News & Updates

  • 15 Feb 2019 2:18 PM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    Something we should all keep a close eye on – could have serious financial impact on safety-net providers, including EMS agencies.


    New Medicaid barrier: Waivers ending retrospective eligibility shift costs to providers, patients

    By Harris Meyer  | February 9, 2019

    Last year, Jackson Memorial Hospital in Miami admitted an uninsured, low-income patient who stayed in the hospital for 86 days and ran up total charges of more than $1 million.

    It took the public hospital's staff 65 days to complete a Medicaid application for the patient. Once it was approved, the Florida Medicaid agency covered bills for the previous 90 days, as per federal Medicaid policy in effect across the country since 1972. Jackson received a payment of $82,000, based on the state's limit of 45 covered hospital days per year.

    But on Feb. 1, Florida ended retrospective Medicaid eligibility under a waiver granted by the CMS in November and effective through June, which likely will be extended. Now it will only cover claims back to the first day of the month in which an application is filed. The state projects this will save it and the federal government $100 million a year. The Trump administration so far has granted similar waivers to five other states.

    If the waiver had been in effect last year, Jackson would have eaten that patient's entire bill. It estimates the new policy will cost the hospital at least $4 million a year in uncompensated care, and likely far more.

    “We get trauma cases where we can't identify the patient or get documentation for weeks,” said Myriam Torres, Jackson's vice president of revenue cycle. “This will save Medicaid dollars at providers' and patients' expense.”

    A costly incentive

    Over the past two years, despite strong objections from hospitals and other provider groups, the CMS has granted waivers of 90-day retrospective eligibility to Arizona, Arkansas, Florida, Iowa and Kentucky. Some were part of broader Medicaid Section 1115 demonstrations of work requirements. Maine also received a waiver but its new Democratic governor announced she won't implement it. The CMS is considering similar waiver requests from Ohio and other states. 

    In its approval letters, the CMS argued that demonstrations ending 90-day retrospective eligibility will test whether that gives beneficiaries an incentive to enroll in Medicaid before they need healthcare services, so they can receive preventive services and stay healthier. It also says the change will facilitate a smoother transition of beneficiaries into commercial health plans, which don't offer retroactive coverage. 

    The CMS is requiring states to develop outreach and education strategies to encourage providers and beneficiaries to submit Medicaid applications as early as possible, though providers say they haven't seen any significant new state activity there.

    A CMS spokesman said that as in all Section 1115 demonstration waivers, the agency is requiring states to monitor and regularly report the outcomes and financial impact.

    But experts say there's no evidence that eliminating retrospective eligibility encourages Medicaid-eligible people to sign up earlier, and there are plenty of reasons why that hypothesis is implausible.

    “Many people who aren't enrolled are not aware they are eligible or they have difficulty with the enrollment process,” said Dr. Benjamin Sommers, an associate professor of health policy and economics at Harvard University. “The notion that most people will sign up by getting rid of retrospective eligibility is unlikely. They typically do not even understand it.”

    Critics say eliminating retrospective eligibility is one more administrative barrier the Trump administration has erected to make Medicaid and other public benefits harder to access. These include work and reporting requirements, premium payments, healthy behavior incentives, benefit lockouts, and proposed penalties for legal immigrants who use public programs. States like Arkansas that have added new hurdles have seen sharp drops in Medicaid enrollment.

    “Shortening the (retrospective eligibility) window gives people less time to figure out they'd be eligible,” said Pamela Herd, a public policy professor at Georgetown University, who calls that form of administrative burden a learning cost. “Republicans have employed these types of changes to reduce use of social welfare programs.”

    Changing nature of waivers

    Under previous administrations, Delaware, Indiana, Maryland, Massachusetts, New Hampshire and Tennessee received waivers of the federal requirement for retrospective eligibility, typically as part of coverage expansions. In contrast, the Trump administration's waivers have been part of programs to restrict coverage.

    Most of these waivers retain retroactive coverage for pregnant women, infants, disabled people and those in nursing homes. Florida's waiver, however, excludes such coverage for the nursing home population.

    Herd and other experts say that if the goal is to get people to enroll as soon as they are eligible, there are proven ways to achieve that, such as streamlining the enrollment process and doing more aggressive outreach. The Trump administration has sharply cut funding for enrollment education and assistance.

    On the other hand, if the goal is to reduce federal and state spending on Medicaid and shift costs to providers and patients, eliminating retroactive eligibility likely is effective. 

    Actuarial analyses of Medicaid payments have shown that about 5% of Medicaid payments occur during the retrospective eligibility period. Ending retrospective coverage would reduce Medicaid outlays by an estimated $13.3 billion from 2017 to 2026, according to the Commonwealth Fund.

    In 2016, Indiana reported that 14% of beneficiaries to whom the waiver applied ran up significant out-of-pocket medical expenses as a result, averaging more than $1,500 per person. Sixteen percent of providers said they saw charity cases and bad debt increase as a result of the policy.

    “If this is really an experiment, what is the policy goal other than to reduce program costs?” asked Joseph Antos, a conservative health policy analyst at the American Enterprise Institute. “Presumably this should have something to do with patient outcomes or efficiencies. I don't see the word efficiency in any of this. I see cut.”

    A history lesson and the impact on beneficiaries

    Retrospective eligibility was built into federal Medicaid law early on as a safety net protection for very low-income people and their medical providers. It encourages providers to treat patients knowing they'll get paid and to help them sign up quickly for the program. 

    Another key rationale is that unlike in private insurance, many Medicaid beneficiaries “churn” on and off coverage due to changes in income and because states impose a demanding annual eligibility redetermination process. It's estimated that 25% or more of beneficiaries are at least temporarily disenrolled as a result of the redetermination process and other factors. 

    Many other people aren't even aware they are eligible. The Kaiser Family Foundation recently reported that 6.8 million uninsured adults and children were eligible for Medicaid but were uninsured in 2017. 

    All these factors leading to loss of coverage for eligible people makes retrospective eligibility an important backstop, patient advocates say.

    But some state and federal officials long have complained about the cost of retroactive coverage, which generally can't be passed on to the private Medicaid plans that administer most state programs. 

    Tennessee received a waiver in 1994 as part of its major Medicaid coverage expansion program known as TennCare. Even though that program largely has been rolled back and the state has not expanded Medicaid under the Affordable Care Act, the elimination of 90-day retroactive coverage remains in place for nearly all beneficiaries.

    That has led to many Medicaid-eligible people incurring large medical bills before their Medicaid applications are approved, with some facing lifetime debt, said Michele Johnson, executive director of the Tennessee Justice Center, which tries to help people clear up these bills.

    The problem was exacerbated by a recent major computer glitch in the state's Medicaid enrollment system, which left thousands unable to file their annual enrollment redetermination applications online.

    Before her Medicaid application was approved, one Memphis woman racked up $250,000 in bills resulting from her baby being born with severe health problems. “She said that was the hardest thing in her life—going home with a disabled child and being consigned to poverty for the rest of her life,” said Johnson, whose group helped with her case. 

    After a nine-month court fight, the woman finally got Tennessee's Medicaid program to pick up the entire bill.

    Yet there has never been a study of the policy's impact in Tennessee. “It hasn't led people to sign up ahead of time,” Johnson said. “All these other policies make it almost impossible to sign up. If the state were interested in that, they would make the whole process less bureaucratic.”

    In 2017, Iowa received a CMS waiver of the 90-day retrospective eligibility requirement, including for nursing home residents, despite warnings that nursing homes would refuse to admit people who were awaiting Medicaid eligibility. Last year, under pressure from nursing homes, the state Legislature restored retroactive coverage for that population.

    Brent Willett, CEO of the Iowa Health Care Association, said it takes an average of 71 days to assemble complicated income and assets information, file the application, and receive approval for Medicaid nursing home coverage. Under the policy the state reversed, facilities only received payment back to the first day of the month when the application was filed, even though they may have admitted the resident many weeks earlier. 

    The association projected that policy would cost Iowa nursing homes $7 million in the first year. “It sounds nice that people should start the application process early and we agree, but it's not practical in practice,” Willett said. “If we are maintaining a system to ensure coverage for people who don't have assets for care, it makes no sense to penalize providers for providing that care. That policy wasn't cost containment, it was a cost shift to providers.”

    Iowa hospitals looking for a reversal

    As to the broader group of beneficiaries affected by Iowa's waiver, the Iowa Hospital Association is pushing to have 90-day retroactive eligibility reinstated this year. The policy hurts urban trauma centers that provide intensive care to people before an application can be completed, as well as rural hospitals that lack a profit cushion to absorb those unexpected costs, said Scott McIntyre, the association's vice president of communications.

    The Legislature ordered it as a cost-containment measure, with the state projecting it would affect nearly 40,000 Iowans and save it and the feds $36.7 million a year. The CMS waiver required the state to provide outreach and education to the public to ensure that eligible people apply for Medicaid as soon as possible.

    But McIntyre said the state has not ramped up enrollment outreach to mitigate the end of retrospective eligibility. 

    In addition, Iowa, which expanded Medicaid in 2014, has not conducted any review of the cost savings to the government or of the financial impact on providers and beneficiaries, according to a spokesman for the Iowa Department of Human Services. The CMS, he said, did not require the state to conduct such a report on the impact of eliminating retrospective eligibility. “We've made so much progress with Medicaid expansion to reduce uncompensated care, and this really undermines that progress,” McIntyre lamented.

    There's already an effort to roll back the new retrospective eligibility waiver in Florida, which didn't expand Medicaid, so that it applies to nursing home residents and all other Medicaid eligibles except pregnant women and children. 

    It's basically impossible for many people who may need a nursing home placement to apply for Medicaid ahead of time because they're living in the community and don't qualify until they enter institutional care, explained Tom Parker, director of reimbursement for the Florida Health Care Association. 

    “I would think that undercuts the main argument for this policy,” he said.

  • 13 Feb 2019 6:29 PM | AIMHI Admin (Administrator)

    Becker's Hospital Review Source Article | Comments Courtesy of Matt Zavadsky

    Customer-focused; disruptive innovation…

    Ambulnz is an interesting model worth visiting their website at the hyperlink below…

    Providers can now request Uber rides for patients: 6 notes

    Jackie Drees 

    Feb 13, 2019

    Uber Health and ambulance services provider Ambulnz teamed up to enable healthcare providers to order non-emergency medical transportation for their patients.

    Six notes:

    1. Ambulnz integrated Uber Health's application programming interface into its platform, which provides healthcare organizations with on-demand medical transport.

    2. Through the new partnership, providers can use Ambulnz's platform to request patient transportation to and from destinations such as a physician's office, clinic or hospital.

    3. Healthcare organizations can also integrate Ambulnz's API into various EHRs, giving providers the option to request non-emergency medical transportation directly from their clinical workflow.

    4. Ambulnz currently operates in Colorado, New York, California and Tennessee. UCHealth in Aurora, Colo., had already been using Ambulnz's platform, and recently began using the Uber Health integration. "By having the ability to order a sedan, ambulette or an ambulance from a single web portal or an app, our facilities will be able to more efficiently manage transportation needs, improving the overall experience and care of our patients," UCHealth CIO Richard Zane, MD, said in a news release emailed to Becker's Hospital Review.

    5. Dan Trigub, head of business development for Uber Health, added: "With access to different types of Uber Health and Ambulnz rides in a centralized place, healthcare providers can spend more time focused on patients instead of the tools and technology to get them where they need to go at exactly the right moment."

    6. Both Uber Health and Ambulnz's platforms are HIPAA compliant, according to the news release.

  • 11 Feb 2019 10:23 AM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    Interesting, but not surprising results from this report.

    The report is attach, with a section highlighted noting the following quote:

    Many ACOs have established themselves as the central hub to enable community organizations and PCPs to more effectively meet the needs of patients. This includes teaming with employers and local gyms to offer exercise and nutrition-based counseling. Others have established free clinics, where food is available, to reduce ED visits for non-medical needs, as well as partnered with community paramedicine programs to build 911 services to support at-risk patients and facilitate home visits to reduce potentially preventable admissions.”


    Unnecessary ED visits from chronically ill patients cost $8.3 billion


    FEBRUARY 7, 2019

    About 30% of emergency department visits among patients with common chronic conditions are potentially unnecessary, leading to $8.3 billion in additional costs for the industry, according to a new analysis.

    The report, released Thursday by Premier, found that six common chronic conditions accounted for 60% of 24 million ED visits in 2017; out of that 60%, about a third of those visits—or 4.3 million—were likely preventable and could be treated in a less expensive outpatient setting.

    The frequency of unnecessary ED visits from the chronically ill is unsurprising given the fee-for-service payment environment the majority of providers remain in, said Joe Damore, senior vice president of population health consulting at Premier. On average, only 10% of providers' payment models are tied to value-based models, he said, so providers don't have an incentive to effectively manage patients to prevent disease progression and promote wellness.

    Premier's findings are in line with other research on patients with chronic diseases, finding they are more likely to use the ED and get admitted to hospitals because they experience poor care coordination. 

    "Value-based care is managing a chronically ill patient in a coordinated way, and the traditional payment model hasn't rewarded that. It's episodic," Damore said. 

    The six chronic conditions used in the analysis are asthma, chronic obstructive pulmonary disease, diabetes, heart failure, hypertension and behavioral health conditions, such as mental health or substance abuse issues. They were selected because they are often cited in the academic literature as the most common and costly conditions in the healthcare system, Premier said. 

    The data from the 24 million ED visits at 747 hospitals comes from Premier's database, which has information on 45% of U.S. patient discharges, according to Premier. To get the results, Premier identified hospitals with the lowest quartile visit rate, or those that had the lowest ED admission rates by condition, and calculated how many visits at the remaining hospitals could be prevented if all hospitals achieved those rates for the six chronic conditions. 

    And then to arrive at the $8.3 billion in costs, Premier used the average cost for an ED visit estimated by the Health Care Cost Institute, which is $1,917. 

    Damore said that although the industry is "mostly fee-for-service at this time," he expects an eventual transition to value. "More and more providers are convinced that the future is going to be value-based payment," he said.

  • 11 Feb 2019 10:21 AM | AIMHI Admin (Administrator)

    EMS1 Source Article | Comments Courtesy of Matt Zavadsky

    Behavioral health patients are a significant challenge for EMS systems and their partner healthcare facilities. 

    The AMR program in Stanislaus County, CA pilot project to provide medical clearance for people with mental health needs and arrange for them to be transported directly to a county-operated mental health crisis center demonstrated excellent outcomes for the patients and healthcare system! 

    Nice to see this study on the project published in the Annals of Emergency Medicine.

    The USCF review of the project is attached for your information.

    Tip of the hat to Paul Ford from Las Cruces Fire Department for this article!

    Journal Watch: Medical Clearance of Psych Patients

    Authors: Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA.  

    Published in: Ann Emerg Med, 2018 Sep 28.   

    Patients with an altered mental status can be challenging, particularly those experiencing a psychiatric emergency. Not only can they be a potential danger to you and your partner, they typically end up in an ED for a lot longer than necessary. Studies have demonstrated that these patients can tax EMS systems and add to ED overcrowding. 

    One factor that contributes to the difficulty of caring for them is that field providers are typically required to transport patients to an ED even if they are sure an ED is not the appropriate destination for their patient. Further, patients who are experiencing psychiatric emergencies are often required to be medically cleared by an ED physician to ensure a life-threatening illness is not responsible for their behavior. Additionally, there is a sizable population of psychiatric emergency patients transported involuntarily to protect their safety or the safety of others. 

    What if we were permitted to choose alternative destinations for our behavioral-emergency patients? Would this be better for them, the EMS system, and the hospitals? Would it be safe for our patients? UCLA emergency physician Tarak Trivedi, MD, and his coauthors recently published a manuscript that seeks to answer these questions. 

    Just for background, there have been some smaller studies that reported that mistaking a psychiatric emergency for a nonpsychiatric life-threatening illness is rare. There are also reports of emergency medicine experts questioning the value of transporting these patients to EDs for medical clearance. 

    Trivedi’s is a retrospective observational study—in other words, that data had already been collected, and there were no interventions introduced by the investigators. The data were collected over five years from EMS systems in Alameda County, Calif. The authors were evaluating a protocol that allows EMS providers to transport patients with isolated psychiatric complaints (i.e., no medical complaint or abnormal vital signs) directly to an appropriate psychiatric facility. 

    The authors had two study objectives. First they sought to describe the characteristics of patients who received involuntary psychiatric holds and compare them to patients transported for other reasons. They defined involuntary-hold patients as those who had at least one involuntary hold during the study period. They also sought to evaluate the safety of the protocol allowing EMS providers to divert these patients to psychiatric emergency services. The authors used “failed diversion” as a proxy measure for safety. A failed diversion was defined as an event in which a patient was initially brought to a psychiatric emergency facility but required transport to an ED within 12 hours. 

    During the study period there were 265,625 unique EMS patients who received care by Alameda County EMS. Almost 10% (26,283) had at least one involuntary hold. When comparing involuntary-hold patients to those who’d never been involuntarily held for a psychiatric emergency, involuntary-hold patients were more often men; they also accounted for substantially more EMS usage. Of the involuntary-hold patients, 48% had only one EMS transport during the study period, compared to 74% of “never-held” patients. Moreover, 4% (1,072) of involuntarily held patients had more than 20 encounters during the study period. There were only 0.4% (820) of never-held patients in this category.

    Besides unique patients, the authors also looked at total EMS calls. During the study period there were 541,731 patient encounters, and 10% of these (53,887) were for patients receiving involuntary holds. Yes, 26,283 patients accounted for 53,887 EMS encounters involving involuntary holds. They also accounted for 74,116 encounters that did not involve involuntary holds. In total, involuntary-hold patients accounted for almost a quarter of all EMS encounters in this county (128,003; 24%). 

    Of the 53,887 involuntary-hold encounters, 41% (22,074) resulted in direct transport to a psychiatric emergency facility. Only 0.3% (60) of these could be classified as failed diversions!

    What is even more impressive is that the authors conducted a manual chart review and discovered that in 54 of the 60 failed diversions, the patient developed new symptoms after arrival at the psychiatric emergency facility, and there was nothing in the PCR that supported transporting these patients to the ED.

    Of the six patients who should have been transported directly to an ED, none died or required CPR or an advanced airway during their second transport. Three patients required critical interventions; these included one glucagon administration, one naloxone administration, and placement of one nasopharyngeal airway. 


    The authors of this study did a nice job outlining their limitations. They included that this study was performed in one county, which the authors note has a notably higher rate of involuntary holds compared to the rest of California.

    The protocol studied has been in place for years, and results may be different during an implementation phase. They also discussed limitations in the data and the matching algorithm they used to identify unique patients. 

    This was a well-done study that significantly adds to the literature. It strongly suggests that a protocol that allows EMS providers to divert psychiatric patients to dedicated psychiatric facilities appears to be safe and beneficial.

    Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.

  • 7 Feb 2019 11:44 AM | AIMHI Admin (Administrator)

    LA Times Source Article | Comments Courtesy of Matt Zavadsky

    Love – Love – Love this idea!

    For hospice agencies, and Hospice/EMS partnerships, this could become a very valuable practice for the families and the patients!

    F.V. nurses capture dying patients’ heart readings for families before they say farewell


    JAN 18, 2019 | 5:10 PM

    Two Fountain Valley nurses are taking clinical EKG readings and making them poetic and personal as mementos for families of dying patients.

    Courtney Snyder and Lisa Ann Behrend, who provide emergency and critical care at Fountain Valley Regional Hospital and Medical Center, developed what they call Vials of Love — small glass vials holding narrow printed electrocardiogram strips that show the heart’s electrical signals as it beats.

    They started handing out the vials, prepared during patients’ final hours, in November.

    Behrend establishes relationships with families during emotionally demanding end-of-life care, so she gets a sense of who might be receptive, she said. She’s offered six of the keepsakes so far.

    “I’ve had nobody say no,” she said. Rather, the survivors cry with gratitude, she added.

    Not everybody can read an EKG, but most are familiar with the image of the peaked waves that literally show a person’s life force — more specifically, atrial contraction and ventricular depolarization, contraction and re-polarization — the heart rate and rhythm.

    Symbolically, the heart represents love and spirit, and the reading shows individuality. Like fingerprints, no two people have identical heart rhythms, Snyder said.

    She saw a similar memento on social media. That version put EKG strips inside blood collection tubes — on point with the cardiovascular theme — but she thought she could do better.

    So she surveyed colleagues, who softened the concept by suggesting vials with cork stoppers, heart-shaped confetti, red lanyards and mesh drawstring pouches to hold the tiny bottles.

    After doctors and nurses establish that a patient can no longer be treated and will die soon, they transition to comfort care. With sedation and pain medication, the patients are calm. The EKG readings show no distress, and the monitoring, which is standard, is non-invasive, Snyder and Behrend said.

    Behrend explains the death process to families, which she believes helps them through the imminent end.

    The memento is a gift and part of the process.

    “Giving them closure is the biggest gift a nurse can give,” she said.

  • 7 Feb 2019 11:36 AM | AIMHI Admin (Administrator)

    FireRescue1 Source Article | Comments Courtesy of Matt Zavadsky


    This is a concern some of us share…

    Iowa fire dept. reverses on-duty weapon policy

    The Delaware Township Fire Department implemented a policy that allowed responders to use guns on duty, but rescinded it after receiving criticism

    Feb 1, 2019

    By News Staff

    DES MOINES, Iowa — A fire department is taking heat for a policy that would allow first responders to use guns on duty.

    KCCI reported that the Delaware Township Fire Department approved a policy on Jan. 8 that would recognize “members’ right to carry a firearm under Iowa law.”

    The policy, which Chief Evan Kellis said “had been in place for a while” and was merely being updated, added that first responders would only be allowed to discharge a firearm if they are in danger of death or seriously bodily injury, or if they are defending another person.

    Former DTFD responder Travis Hurley, who left the department after not seeing eye to eye with Kellis, said “it’s just not a good policy.”

    "In over 20 years of service in fire service, there has never been a single time or incident where I thought to myself, 'Boy, I sure wish I had a weapon on that call,'" he said.

    Hurley added that guns would destroy the trust between first responders and their patients.

    "You turn around then put a weapon on our side. Now you're going to look like law enforcement," Hurley said. "It takes away our ability to get to the bottom of the story and earn those peoples' trust."

    Kellis said he and other officials decided it was “not the best policy” and rescinded the approval.

    "Once we had written that policy, we kind of talked with everybody and went, ‘You know, the policy we had longstanding for a while is not a good policy. The policy should be that we don't carry weapons,’” he said.

    Sen. Jeff Danielson, who is also a firefighter, said he agrees with the decision to rescind the policy.

    "You're giving them a false sense of security that they can enter the scenes because they somehow have a gun now and can do something about it," he said.

    Kellis agreed and said guns should be left to law enforcement.

    "Carrying weapons is for a police officer who is duly trained and qualified to carry that weapon, not a firefighter," he said.

  • 4 Feb 2019 1:29 PM | AIMHI Admin (Administrator)

    HealthAffairs Source Article | Comments Courtesy of Matt Zavadsky

    States have always been at the forefront of healthcare regulation, and innovation.  Here’s a summary from Health Affairs of what’s likely on the Governor’s agenda’s.

    The National Governor’s Association Center for Best Practices – Health Division is very active in creating forums for model state healthcare policy.  They have invited EMS to the table on numerous occasions. 

    This is also why part of NAEMT’s current strategic plan is to support state EMS associations engage at the state level and catalog model state EMS legislation.

    Governors Set The Agenda For Health Care

    Heather Howard

    FEBRUARY 1, 2019

    Against the background of the federal government partial shutdown, 36 governors (new or re-elected) have been sworn in this year, many of them announcing ambitious agendas on health care. Even before the shutdown, prospects for health care legislation emerging from a divided Congress were unlikely, and governors have jumped into this breach and seized the opportunity to set robust agendas. 

    A review of the governors’ inaugural, state of the state, and budget addresses reveal a wide range of state health care initiatives, including expansions of health insurance coverage, efforts to address the affordability of health care, and a continued focus on the opioid crisis and increasing access to behavioral health services. 

    Coverage Expansions

    One clear theme from the governors has been a focus on expanding health insurance coverage. In Maine, Governor Janet Mills’ first action was an executive order directing the Department of Health and Human Services to implement “expeditiously” the expansion of Medicaid approved by the voters in 2017 but opposed by the previous governor. Three states—Idaho, Nebraska, and Utah—are implementing expansions of Medicaid approved by voters in 2018 ballot initiatives, and Kansas Governor Laura Kelly proposed a path forward on expansion. In Wisconsin, a state that covers residents up to 100 percent of the federal poverty level on Medicaid, the new governor issued an executive order starting the process to expand Medicaid up to 138 percent of the federal poverty level, which will increase federal funding to the state. 

    Some governors signaled their intent to pursue even more far-reaching efforts to increase coverage. Several states are actively considering proposals to leverage Medicaid to further reduce the numbers of uninsured. In New Mexico and Colorado, there are proposals for a Medicaid buy-in, to make coverage more affordable for consumers and to improve access to care. Washington State is considering a public option, with plans procured by the Washington Health Care Authority, home of Washington’s Medicaid program, Apple Care. Plans would be available for purchase on the state health insurance Marketplace. These proposals may gain traction in other states and add fuel to national debates on universal coverage. 

    California’s governor unveiled an ambitious package, which includes expanding state-funded coverage to undocumented immigrants from ages 19 to 26, enhanced subsidies to make coverage more affordable for those purchasing Affordable Care Act (ACA) plans, and a plea to President Donald Trump and Congress for “Transformational Cost and Universal Coverage Waivers...that provide the path to single-payer health care.” Together, the initiatives would “bring the state closer toward health care for all.” 

    Protecting ACA Coverage Provisions

    Facing uncertainty resulting from the recent legal challenge to the ACA, some states are looking to codify ACA protections in their own laws. Governors in NevadaNew YorkRhode Island, and Wisconsin are focusing on protecting provisions related to preexisting conditions and guaranteed issue. For example, in Rhode Island, the governor called for ACA protections, such as essential health benefits, to be enshrined in state law to guard against repeal efforts or court action. Similarly, in Wisconsin, the newly elected governor signed an executive order directing state agencies to provide him with recommendations to ensure that people with preexisting conditions are able to obtain health insurance. 


    After Congress effectively repealed the individual mandate to purchase health insurance in late 2017, experts predicted higher premiums and uninsurance rates. CaliforniaNevada, and Rhode Island are considering implementing a state-level individual mandate, following the lead of the District of Columbia, New Jersey, and Vermont, to avert the negative consequences of repeal. Proposals in Colorado and Rhode Island call for a reinsurance program to help stabilize premiums, following seven other states that have received federal approval of a Section 1332 waiver to help bring down premiums through reinsurance.

    Many governors mentioned the burden of rising health care costs on their states, but Colorado Governor Jared Polis offered a novel idea: the creation of an Office for Saving People Money on Healthcare, to be led by Lieutenant Governor Dianne Primavera. He noted, “We aren’t giving this office a fancy name to make it SOUND important. Instead, we’re giving it a simple name because it IS important.” 

    Prescription Drugs

    As rising prescription drug prices draw increased attention from the Trump administration and Congress, so too are states confronting the impact of increasing costs on residents and state health care programs. Colorado proposed allowing prescription drugs to be imported from Canada, an idea that Vermont is already pursuing. However, the big news on this front was California Governor Gavin Newsom’s first act—an executive order consolidating the state’s purchasing authorities to create the country’s largest single purchaser for prescription drugs and eventually to include private purchasers. Governor Newsom noted, “We will use both our market power and our moral power to demand fairer prices for prescription drugs.” 

    Behavioral Health And Addressing The Opioid Crisis

    With the opioid epidemic showing no sign of abating, governors across the political spectrum vowed to step up efforts on treatment and prevention. Governors in ColoradoIowaNew HampshireRhode Island, and South Carolina focused on the need to address behavioral health in schools by training teachers to recognize potential signs of depression and suicide, and allocating more resources for school personnel. Additionally, the governor of Iowa is calling for comprehensive behavioral health reform and is focusing on shoring up the children’s mental health care system in the state. 

    States have always been at the forefront of health care innovation, spurred by the local nature of health care and a combination of necessity borne of balanced budget requirements and our federal system. Notable this year is the bold tone many new governors are taking, with talk of “guaranteed health care,” “health care is a human right,” “health care is a fundamental right,” and “health care is a basic human right.” Clearly, for health policy observers, the states bear watching in 2019.

  • 4 Feb 2019 1:27 PM | AIMHI Admin (Administrator)

    CNBC Source Article | Comments Courtesy of Matt Zavadsky 

    Nice news story from CNBC – maybe discussions like this will help communities across the country recognize the value of EMS personnel and work to change the economic model that will facilitate higher pay rates.

    The need for EMTs and paramedics is growing, but finding people to fill the jobs isn't easy

    Kate Rogers | @KateRogers

    February 1, 2019

    • Northern Light Health's medical transport and emergency care in Maine is currently about 10 percent understaffed.
    • EMTs and paramedics are in demand around the country, with some 37,400 jobs set to be added through 2026, a 15 percent increase.
    • About five years ago, there were 15 to 20 applicants per open position at Northern Light. Today, it's not uncommon to post a job and have zero applicants.
    • The health-care industry has added 368,000 jobs over the past year, while unemployment continues to hover near historic lows.

    On any given day, Eric Mailman may transport a baby born into a neonatal intensive care unit from one hospital to another, or he could answer a call for an elderly person in cardiac arrest.

    The paramedic and operations coordinator at Northern Light Health's medical transport and emergency care in Bangor, Maine, can answer anywhere between four and 17 calls in a day, on shifts that can stretch from 12 to 24 hours. The only guarantee is that work will be busy and unpredictable.

    "The positive is that you get to step in on the chaos of the worst day of someone's life and bring some calm and peace — to me that is priceless," Mailman said. "But there are days when you can't intervene, where things are out of your control. It's impossible to help everybody, and those days are the hardest."

    At Northern Light, some 170 people work in emergency medical services and transport, but the system is currently about 10 percent understaffed. Challenges are many in hiring — the community is rural, and while the pay and benefits can be competitive, the job itself is a big commitment, requiring sometimes up to two years of training, recertification and continuing education. Roughly five years ago, there were 15 to 20 applicants per open position, says Joe Kellner, vice president of emergency services and community programs at Northern Light. Today, however, it's not uncommon to post a job and have zero applicants respond, he said.

    The tight labor market is particularly weighing on the health sector. The health-care industry added 42,000 new jobs in January, with more than 22,000 in ambulatory health-care services and another 19,000 in hospitals, according to Friday's closely watched Labor Department report. The health-care sector has added 368,000 jobs over the past year, while unemployment continues to hover near historic lows.

    "Fewer people are entering the profession, unemployment is low, and this is also a job that many people used to get into through volunteerism and in local communities — there is a lot less of that," Kellner says. "The pathway in is harder and harder, but we try to create solutions for that."

    Northern Light's system is run in partnership with a larger nine-hospital system throughout the state, allowing for more reliable funding and options for those using emergency medical services as a stepping stone to other areas of health care. The company also reimburses for tuition, offers competitive paid time off and a retirement plan with a matching employer contribution. Highly trained paramedics are paid about $27 an hour.

    Emergency medical technicians and paramedics like Mailman are in demand, not just in Bangor but around the country. Challenges persist beyond just finding people to fill jobs in more rural areas, however — 2017 median nationwide pay was just more than $33,000, or about $16 an hour.

    Funding can also be an issue in some communities, as reimbursements from insurers, patients, and Medicare and Medicaid are outpaced by wage pressures and costs to operate. This is especially common in volunteer programs, funded in large part by community donations and local taxpayer dollars.

    "If people really want to feel confident that they can call 911 and someone will come, they need to support their community so it will provide that kind of service," says Kathy Robinson, program manager for the National Association of State EMS Officials.

    Health-care hiring boom

    The need for EMT and paramedic workers comes as the health-care sector continues to boom.

    "The strong economy definitely has an impact," says Ani Turner, co-director of sustainable health spending strategies at nonprofit research organization Altarum. "We are at full employment, so along with expanded insurance coverage in the Affordable Care Act that started to take effect part way through 2014, we have a lot of people that now have health insurance coverage. More people with health benefits, more people with insurance increases the demand for health care and therefore health jobs."

    Much of this growth came from the ambulatory sector, with an emphasis on outpatient care, which added 37,800 jobs in December 2018. What's more, out of the 30 fastest-growing occupations through 2026, per BLS, nearly half fall under the health-care category, and analysts say there's likely no slowing down ahead. The workforce continues to age, as does the population in need of care, the opioid epidemic persists, and the pool of skilled labor remains tight.

    With all that growth, there's no doubt demand will continue within systems like Northern Light, where trained professionals like Mailman are ready to answer the call.

    "I love my job. I can't imagine doing anything different than what I do," Mailman said.

  • 4 Feb 2019 9:08 AM | AIMHI Admin (Administrator)

    The Academy of International Mobile Healthcare Integration (AIMHI) represents high performance emergency medical and mobile healthcare providers in the U.S. and abroad.

    This week, we are proud to welcome our newest member organization, Medic Ambulance of Vallejo, California!

    About Medic Ambulance

    Medic Ambulance has a rich history of providing quality advanced life support ambulance services in the North San Francisco Bay area. They are the exclusive 911 ambulance provider for all of Solano County with the exception of Vacaville.

    Medic Ambulance is a family business with strong ties to the community. Medic support its community in a variety of ways, including offering ambulance stand-by services for special events. 

    Medic maintains a standard of excellence in everything from response times, to fleet maintenance, to operations. To meet that standard, they employ the latest technology in all areas to give patients the best care possible, including a state-of-the-art Computer Aided Dispatch center, web-based crew scheduling, Zoll monitor/defibrillators, Stryker Power Pro gurneys, and more.

    By utilizing the best equipment, technology, and personnel, Medic Ambulance is able to constantly adhere to the cornerstone of their mission statement ”Give the best people the best tools to do their jobs, and they will do the best job possible.”

    Medic Ambulance maintains it's accreditation from the Commission on Accreditation of Ambulance Services (CAAS).

    Medic Ambulance WebsiteFacebookTwitter

  • 1 Feb 2019 11:01 AM | AIMHI Admin (Administrator)
    D CEO Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    Interesting, while not necessarily surprising results from this study.

    Something to think about if you have these types of facilities in your service areas.

    Blue Cross Insurance Data Reveals Texas’ Freestanding Emergency Department Charges

    01/31/2019by Will Maddox

    New research shows what many have already discovered: freestanding emergency departments may charge more than urgent care centers to fewer patients who have similar conditions.

    The study looked at three urgent care centers that were converted to FSEDs in Texas using insurance claims from Blue Cross Blue Shield of Texas, based in Richardson. They show that patient volume went down between 29.5 and 94.8 percent, but reimbursement per patient increased between 970 and 1,369 percent. The study showed no significant difference in the age, gender, or conditions of patients managed by both the UCCs and FSEDs.

    Researchers did find a small uptick for more severe conditions such as chest pain, which was .5 percent of UCC visits and 2.3 percent of FSED visits.

    “This study highlights some of the payment reimbursement structures that are not ideally suited to the patient or to our health care system as a whole. While this is a case study of three facilities and is not generalizable to all FSEDs, this study shines a light on these reimbursement structures and how they can potentially be used to increase revenue,” said Dr. Sabrina J. Poon, instructor of Emergency Medicine at Vanderbilt University Medical Center, via release.

    The Journal of Emergency Medicine study describes FSEDs as emergency departments not attached to an acute care hospital, though they are at times affiliated with one. In 2009, Texas passed the Texas Freestanding Emergency Medical Care Facility Licensing Act, which allowed the facilities to be built in the state. Texas led the charge in allowing freestanding emergency rooms, which often pop up in wealthier neighborhoods.

    “You have to look at why patients are going to FSEDs, as there are benefits. They are convenient, they are located in a place that is easy to get to, there is a shorter wait time, and the list of services or care provided is what patients are looking for. The question is, how can we provide this care in the most valuable way for both patients and the health care system?” said Poon via release.

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