectified by decreasing demand for that product. This is the basis of this discussion.

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ModernHealthcare Source Article | Comments Courtesy of Matt Zavadsky

This is a little long, but very much worth perusal. For our EMS stakeholders, what things have you changed in your organization to make your care more ‘person’ centered, as contemplated in the EMS Agenda 2050?

Also, what role can transformed EMS agencies play in collaboration with other healthcare system stakeholders (hospitals, payers, physicians, home health agencies, etc.) in the march to ‘person centered care’? Supporting hospital in the home programs? Navigating 9-1-1 callers to dispositions other than a de facto transport to an ED (much like CMS’ ET3 model contemplates)?

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Patient-centered care becoming 'person-centered care'

JESSICA KIM COHEN

September 14, 2019

Health systems are broadening their definition of patient-centered care, sometimes extending the concept beyond clinical care by replacing the term “patient” with a seemingly more holistic “consumer” or “person.”

Patient-centered care, a term popularized by the Institute of Medicine in 2001, initially described an approach to care that allows patients to guide their own clinical decisions. Now its definition has expanded—health systems see it as encompassing not just clinical care, but also patient experience, including how encounters stack up to patients’ expectations from other consumer-facing industries and, subsequently, whether patients view their care as worth the expensive price tag.

But even as the term’s definition changes, health systems are in general agreement about the concept’s continued importance, according to Modern Healthcare’s most recent Power Panel survey of top healthcare CEOs. Nearly 70% of CEOs said they’ve made changes to the structure of their organization to be more patient-centered, and more than half have someone formally in charge of leading those efforts.

CONTINUE READING►

Axios source article | Comments courtesy of Matt Zavadsky

How air ambulances got so expensive

 

 

Air ambulances have become a lucrative business over the last few decades, at patients' expense, fueled by private equity and aided by the industry's relationships with providers, John Hopkins' Marty Makary writes in a new book out today.

 

Why it matters: The rise of the air ambulance industry has resulted in massive surprise medical bills and a spike in unnecessary use.

• Congress has included air ambulances in its effort to crack down on surprise medical bills, and the industry is fighting to avoid this regulation.

 

Background: Air ambulances used to be owned and operated by hospitals, which sometimes took financial losses on their helicopter programs.

• But that changed when investors saw a profit opportunity and began buying the ambulance services from hospitals. They then billed patients directly for rides.

 

By the numbers: Between 2007 and 2016, the average price charged by one air ambulance company for a transport rose from $13,000 to $50,000.

• With this kind of money on the table, the number of air ambulance companies rose by 1,000% between the 1980s and 2017.

 

People in rural areas are hit the hardest. While some of these transports are necessary and life-saving, many others could be avoided, Makary writes.

• Of the more than half a million ambulance flights a year, 80% aren't emergencies, but rather more like routine transfers.
• To grow their business, companies began paying paramedics, nurses and doctors to become advisers with "informal agreements" to promote the company to emergency personnel and other providers.

 

The other side: Air ambulances say that they have to charge higher rates to commercially insured patients to make up for lower government rates.

 

The bottom line: "The air ambulance industry has become big business in America," Makary writes.

 

• Go deeper: Air ambulances are expensive and most likely out of network

Order the book.

FierceHealthcare Source Article | Comments from Matt Zavadsky

The findings in the referenced study could be due to a myriad of reasons – Many EMS agencies have protocols that determine patient destinations – including patient preference.

Two seemingly most important quotes:

Although proximity is important, previous studies reveal that the capabilities of an ED are also significant when EMS or patients make decisions about which ED to visit. For example, patients with a history of using inpatient care at a specific hospital may prefer to be transported to their so-called "home ED."

The study also supports the idea that family or patient choice of ED may have a big impact on transport. Although data were not given specifically for ED destination by patient preferability, there was considerable overlap in the ED destination patterns of EMS transports and walk-ins (61.3% versus 52.9%), supporting this notion that patients have a choice in their destination hospital.

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White Medicare patients transported to closest ED more often than blacks, Hispanics

by Jacqueline Renfrow 

Sep 6, 2019

White Medicare patients are more likely to be transported to the closest emergency department (ED) than their black or Hispanic counterparts, according to a new study out of Boston University’s School of Medicine.

Researchers recently set out to discover whether black and Hispanic Medicare patients are likely to be transported by emergency medical services (EMS) to the same emergency departments as white Medicare patients living in the same area—and to the closest available ED, according to proper protocol.

KEEP READING>

New York Times Source Article | Comments by Matt Zavadsky

Nice article about North Carolina’s efforts.  Raleigh was one of the 1^st EMS systems in the country to deploy EMS-based Mobile Integrated Healthcare with outstanding results!

And, prior to joining BCBS of North Carolina, Dr. Conway was the CMO at CMMI – in meetings with Dr. Conway in that role, we was acutely aware of the impact EMS-based MIH programs were having in their communities – CMMI funded several MIH initiatives with Health Care Innovation Award grants.

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Inside North Carolina’s Big Effort to Transform Health Care

By Steve Lohr

Aug. 26, 2019

 

RALEIGH, N.C. — North Carolina seems like an unlikely laboratory for health care reform. It refused to expand Medicaid coverage under the Affordable Care Act, and ranks in the bottom third among states in measures of overall health.

But the state has embarked on one of the country’s most ambitious efforts to transform how health care is defined and paid for.

North Carolina is in the early stages of turning away from the traditional fee-for-service model, in which doctors and hospitals are paid for each office visit, test or operation. Instead, providers will often be paid based on health outcomes like controlling diabetes patients’ blood sugar or heart patients’ cholesterol. The better the providers do, the more they can earn. If they perform poorly, money could eventually come out of their pocket.

The goal is to keep people healthy and out of the hospital and to save money on health care spending.

Continue Reading>

A very innovative proposal by Wyoming!  There are several Public Utility Model (PUM) EMS systems that have stood the test of time by continually proving value.  These systems provide exceptional clinical outcomes, excellent operational effectiveness and unparalleled economic efficiency. 

PUM systems are set up under the premise that the fixed cost of providing EMS (capital, readiness, etc.) are best managed by empowering a governmental authority with the responsibility to provide all services – thus assuring consistency of clinical oversight and QA, maximizing operational synergy and distributing the infrastructure cost over all ambulance calls in the service area.

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Wyoming's air ambulance coverage pitch

Wyoming has come up with a unique way to make air ambulances — a common source of huge surprise medical bills — more affordable, according to the Georgetown University Health Policy Institute's blog.

The big picture: The state is essentially proposing to turn air ambulances into a public utility.

• Wyoming's health department has put together a Medicaid waiver that would make all residents, regardless of their income, eligible for Medicaid coverage of air ambulance services.
• Providers would submit bids to serve as the only air ambulance operator within a particular geographic region.
• The state would make flat payments to the operator that wins the bid, rather than paying them for each ambulance ride.
• Patients' cost-sharing would vary based on their income, and insurers would pay into the program rather than covering air ambulances themselves.

What we're watching: To go into effect, the proposal first has to be approved by CMS. State lawmakers would then have to make the necessary policy changes.

Yes, but: The blog's author, Sabrina Corlette, correctly warns that "both federal officials and state lawmakers will likely be lobbied extensively by the air ambulance industry, which has a vested interest in maintaining the status quo."

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Will it Fly? Wyoming Attempts End Run Around High Air Ambulance Prices

August 21, 2019 

by Sabrina Corlette

http://chirblog.org/will-it-fly-wy-end-run-air-ambulance/

As we’ve written before in this space, air ambulance charges are a growing source of surprise medical bills for consumers, and the charges can be eye-popping – five figures or more. Unfortunately, state-level efforts to limit balance billing by air ambulance companies have thus far been stymied by the Airline Deregulation Act (ADA) of 1978, which prevents states from enacting laws regulating the prices of any air carrier, including air ambulance. In 2018, the U.S. Congress considered legislation that would have given state officials the ability to regulate the more egregious billing practices of air ambulance providers, but congressional leaders ultimately bowed to pressure from the industry. The enacted bill authorized a Department of Transportation advisory committee to study the issue, the ultimate “kick the can” solution to the problem.

This year, although Congress is debating several bills to protect patients from surprise medical charges, only one – sponsored by Senators Lamar Alexander and Patty Murray – would extend those protections to patients needing emergency air transport. Meanwhile, air ambulance bills are only getting higher (for example, air ambulance charges in New Mexico have risen 300 percent since 2006) and more air ambulance providers are choosing not to participate in health plan networks, making it easier for them to sock patients directly with their high charges.

Some states have tried to protect consumers, but the scope of these efforts are curtailed by federal law. For example, Texas and North Dakota laws to limit air ambulance balance billing were ruled as preempted by the ADA in two federal district courts. Another federal law – the Employee Income Security Act (ERISA) – preempts states from regulating self-funded employer plans, including any imposition of a requirement that these plans include air ambulances in their networks or hold enrollees harmless for out-of-network charges.

Wyoming may have hit on a unique solution. The state is proposing to turn air ambulances effectively into a public utility.

Wyoming’s Plan

The Wyoming Department of Health has developed an 1115 Medicaid waiver application that would make all Wyoming residents, regardless of income, eligible for Medicaid for air ambulance services only. Under the plan, the state would:

• Set the basic parameters of air ambulance coverage under the Medicaid program.
• Solicit competitive bids from air ambulance providers to serve as the sole provider within a prescribed geographic area within the state.
• Create a centralized call center that would direct all calls for air ambulance services to the approved providers.
• Make regular flat payments to these providers (instead of reimbursing on a fee-for-service basis).
• Set patient cost-sharing on a sliding scale, based on income.
• Recoup costs for operating the program from private insurers, employer plans, and individuals already paying for transports.

In its pitch to state lawmakers and stakeholders, the Department of Health argues that the air ambulance industry is an example of market failure, noting that most patients cannot “shop around” for air ambulance services. Even in situations when the patient is conscious or in serious medical distress, the cost is not transparent because of differences in network arrangements and cost-sharing among plans. Officials further note that the supply of air ambulances has risen dramatically in the past five years, and these providers have very high fixed costs that they must recoup, largely from private payers and patients. Indeed, in 2018, Wyoming employers paid an average of $36,000 per flight. The Department argues that, as with other critical commodities with high fixed costs such as water and electricity, a regulated monopoly is a more efficient way to deliver the needed services.

Questions and Next Steps

There remain a number of hurdles before Wyoming’s unique plan can take effect. First, the federal government would have to approve the waiver proposal. The Wyoming legislature would then have to enact state-level legislative changes to authorize the program. Both federal officials and state lawmakers will likely be lobbied extensively by the air ambulance industry, which has a vested interest in maintaining the status quo. Also, although the state argues that the Medicaid program should not be preempted under the Airline Deregulation Act, that premise has not yet been tested in court. Other questions include whether self-funded employer plans, which are not subject to state regulation, will opt-in to the state program, enabling it to be budget neutral.

Wyoming has posted its waiver application and invited public comment. It expects to submit the proposal to federal authorities by September 1, 2019, with another public comment period expected later in the year.

The latest report from the Healthforce Center and Philip R. Lee Institute for Health Policy Studies at UC San Francisco. 

The full report can be downloaded at the link below, but we’ve included some outcome highlights, specifically because many of you are evaluating the initiation of similar programs, and one, the Alternate Destination – Urgent Care project seems to be similar to one of the interventions included in the CMMI ET3 model.  The experience and findings in the CA model may help potential ET3 participants refine their programs.

https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/UpdateEvaluationCACommunityParamedicine.pdf

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Evaluation of California’s Community Paramedicine Pilot Program

Author(s): Janet M. Coffman, Cynthia Wides, Lisel Blash,Ginachukwu Amah, Igor Geyn and Matthew Niedzwiecki

Date: August 6, 2019

Community paramedicine, also known as mobile integrated health, is an innovative model of care that is being implemented throughout the United States. The California Emergency Medical Services Authority has sponsored a pilot project under which specially trained paramedics perform duties beyond their traditional roles of responding to 911 calls, transporting patients to emergency departments and performing inter-facility transfers. Healthforce Center at UCSF is conducting an evaluation of the pilot project that was funded by the California Health Care Foundation.

The evaluation found that community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals and social workers to fill gaps in the health and social services safety net. The evaluation has yielded consistent findings for six of the seven community paramedicine concepts tested. All of the post-discharge, frequent 911 users, tuberculosis, hospice, and alternate destination – mental health projects have been in operation for at least two and one half years and have improved patients’ well-being. In most cases, they have yielded savings for payers and other parts of the health care system. Findings regarding outcomes of a project testing the sixth concept, alternate destination – sobering center, suggest that this project is also benefitting patients and the health care system over the course of its first 14 months. The seventh concept, alternate destination – urgent care, shows potential but further research involving a larger volume of patients is needed to draw definitive conclusions.

Conclusion

The community paramedicine pilot projects have demonstrated that specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California. No adverse outcome is attributable to any of these pilot projects. The projects are enhancing patients’ well-being by improving the coordination of medical, behavioral health, and social services, and reducing ambulance transports, ED visits, and hospital readmissions. The majority of potential savings associated with these pilot projects accrued to Medicare and Medi-Cal and hospitals that care for Medicare and Medi-Cal beneficiaries because Medicare and Medi-Cal beneficiaries accounted for the largest share of persons enrolled in the pilot projects.

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Alternate Destination – Mental Health

·       The three Alternate Destination – Mental Health projects enrolled 2,045 persons between September 2015 and March 2019.

·       The City of Los Angeles launched an Alternate Destination – Mental Health project in late June 2019 and will be included in subsequent updates to this report.

·       Across the three Alternate Destination – Mental Health projects, 28% to 45% of patients screened were transported to the mental health crisis center rather than an ED. In Stanislaus County, an additional 27% could have been transported to the crisis center if the county had more inpatient psychiatric beds or if the crisis center accepted people with private insurance or Medicare.

·       Transport of these patients directly to a mental health crisis center has reduced the number of persons in EDs who need only mental health services, which can help reduce ED overcrowding.

·       Only 2% of patients enrolled in the three Alternate Destination – Mental Health projects (n = 47) were transferred from the mental health crisis center to an ED within six hours of admission. None of the transfers involved a life-threatening condition, and only four of the patients transferred to an ED were admitted for inpatient medical care.

·       In addition to responding to 911 calls regarding mental health emergencies, the community paramedics in Stanislaus County screen “walk-in” clients, who come to the mental health crisis center on their own or who are brought by friends or family, to determine whether they have any medical conditions that might necessitate transport to an ED instead of direct admission to the crisis center.

·       Law enforcement officers in Stanislaus County report that having community paramedics available enhances their ability to respond effectively to persons with mental illness.

·       The three Alternate Destination – Mental Health projects avoided potential costs of $2.2 million by reducing the number of 911 calls that resulted in an ED visit and subsequent transport of a patient from an ED to an inpatient psychiatric facility.

Alternate Destination – Urgent Care

·       The three Alternate Destination – Urgent Care projects enrolled 48 persons from September 2015 through November 2017.

·       One of the Alternate Destination – Urgent Care projects closed in May 2017, and the other two projects closed in November 2017.

·       Enrollment in the Alternate Destination – Urgent Care projects was substantially lower than anticipated because fewer 911 calls than expected met the strict inclusion criteria and many calls for eligible patients occurred at times of the day during which urgent care centers were closed. In addition, clinicians at urgent care centers were reluctant to treat some conditions, such as a dislocated shoulder, that could be treated safety and effectively in that setting.

·       Most patients enrolled had a laceration or an isolated closed extremity injury.

·       During the time period in which the Alternate Destination – Urgent Care projects enrolled patients, two patients (4%) were transferred from an urgent care center to an ED within six hours of arrival at the urgent care center. Nine patients (19%) were transported to an urgent care center and then rerouted to an ED because clinicians at the urgent care center declined to treat the patient.

Alternate Destination – Sobering Center

·       San Francisco’s Alternate Destination – Sobering Center project enrolled 1,627 persons from February 2017 through March 2019. Two hundred and thirty-three patients (14%) were treated at the sobering center more than once.

·       97.9% of patients enrolled in the Alternate Destination – Sobering Center project were treated safely and effectively at the sobering center. Only 34 patients (2%) were transferred to an ED within six hours of admission to the sobering center, and only two (0.1%) were rerouted from the sobering center to an ED because registered nurses at the sobering center declined to accept them. Only two patients were admitted to a hospital for inpatient medical care.

·       Community paramedics participating in the project provide feedback to paramedics on 911 crews on how to screen acutely intoxicated persons to determine if they are candidates for transfer to the sobering center. They are also collaborating with homeless outreach workers to encourage people who use the sobering center frequently to seek treatment for chronic alcoholism, housing, and other services.

·       San Francisco’s Alternate Destination – Sobering Center project avoided potential costs of $551,257 by replacing ED visits with sobering center services. The majority of potential savings accrued to Medi-Cal because the majority of patients enrolled in the project are Medi-Cal beneficiaries.

·       The Santa Clara County EMS Agency and the Gilroy Fire Department launched a new Alternate Destination – Sobering Center project in June 2018, but the project had not enrolled any patients as of March 2019.

·       The City of Los Angeles launched an Alternate Destination – Mental Health project in late June 2019 and will be included in subsequent updates to this report.

Interesting that the community paramedic concept has made it into the presidential campaign discussions…  J

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Pete releases white paper on rural health care 

South Bend Tribune Report

Aug 9, 2019

https://www.southbendtribune.com/news/local/pete-releases-white-paper-on-rural-health-care/article_aa2215a6-c1c4-59a2-bc8a-0f3a9007ae57.html

Presidential candidate Pete Buttigieg on Friday called for efforts to increase affordable health care options for people living in rural communities.

In a statement of his rural health care plan released Friday, Buttigieg would strengthen the Affordable Care Act and implement Medicare for all who would want such coverage. He also promised to work to increase subsidies for low-income Americans and expand those for middle class consumers.

Access to rural health care and availability of medical professionals would be bolstered by his plan to increase incentives for loan forgiveness programs for health professionals. Plans call for offering incentives for doctors to settle in rural areas, and increasing community paramedic programs.

Rural hospital closures also are having an impact on delivery and availability of health services. Buttigieg proposes using incentives, technology and designations to help keep these facilities open with the type of staffs to serve rural communities.

He also offered ways to improve health outcomes for veterans and tribal communities with a series of programming and personnel improvements and proposals.

Nice article by Charlotte Huff, who has been a big supporter of EMS collaborations designed to reduce preventable acute care utilization. 

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Paramedics providing care before it is an emergency

EMS providers are making house calls and helping people gain access to primary care with the goal of reducing unnecessary ED utilization.

July 5, 2019

CHARLOTTE HUFF

https://www.managedcaremag.com/archives/2019/7/paramedics-providing-care-it-emergency

Amid heightened efforts to reduce unnecessary emergency visits, including a recently announced federal pilot to treat low-acuity patients elsewhere, some insurers have already been striving to intervene even before patients resort to 911.

Some patients return to the emergency department again and again because they don’t know where else to seek help, says Eugene Sun, MD, chief medical officer at Blue Cross Blue Shield of New Mexico. “A lot of times it’s a social issue,” Sun says. “They’re hungry. They’re lonely. And sometimes it’s a clinical issue,” he says, “but they don’t know how to get into primary care or they don’t have a primary care doctor assigned.”

So starting in 2016, the New Mexico insurer began contracting with Albuquerque paramedics to provide home support for frequent users of the emergency department as well as some recently discharged hospital patients. Once at-risk patients are referred, a paramedic visits the home at least once, checking on everything from home safety to medication difficulties.

The New Mexico program is just one of a number of initiatives that have health care systems, payers, and others teaming up with local emergency responders to reduce unnecessary ED trips. By 2017, there were at least 129 such programs, according to the most recent survey by the National Association of Emergency Medical Technicians. Until recently the lack of payment was a hurdle, but now the money is beginning to flow.

Since early 2018, Anthem has been paying ambulance providers for treatment of minor injuries and illnesses at home or another site, an option that’s now available in all 14 states where Anthem has commercial plans, according to a spokeswoman. In February, CMS announced a pilot program in which it will reimburse ambulance providers for treatment on scene or transport to a nonemergency site, such as an urgent care clinic or a doctor’s office.

Like the New Mexico Blues plan, other payers are channeling payment upstream for services delivered to at-risk patients before they seek out emergency care. In Milwaukee, for example, UnitedHealthcare Community Plan has contracted with the city fire department to make home visits—typically four of them—to vulnerable patients. The first eight patients referred to the program had visited the emergency department a total of 96 times during the prior six months, says Kathleen Schoenauer, director of medical and clinical operations at the plan, which manages care for Medicaid and dual special needs patients in Wisconsin. During the visits, paramedics help patients with their medications and identify any hurdles to primary care access, among other challenges. UnitedHealthcare coordinators accompany the paramedic on the fourth visit to introduce themselves as the patient’s new contact moving forward. “They know that they can call us, if their housing is at risk again, if they are having trouble getting transportation to their doctor, if they want to change doctors,” Schoenauer says.

In the first group of eight patients, costs from ER visits dropped by 42% from the six months prior to their enrollment compared with the six months after. Schoenauer says that as additional patients enrolled in the program who weren’t as-frequent users of the ED, the reduction in ED visit costs leveled off to 27%. Currently the program is enrolling about 60 people annually.

In 2018, Blue Cross Blue Shield of New Mexico’s program reached about 2,000 high utilizers. The reduction in emergency visits has stayed pretty consistent in recent years at 50% to 60% when comparing before and after enrollment, according to Sun. In 2018, the total savings was about $1.3 million due to reduced emergency visits and hospital readmissions.

Now the New Mexico Blues plan is also looking at contracting with additional first responders to provide in-home support, Sun says. The insurer is talking with other hospitals, ambulance services, and health care organizations in Albuquerque about developing a triage system for the city and its surrounding county that would, among other things, send nonemergency patients to urgent care centers instead of hospital EDs. The approach being discussed is similar to what federal officials plan to pilot, says Scott Kasper, executive director of the Albuquerque Ambulance Service. “Lots of patients don’t need to go to the ED,” he says. “We could be taking them to a more appropriate place.”

Source Article | By Chuck Gipson, MEDIC EMS

Knowing and studying engagement can yield some great techniques to encourage engagement with your staff but nothing beats firsthand knowledge of what motivates your staff. When we started asking this of the crews, we had some of the same questions that others may have. What would make anyone in their right mind run into, rather than away from, a stressful and possibly dangerous situation day after day to altruistically care for others? Some of the answers are what you would expect and others were somewhat of a surprise. Many of the usual answers of why our staff was motivated to come to work was the great partner that they had, the good equipment they had to use, the desire to be part of something bigger than themselves and do something for others. Some of them are engaged to come to work simply to collect a paycheck and pay their bills. Many of them were engaged by not knowing what was going to happen next in their course of work, appreciating the excitement of the unknown, as well as the varied work environment...

Read on in JEMS!►