News & Updates

In cooperation with the American Ambulance Association, we and others have created a running compilation of local and national news stories relating to EMS delivery. Since January, 2021, over 1,800 news reports have been chronicled, with 45% highlighting the EMS staffing crisis, and 29% highlighting the funding crisis. Combined reports of staffing and/or funding account for 74% of the media reports!

Click below for an up to date list of these news stories, with links to the source documents.

EMS Media Log - 2-28-24.xlsx

  • 26 Jul 2019 8:00 PM | AIMHI Admin (Administrator)

    Civil Beat source article | Comments courtesy of Matt Zavadsky

    A VERY well done article and even better program!  Kudos to our pacific island EMS crews and their governing body for taking this step!

    Note the use also of Community Health Workers.  And, Hawaii has a nearly universal payer system, which helps these types of programs demonstrate value.

    We were blessed to host Jesse Ebersole and Vern Hara from Hawaii County EMS at MedStar a couple of years ago, they have very unique challenges and now, it seems, unique solutions!

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    State Aims To Reduce Unnecessary ER Visits By Empowering Paramedics

    Hawaii is creating a community paramedicine program that officials hope will mean fewer ambulance trips to hospitals.

    By Lorin Eleni Gill

    July 26, 2019

    Minor wounds, rashes, gout pain — these are some of the many medical conditions that should be taken seriously, but they may not merit a 911 call or a trip to the emergency room.

    Hawaii health officials are considering how to reduce unnecessary ER visits through a community paramedicine program. The revised emergency transport system that could begin next year would allow medical professionals to transfer patients to predesignated destinations, such as urgent care clinics, or even provide complete treatment at the scene.

    “Can paramedics go treat people in the field, in the community setting under a physician’s direction, and offer a treatment when they don’t need to go anywhere?” asked James Ireland, a nephrologist and the former director of the Honolulu Emergency Services Department. “Can they do some simple wound cleaning and start the patient on some antibiotics under the guidance of a physician? I think that’s where the huge cost savings can be.”

    When Gov. David Ige signed Act 140 into law June 25, it marked the latest development in an effort to make Hawaii’s emergency response system run more smoothly. Starting as early as next year, the law will allow paramedics or other medical professionals to treat some patients at the scene of an emergency — or nonemergency —  and navigate them to appropriate care at other clinical sites.

    CONTINUE READING►


  • 23 Jul 2019 10:42 AM | AIMHI Admin (Administrator)

    Fierce Healthcare source article | Comments courtesy of Matt Zavadsky

    A very interesting perspective on our healthcare system as experienced by an “insider”.  We’ve all heard similar tales from our partners IN the healthcare system. 

    This is why healthcare system partners, especially that payer community, is more and more looking to partner with “EMS” to assist with patient navigation from 9-1-1 activations, and to help manage super-utilizer patients.

    Here’s a link to a tragically ironic video depicting what it would be like if air travel worked like our healthcare system.  It’s hilarious, but only because it’s sadly true – worth the 7 minutes you will invest watching the video – you’ll laugh, but maybe it will spur some thoughts on how we fix this.

    https://youtu.be/5J67xJKpB6c

    Editor's Corner—I write about healthcare. I still found myself lost in the unnavigable healthcare system

    by Jacqueline Renfrow | 

    Jul 15, 2019

     

    We need a healthcare system that uses all of the amazing technology and ingenuity that is available in 2019 while staying affordable and, most importantly, puts the patient’s well-being first.

    It began back in January with a simple rash—or so we thought.

    My daughter had a rash all over her body, so I took her to the pediatrician. “Maybe it is a virus, or maybe it is just dermatitis. Don’t worry about it,” the doctor said. I was told to apply lotion and give it time.

    A month later, we were at the dermatologist. We went back two weeks later, and then four weeks later, and then again another two times. With each visit, we got another cream, another possible diagnosis. No change in the rash.

    So we returned to our pediatrician's office, which employs more than half-a-dozen physicians. 

    Each of the five times we went back, a different physician offered a different diagnosis. I'd repeat the same story and answer the exact same line of questioning (both to a nurse and a doctor at every visit). At doctor after doctor, my daughter’s height and weight were taken, to the point that she’d announce, “47 inches and 47 pounds” before she even got on the scale. She knew the drill by heart, as did I.

    The ones not in the know were the physicians.

    Each specialist we saw asked which creams she had tried, which antibiotics she had taken and which labs had been run. After my daughter’s second blood draw, I realized that from one doctor to another, no one knew which tests had already been performed. So I started carrying a folder with lab results and a bag of medicine bottles so I had the answers in hand.

    As a mother, I knew something serious was wrong. My daughter had headaches, stomachaches, she couldn’t sleep and was barely eating. Plus, she had one dilated pupil. And her skin was so itchy that she scratched until she bled, meaning several rounds of antibiotics had to be taken to avoid infection.

    We met with an ophthalmologist, an allergist, a rheumatologist and then another dermatologist. I was given ridiculous answers such as: “It’s most likely that the headaches are just behavioral.”

    I was also given scary possible scenarios such as: “There could be a mass behind her eye.”

    And beyond my new role as the walking data collector, I had to fight to get my child in for an appointment.

    Apparently, specialists for children are few and far between, even around the major metropolitan area in which I live. I was told I’d have to wait more than two months to get an appointment with a pediatric ophthalmologist and around the same amount of time for a pediatric allergist.

    But how can you tell a mother that her child could have a brain mass and then expect her to wait to see a physician for more than eight weeks?

    I called in favors. I called friends with specialists and doctors and asked them to get me in. I was willing to pay out of pocket. Insurance was an afterthought at this point. I was willing to travel to any office, any time of day or take any cancellation. And I considered myself lucky to get scheduled with a nurse practitioner at the rheumatologist’s office because the doctor could not get us in until the fall.

    Almost six months after this all began, I reluctantly took my daughter to yet another dermatologist. I’d been on his waiting list awhile. I was told he was older, unfriendly and very off-putting to children. But at this point, I had nothing to lose: The next step was the neurologist.

    Bedside manner aside, this gruff physician finally gave us the answer we'd been searching for. He found a rare bacteria on my daughter’s skin and told us how to treat it. Two weeks later, her rash, along with all of her other symptoms, were gone. It was a relief. 

    But the experience left me feeling frustrated, exhausted, lost and desperate for a different way. I wondered how anyone, sick or healthy, could be expected to navigate a system so divided in communication.

    As a reporter, I’m well aware of the challenges in the U.S. healthcare system. I’ve followed the debates on pricing transparency, drug rebates, value-based care, electronic health record connectivity, physician burnout and access to care. But I learned how frightening it is to be a patient—or the parent of a patient—and have so many physicians give you so many varying opinions and diagnoses.

    I also learned that no one in the healthcare system was going to advocate for my daughter, so it was going to have to be me.

    And I learned that healthcare providers and systems do not communicate with one another. There is no sharing of opinions, lab results, data or doctor-patient relationships.

    I am left with a stack of medical bills and a pit in my stomach that this country has a long way to go to create a clear, navigable system for Americans. We need a system that uses all of the amazing technology and ingenuity that is available in 2019 while staying affordable and, most importantly, puts the patient’s well-being first.


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

    FierceHealthcare source article | Comments courtesy of Matt Zavadsky

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

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

    by Jacqueline Renfrow

    Jul 22, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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


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

    Health Affairs source article | Comments courtesy of Matt Zavadsky

    Interesting data report in this month’s Health Affairs.

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

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    Air Ambulances With Sky-High Charges

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

    JULY 2019

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

    ABSTRACT

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

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

    STUDY RESULTS

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

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

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

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

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

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

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

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

    July 2, 2019

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

    Please send donations to:

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

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


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

    EMSWorld Source Article | Comments courtesy of Matt Zavadsky

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

    Ohio Health System Launches EMS-Based Accountable Care Network

    06/25/2019

    John Erich

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

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

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

    CONTINUE READING►


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

    HealthAffairs Source Article | Comments courtesy of Matt Zavadsky

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

    Unpacking The Executive Order On Health Care Price Transparency And Quality

    Katie Keith

    JUNE 25, 2019

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

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

    CONTINUE READING►


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

    JAMA Network source article | Comments courtesy of Matt Zavadsky

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

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

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    Realignment of EMS Reimbursement Policy

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

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

    Viewpoint

    June 21, 2019

    doi:10.1001/jama.2019.7488

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

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

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

    Moving Beyond Transport

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

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

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

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

    Remaining Barriers

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

    Patient Safety

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

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

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

    Measuring and Ensuring Quality

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

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

    States, Municipalities, and Other Payers

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

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

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

    Unintended Consequences

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

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

    Conclusions

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


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

    Modern Healthcare source article | Comments courtesy of Matt Zavadsky

    Interesting perspective…

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

    Conservative legal expert calls surprise bill proposals unconstitutional

    June 21, 2019

    HARRIS MEYER  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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