News & Updates

  • 31 Oct 2016 12:14 PM | AIMHI Admin (Administrator)

    Fort Worth, TX – October 31, 2016 – For the past two years, 28 stakeholder organizations and 65 program agencies have participated in the development of measures designed to help EMS agencies create and evaluate community paramedic and nurse triage programs.  Countless task force and workgroup meetings, national webinars, discussions at national meetings and national EMS conferences, and over 50 formal recommendations for enhancements were received during the project term. The project development team is today releasing to the internal and external EMS stakeholders the final outcome measures document and a toolkit for EMS stakeholders.  These tools create the first set of standardized measures to evaluate, benchmark and publicly report the outcomes of EMS-Based Mobile Integrated Healthcare (MIH) programs.

    “A high level official at CMS recommended that the EMS industry measure and report outcomes consistently across programs in order to demonstrate the safety and efficacy of EMS-Based MIH programs” explained Dan Swayze, Vice President, Center for Emergency Medicine of Western Pennsylvania, Inc., and a member of the measures core team.  “After two years of incredible work by countless experts, we feel confident that the measures in our document provide a good foundation on which to build the evidence base for MIH programs.”

    Brenda Staffan, also a core team member and the Director of New Ventures for the Regional Emergency Medical Services Authority in Reno, Nevada explains, “We focused on the measure domains that payers and other stakeholders most often request: Program Integrity, Patient Safety and Quality, Experience of Care, Utilization and Cost of Care, and Balancing.  The measures for the Community Paramedic and 9-1-1 Nurse Triage interventions were developed first because these were the most common interventions being implemented in most MIH programs.”

    “Our goal in releasing these standardized measures is for agencies, payers, accreditation organizations and other stakeholders to evaluate program results more consistently.  This will help demonstrate not only the value of these programs, but also allow agencies to find opportunities for improvement by comparing their results to other programs across the country”, said Matt Zavadsky, core team member and Chief Strategic Integration Officer for MedStar Mobile Healthcare in Fort Worth, Texas. “We also want to give special thanks to Anne Jensen, Program Manager for the San Diego RAP Team, for developing an accompanying worksheet that programs can use to enter and calculate the impact of their program and that we can use to establish industry benchmarks.”

    Commenting on the process of the measures development, Gary Wingrove, Government Relations Specialist for Mayo Clinic Medical Transport in Rochester, Minnesota, and President of the Paramedic Foundation states “This is one of the most collaborative processes I’ve had the pleasure of being a part of.  We’ve had participation from almost every national EMS association, multiple provider agencies, institutes of higher learning, and healthcare quality organizations such as the National Committee on Quality Assurance, (NCQA), the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ) and CMS Quality Innovation Networks.  It has been an incredible team effort that will continue as we develop additional outcome measures for interventions such as Ambulance Transport Alternatives and process measures for Community Paramedic and 9-1-1 Nurse Triage programs.”

    Speaking on behalf of the project leadership team, Brian LaCroix, President of Allina Health EMS, in St. Paul, Minnesota thanked all the experts who have been, and continue to be, part of this important project for EMS agencies. “The amount of time invested not only by the core team but so many participants in the process has been incredible.  Agencies from every corner of the country and external stakeholders such as Kaiser Permanente, the National Rural Health Association, and even EMS program support partners such as Zoll, Intermedix, ESO Solutions and ImageTrend have been involved in this process.”

    The Program Structure, Community Paramedic and 9-1-1 Nurse Triage outcome measure documents, the workbook tool for data entry and the complete listing of the agencies and people involved in the measures project are included with this release.  They are also available on the National Association of Emergency Medical Technician’s MIH-CP Program Toolkit.

    Commenting on the next steps in this process, Zavadsky explains, “As we continue to develop additional outcome and process measures, we will also be working with selected associations, national measures organizations, or accrediting bodies, to determine the best options for hosting the measures and/or the data collected through this process, as well as the process for updating the measures as programs continue to evolve.”

  • 27 Oct 2016 10:00 AM | AIMHI Admin (Administrator)

    From ACA mandates to baby boomers rapidly switching to Medicare, there are a number of factors influencing healthcare costs in the U.S.

    Here are 25 things to know about those costs.

    The difference between costs, charges and payments
    1. Before delving into an analysis of healthcare costs, it is critical to understand the difference between healthcare costs, charges and payments. Hospital charges are essentially their list prices for medical services, which are different from hospitalization costs, or the actual amount of money insurers, patients or the government end up paying hospitals in exchange for services.

    2. Hospital input costs are the costs a hospital incurs to provide care to a patient. This includes both variable costs (salaries of clinicians and costs of supplies and medications) and fixed costs (overhead expenses and cost of equipment, land and buildings), according to a report from The Advisory Board Company.

    3. The prices on a hospital’s chargemaster bear little relationship to the amount most patients are asked to pay. That’s because commercial insurers negotiate discounts with healthcare providers on behalf of their members, and Medicare and Medicaid set fixed payment rates for hospital services, which are often less than the actual cost of care. Additionally, most hospitals allow low-income patients to receive free care or care for a reduced charge.

    4. Hospital list prices aren’t completely irrelevant, however, as they usually serve as a starting point for negotiations with commercial payers.

    5. Hospitals may use chargemasters to boost their finances. A study published in the September issue of Health Affairs suggests hospitals were using chargemaster prices to drive up revenue in 2013.

    National healthcare spending
    6. National healthcare spending grew 5.5 percent in 2015, reaching $3.2 trillion, according to estimates from CMS’ Office of the Actuary published in July.

    7. This growth marks an increase from 2014, when rapidly rising drug prices and health insurance expansion under the ACA drove spending upward 5.3 percent.

    8. National healthcare spending is expected to grow at an average annual rate of 5.8 percent over the next decade, according to CMS.

    9. From 2015 to 2025, health spending is projected to grow 1.3 percentage points faster than gross domestic product.

    Medicare, Medicaid and CHIP spending
    10. Spending for the major government healthcare programs will rise by nearly $55 billion, or about 6 percent, in 2016, and Medicare will account for more than half of that increase, according to budget projections from the Congressional Budget Office.

    11. Outlays for the Medicare program are expected to increase by $30 billion, or 6 percent, this year, with growth largely driven by increased spending per person on prescription drugs.

    12. Medicaid outlays are expected to increase by $15 billion, or 4 percent, this year. The CBO anticipates Medicaid enrollment will be roughly flat in 2016.

    13. The CBO estimates outlays for the Children’s Health Insurance Program will climb $5 billion this year, to $14 billion.

    Prescription drug costs
    14. Prescription drug spending increased 12.2 percent to $297.7 billion in 2014, faster than the 2.4 percent growth in 2013, according to CMS.

    15. Inpatient hospital drug costs increased by an average of 38.7 percent per admission between 2013 and 2015, according to an analysis from the independent research organization NORC at the University of Chicago.

    16. According to a Kaiser Family Foundation poll, 82 percent of Americans want the federal government to negotiate with drug companies to get lower prices on medications for Medicare beneficiaries.

    17. Seventy-eight percent of Americans support limiting the amount pharmaceutical companies can charge for high-cost drugs for illnesses like hepatitis or cancer, according to the KFF poll.

    Out-of-pocket healthcare costs
    18. In recent years, patients have become increasingly responsible for a greater share of their healthcare expenditures due to changes in health insurance policies.

    19. Out-of-pocket spending on healthcare costs increased 2.1 percent in 2013. Due to expanded coverage through Medicaid and private insurance, out-of-pocket healthcare spending growth slowed to 1.3 percent in 2014, according to CMS.

    20. In 2009, annual out-of-pocket spending on hospital care was $25.6 billion, according to the Peterson-Kaiser Health System Tracker. Out-of-pocket spending on hospital care steadily increased over the next three years, reaching $32.7 billion in 2013.

    21. Annual out-of-pocket spending on hospital care fell 4.1 percent to $31.4 billion in 2014.

    22. Out-of-pocket spending on prescription drugs increased 2.7 percent to $44.7 billion in 2014, according to CMS.

    Costs broken down by hospital type
    23. The average cost per inpatient day in 2014 at state/local government hospitals was $1,974, according to the latest statistics from Kaiser State Health Facts. That’s up from $1,878 per inpatient day in 2013. These figures are an estimate of expenses incurred in a day of inpatient care and are adjusted higher to include an estimate of the volume of outpatient services, according to Kaiser State Health Facts.

    24. The average cost per inpatient day in 2014 was $2,346 at nonprofit hospitals, compared to $2,289 per inpatient day the year prior.

    25. The average cost per inpatient day at for-profit hospitals in 2014 was $1,798, up slightly from $1,791 per inpatient day in 2013.

    Original Article can be accessed here.

  • 20 Oct 2016 12:10 PM | AIMHI Admin (Administrator)

    We’re so excited to partner with FirstWatch to bring you our first webinar introducing our rebranding (formerly the Coalition of Advanced Emergency Medical Systems (CAEMS), that highlights high performance EMS systems’ focus to highlight the rapidly transforming role of EMS agencies across the United States and Canada.

    This first of its kind webinar introduced over 100 participants to AIMHI and its mission, and explain the concepts of High Performance EMS (HPEMS).

    In this webinar you’ll hear from AIMHI members Doug Hooten, MedStar Mobile Healthcare, Kevin Smith, Niagara Emergency Medical Services, and Jonathan Washko, Center for EMS – Skyealth, Northwell Health.

    If you missed it, don’t worry, click here to access it.

  • 19 Oct 2016 12:08 PM | AIMHI Admin (Administrator)

    Texas and its state medical board on Monday withdrew their appeal that questioned whether Teladoc could challenge the state’s controversial telemedicine restrictions.

    The Texas Medical Board said its board on Friday voted to withdraw the appeal before the U.S. Court of Appeals for the 5th Circuit. The board had vehemently opposed Teladoc’s suit that alleges the state’s telemedicine rules violate federal antitrust laws, launching an unusual appeal after a lower court refused to dismiss Teladoc’s case.

    The board’s proposed rule requires physicians to meet with patients in person before they can treat them remotely, or another provider must be physically present during the first telemedicine appointment to establish a doctor-patient relationship. Lewisville, Texas-based Teladoc maintains that the board violated the law because federal antitrust laws require the board to be supervised by the state in order to create the rules, which the company maintains will affect access to care. According to the board, the restrictions are to ensure quality of care.

    But the U.S. Justice Department and the Federal Trade Commission recently took Teladoc’s side in the dispute, telling the 5th Circuit the state rules were anticompetitive and lacked appropriate review. The federal agencies encouraged the appeals court to reject the medical board’s appeal and maintained the underlying rule should be eliminated.

    Teladoc’s chief legal officer, Adam Vandervoort, said the Texas Medical Board’s outgoing executive director called the decision to withdraw “purely strategic.” “The Texas Medical Board evidently withdrew its appeal because it didn’t want to suffer a ninth loss to Teladoc in the courts,” he said.

    “That raises troubling questions about the (board’s) motives or its competence in both filing, and subsequently retracting, the appeal,” he added. “Teladoc and its amicus parties expended substantial resources on defending the appeal, all of which may have been wasted.”

    Although this appeal is over, the medical board said it will continue to fight Teladoc’s challenge in court and claimed it is immune from federal regulation. The case will continue to be litigated in U.S. District Court in Austin, Texas. While most appeals are sparked by the end of a lawsuit, Texas and the medical board took a rare legal step when they asked the 5th Circuit to weigh in on a federal judge’s rejection of its motion to dismiss Teladoc’s case. Such appeals are seldom granted.

    “The regulation of medicine is a right reserved for the states, and the board stands behind and will seek future vindication of its state-action immunity for performing the duties assigned it by the Texas Legislature,” said Scott Freshour, interim executive director of the Texas Medical Board.

    Texas is experiencing a severe physician shortage, with 35 counties lacking a single practicing physician within their boundaries. Teladoc has said in court filings that telemedicine can help bridge this gap, as it’s often cheaper than traditional doctor or emergency room visits.

    Original article can be accessed here.

  • 13 Oct 2016 12:05 PM | AIMHI Admin (Administrator)

    As physician leaders in North Texas, we have concerning news. Healthcare for the most vulnerable patients in Texas is threatened even more as the likelihood increases that we’ll see less federal funding in the coming years. In 2015, the state of Texas asked the federal government (through the office of the Centers for Medicare/Medicaid, or CMS) for a renewal of a funding model (we know it as the 1115 Waiver) that would have totaled more than $30 billion statewide.

    The request was only partially granted. CMS gave Texas 15 months of funding instead of the five years requested; this would reduce our state’s healthcare system funding by more than $20 billion. Time is running out for the state to address some of CMS’ concerns and receive approval for all the funds previously requested, and it does not take a physician to diagnose this as a serious problem. Not making a counteroffer would create a disaster to the already tenuous safety net. And to provide a counteroffer, the physicians of the Dallas County Medical Society, along with community partners, spent the last two years building a model healthcare delivery plan that we believe can solve this very large problem.

    We call it the Dallas Choice Plan.

    Initiated in 2012, the 1115 Waiver, also called the Texas Healthcare Transformation and Quality Improvement Program, was intended to “redesign healthcare delivery” with an overarching goal to “transform the current delivery of care and payment systems in Texas to a system that is more transparent and accountable.”

    While the waiver has incentivized transformation of healthcare delivery in hospitals and healthcare systems that receive CMS funds toward uncompensated care, the waiver has not had a tangible positive impact on the health of the community at large, nor on physicians who provide care for the vulnerable population in our county and state. The Dallas County Medical Society believes the Dallas Choice Plan is a solution that Texas and CMS are looking for, enabling the restoration of the federal government’s funding for the most vulnerable in our county and state.

    We are in the process of asking Gov. Greg Abbott, Lt. Gov. Dan Patrick, Speaker Joe Straus, and Texas Health and Human Services Commissioner Charles Smith to look at our plan. We believe it could serve as the next step and the next model of care for communities across Texas after the 1115 Waiver ends next year.

    Instead of debating how to reform our local healthcare system, the Dallas Choice Plan proposes a pragmatic and creative solution to address the “access gap” that still impacts about 30 percent of our citizens. Thousands of patients in the gap today are in working families with children. Lack of affordable healthcare for parents and children affects each family’s security and wellbeing, and affects us all through the impact on our businesses, schools, hospitals, and neighborhoods.

    Before we share the basics of the Dallas Choice Plan, let’s look at why we need a new model. Dallas is a great city, with great communities and great people. However, Dallas has its blemishes. Although our healthcare industry exists under a free-market economy, today’s crushing, competitive environment among Dallas’ large hospital systems diverts attention from effective planning and execution of community-based health delivery solutions for vulnerable populations.

    As hospital systems continue to use profits and federal funds for competitive advantage, they minimize investments in prevention and before-hospital healthcare, placing at risk those vulnerable patients who could benefit from such services. Hospitals clearly hold the largest share of resources and carry the greatest influence toward supporting community-wide solutions. Yet currently, none of the federal funds go toward covering costs for healthcare provided by independent private physicians; this seriously limits non-hospital access to physician services for vulnerable patients.

    Here are two simple examples of the unfortunate outcomes of the competitive landscape among our Dallas hospitals. While no patient prefers waiting in a crowded emergency room to treat an issue that could be managed in a doctor’s office, the waiver funds rarely are used to address this concern. Further, no one wants a second or third MRI test simply because our hospitals do not want to share information among themselves.

    As Matt Goodman wrote in D Healthcare Daily on Sept. 8, 2016, the federal government has provided more than $3 billion directly to hospitals in North Texas over the last five years through 1115 Waiver funding. Instead of using these funds to transform the system, we argue that we have seen what could be described as a “medical arms race” in hospital facility construction. This surge of hospital construction has targeted the more affluent (and insured) areas of North Dallas, not the needier areas in southern and western Dallas County. This is contrary to the purpose for which we believe these funds were earmarked—to address the unmet needs of thousands of people without health insurance or unable to pay for health care themselves.

    The 1115 Waiver Community Needs Assessment Task Force in 2012 listed “Primary and Specialty Care Capacity” as the region’s top community healthcare priorities, stating that “demand exceeds available medical physicians in these areas, thus limiting healthcare access.” Because 1115 Waiver funds flowed entirely into Dallas hospitals, we believe these funds have not been used to their full potential to help solve the decades-long problem of unequal access to primary and specialty physician health care for vulnerable people in Dallas.

    As an alternative, the heart of the Dallas Choice Plan is a true Community-based Accountable Care Organization (ACO). A Community ACO is a new term for a healthcare organization that includes physicians, hospitals, and other health providers to care for a population of people. The organization is transparent with regard to performance of its provider network in relation to costs and quality. All health providers in a Community ACO must meet quality and efficiency standards within budget. This is just what the doctors are ordering for Dallas’ solution to this vexing access problem.

    The Dallas Choice Plan would rely on Parkland Health and Hospital System’s support and leadership to anchor the Community ACO. Just as the community strongly supported building Parkland’s state-of-the-art hospital facility, we see a great opportunity for Parkland to be supported in this new role. Physicians in North Texas have a strong connection to Parkland, as most of us either trained or worked at this great institution during our careers. This trusted community health system could be the foundation that recruits private hospitals and independent physicians, along with community clinics and a host of other community-based health providers, thereby further strengthening Dallas’ healthcare safety net.

    The Dallas Choice Plan is transparent, accountable, and transformative in its emphasis on real and meaningful access to care. It was designed by many of our long-time partners in the Dallas community who care deeply about vulnerable patients. We long ago reached out to Dr. Fred Cerise, CEO of Parkland Health and Hospital System, and his team; they agree with many of our ideas and have expressed an interest in working with us on this. Certainly, much work needs to be done, but let’s be sure to create a model that supports everyone who is serving this patient population. Let’s not waste one more dollar on competing hospital systems.

    We propose to test this model in Dallas County, and if successful, believe it could be effective in other areas of Texas. But to even test the model, we need state leaders and CMS to agree to try.

    As leaders of the Dallas County Medical Society for the past three decades, we believe our state, our county and our patients need a viable alternative now.

    Original Article can be accessed here.

  • 4 Oct 2016 12:00 PM | AIMHI Admin (Administrator)

    The former Coalition of Advanced Emergency Medical Systems (CAEMS) is now The Academy of International Mobile Healthcare Integration (AIMHI). This rebranding demonstrates high performance EMS systems’ focus to highlight the rapidly transforming role of EMS agencies across the United States and Canada. This first of its kind webinar will introduce the participants to AIMHI and its mission, and explain the concepts of High Performance EMS (HPEMS).

    About the Presenters
    Douglas Hooten
    CEO
    MedStar Mobile Healthcare

    Doug Hooten is the Chief Executive Officer of MedStar Mobile Healthcare in Fort Worth, Texas. He has over 35 years of experience in EMS, having served as senior vice president of operations and regional director for American Medical Response, CEO of the Metropolitan Ambulance Service Trust (MAST) in Kansas City, and a variety of leadership roles with Rural/Metro Ambulance, Inc. in South Carolina, Georgia, Ohio and Texas. He has demonstrated considerable expertise in change management, cost optimization, process improvement and clinical excellence.

    Having started his career in EMS as a field paramedic in Conroe, Texas, Hooten holds an undergraduate degree in business administration from Sam Houston State University in Huntsville, Texas and a Master of Business Administration from Rockhurst University in Kansas City, Missouri. He serves on the National EMS Advisory Committee (NEMSAC), and is the president of the Academy of International Mobile Healthcare Integration. Doug is also a Board Member for the American Ambulance Association and the Texas EMS Alliance.

    An expert in Mobile Integrated Healthcare, Doug is a co-author of the Jones and Bartlett book “Mobile Integrated Healthcare – Approach to Implementation” and is a regular speaker for industry conferences.

    Jonathan D. Washko, MBA, NREMT-P, AEMD
    Assistant Vice President
    Northwell Health – Center for EMS

    Jonathan Washko as been involved in the EMS industry for over 30 years and has held progressive leadership position with small, medium and large EMS systems in government, private, for-profit and not-for-profit entities. Mr. Washko is considered the leading industry expert on EMS system design, High Performance EMS concepts, Industry Best Practices, EMS Deployment, Lean Business Processes, System Status Management and EMS Finance and is often called upon by EMS systems in crisis as well as those considered at the top of their game, in order to help transform these organizations to become the best they can be. Mr. Washko frequently speaks at national conferences, sits on various industry boards, consults on an international basis and currently serves as the Assistant Vice President of Operations with Northwell Health Center for EMS.

    Kevin Smith
    Chief
    Niagara Emergency Medical Services

    Kevin Smith started his career as a paramedic in Niagara after graduating from Niagara College in 1992 and going on to receive his Advanced Care Paramedic designation from the Michener Institute, Toronto in 1998. Receiving his Bachelors of Applied Business in Emergency Services degree in 2010, Kevin has worked through various levels of the profession to his current position as chief of Niagara Emergency Medical Services. Kevin is responsible for providing emergency services to the 12 local municipalities that make up the Niagara Region comprising a population of over 425,000 residents as well as over 2.5 million visitors to Niagara per year. He oversees a department budget of more than $40 million including the portfolios of land ambulance, dispatch (ACE), regional emergency preparedness, regional fire coordination, and regional 911 services. Kevin leads a team of more than 340 advanced and primary care paramedics, emergency medical dispatchers, emergency planners and administrative staff and his team handles 90,000 calls per year with over 50,000 patients transported to local hospitals. Kevin is active in national, provincial and regional paramedic organizations and currently leads the Paramedic Chiefs of Canada (PCC) in strategic planning, receiving the PCC President’s Award in 2016.

    Introduction to AIMHI and The New Role of High Performance / High Value EMS – Part 1
    October 19, 2016
    12:00 pm EST.

    REGISTER NOW

    Thank you to our webinar provider, FirstWatch

  • 28 Sep 2016 2:00 PM | AIMHI Admin (Administrator)
    September 28, 2016

    Kenneth W. Kizer, M.D., was a firefighter when paramedicine was emerging in the Los Angeles area and, as director of California Emergency Medical Services Authority in 1983, he wrote the regulations for paramedicine in the state. Now he is a thought leader in population health — and an advocate for community paramedicine in value-based care.

    You have defined community paramedicine (CP) as “a new and evolving method of community-based health care in which paramedics function outside their customary emergency response and transport roles in ways that facilitate more appropriate use of resources and/or enhance access to primary care for underserved populations.” What is the state of CP currently?

    KIZER: I’ve seen paramedicine evolve from its earliest days to where it is now, and I think community paramedicine is perhaps the next big evolution for paramedicine.

    There are programs in varying stages of development in more than 20 states and more than 150 communities. The programs are spreading pretty rapidly, and I think they will continue to do so.

    Community paramedicine is an important component of population health management and the new emerging value-based health care economy because it fills gaps in the typical health care delivery infrastructure that are especially relevant to value-based payment.

    The focus of CP programs varies widely — from paramedics providing directly observed treatment for tuberculosis patients at their homes to providing transportation to health care facilities other than emergency departments and many other concepts.

    What do you consider to be the most promising applications for CP?

    KIZER: The programs that respond to the 9-1-1 superusers hold a lot of promise for better utilizing scarce emergency care resources, including ambulances and hospital emergency departments. We know that in many communities some people call 9-1-1 multiple times per week when what they really need is help with basic primary care or other support services. Many of these persons may be homeless or have mental health needs or other problems that are not always better managed in the ED.

    Another type of program that I think is going to prove to be very helpful is one that provides follow-up care after a hospital discharge or an ED discharge. These programs serve patients before they can get in to see their usual provider or — probably more often — until they can establish a relationship with a regular health care provider.

    I also think CP programs that provide in-home care for frail elderly persons who have multiple chronic conditions and may have limited mobility are going to be quite successful. These patients may have cognitive issues that impair their ability to comply with medication or other treatment regimens. They may lack transportation. And too often their only resource is to call 9-1-1 and take an ambulance to the hospital ED, when their needs could be much more economically and effectively — and I would argue, compassionately — dealt with by paramedics who come in to help them with their medications or wound care or whatever their individual needs may be at the moment.

    Despite its obvious merits, telemedicine has been slow to gain widespread adoption until recently. Do you expect CP to have a similar slow path to reaching its potential?

    KIZER: Community paramedicine shares many of the same barriers and challenges that telemedicine does, although it has some things working to its advantage that I think will speed up its widespread implementation.

    For many providers and patients, telemedicine is a really new way of delivering or receiving care and it requires the provider to buy new technology, which people then have to become familiar with. By contrast, paramedics are an already existing and very large workforce that is well-integrated into local communities and very well-trusted and highly regarded by the public. Another advantage that CP has is the rapid evolution to a value-based economy in which it can fill a clear and demonstrated need. CP provides a bridge between primary care and emergency care and can fill gaps in the underlying health care delivery infrastructure that exist in so many communities across the country.

    One of the barriers for the widespread adoption of community paramedicine is the limited data about safety, efficacy and long-term outcomes. Many different models of community paramedicine have arisen independent of each other to address particular local needs. As a result, there is a lot of variability in exactly what CP programs do, so it is difficult to compare outcomes from one program with outcomes from another — or to combine data from different programs to analyze CP in the aggregate. Various programs have demonstrated they have reduced 9-1-1 calls, ED visits, hospital admissions and readmissions, and emergency transport charges, but those data are not as compelling as what either Medicare or other health care payers generally want to see before they decide whether they’re going to cover a new service.

    And that leads to another barrier — reimbursement for services — that CP shares with telemedicine. Most of the CP programs to date have been developed out of grant monies or other short-term funding. And some of the programs have closed shop because they were not economically viable in the long term. The interrelated problems of outcomes data and reimbursement have to be addressed for CP to move forward.

    In response to a recommendation from your report — “Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care” — California authorized several CP pilots. What is the purpose of these pilots?

    KIZER: In California and a few other states, paramedics’ scope of practice is defined both by what they do and where they do it, unlike most other health care workers for which the scope of practice is just what they do. Our recommendation was that the state needed to do pilots to establish safety, efficacy and outcomes data as a basis for changing the state laws to permit community paramedicine.

    There are 12 pilots underway. The largest number of those have paramedics providing transportation to destinations other than a hospital ED, such as a mental health clinic, an urgent care clinic, a doctor’s office or a sobriety center.

    Another group of pilots allows paramedics to provide follow-up care after an ED or a hospital discharge.

    Other pilots are experimenting with different models of community paramedicine. The pilots are still underway, and an assessment should be completed in 2017.

    How does CP fit into the current health care delivery system?

    KIZER: Emergency medical services are clearly a well-established and essential part of the health care delivery system, but are often viewed as outside of the usual care delivery system. Many physicians who don’t interface with the emergency care system don’t really understand paramedics or how the pre-hospital care system works.

    Physicians and health system leaders need to see CP as a very promising model of community-based care that can help to support their population health management goals and their clinical integration goals and help them to thrive in a value-based health care economy.

    Original article can be accessed here.

  • 26 Sep 2016 1:00 PM | AIMHI Admin (Administrator)

    There’s a revolution taking place in emergency medical services, and for many, it could be life changing.

    From the increasingly sophisticated equipment they carry and the new lifesaving techniques they use, to the changing roles they play in some communities—providing preventive care and monitoring patients at home—ambulance crews today are hardly recognizable from their origins as “horizontal taxicabs.”

    Here’s a look at some of the most important changes happening in EMS care around the country—including a few plans in the testing phase still, and the challenges EMS professionals face to bring those to reality.

    In case of emergency …

    EMS crews today are better equipped than ever for the worst kinds of emergencies, from cardiac arrests and gunshot victims to car crashes and other life-threatening injuries. These days, more ground and air ambulances include X-ray and ultrasound devices, machines that perform automatic chest compressions for CPR, communications systems that forward electrocardiograms to the emergency room, and equipment for lab tests that can identify dangerous conditions such as a developing septic infection.

    Much of the best equipment—including a helicopter equipped as a mobile emergency room or intensive-care unit—can be found at the Mayo Clinic, in Rochester, Minn. Regarded as a leader in sophisticated onboard equipment and communications, Mayo often consults with other medical transport systems to share best patient care strategies, and works with U.S. military physicians to share expertise on how treatment of battlefield wounds might apply to civilian medicine.

    Mayo provides increasingly advanced pre-hospital treatment, saysScott Zietlow, a trauma surgeon and medical director of the Mayo One trauma helicopter program. External defibrillators and pacemakers are standard, as are portable analyzers for lab tests and noninvasive devices to determine if a blood transfusion or antibiotics are needed. Because Mayo has its own blood banks, its air ambulances are able to provide a growing array of blood products that most others don’t carry.

    In addition to featuring state-of-the-art equipment, Mayo’s emergency medical service has helped test a number of EMS innovations, including capnography, a monitoring device that helps in the placement of breathing tubes and measures the concentration of carbon dioxide in exhaled air. This can guide the effectiveness of CPR chest compressions and gauge the likelihood that a patient can be revived. Mayo Clinic can also transport patients on a machine that does the work of a heart and lungs.

    Mayo’s work with the military has led its EMS crews to adopt quick-clotting bandages and tourniquets for blunt trauma and penetrating wounds. A study of 125 patients that Dr. Zietlow co-wrote, published last year in the Journal of Special Operations Medicine, concluded that civilian use of tourniquets and hemostatic gauze is highly effective at stopping bleeding.

    Mayo EMS crews also plan to adopt a practice the military uses as an alternative to intravenous lines, particularly when a limb has been lost: sternal intraosseous infusion, in which fluids and medications are administered into the bone marrow directly through the sternum.

    Coming soon: preventive-care teams

    In what could amount to a sea change for many EMS workers, health-care policy makers are looking at having so-called community paramedicine teams provide preventive care—and even make regularly scheduled house calls.

    In a concept some are calling “EMS 3.0,” ambulance crews with advanced medical training in more communities already are treating patients in their homes, including frail or elderly patients, helping to manage chronic conditions like diabetes, and are checking on recently discharged hospital patients to ensure they are following their care instructions.

    “We are a natural provider of care outside of hospitals and other institutions,” says Kevin McGinnis, program manager, community paramedicine, mobile integrated health care and rural emergency care for the National Association of State EMS Officials. “The majority of calls that go through 911 are nonemergencies, and we can use EMS resources to address otherwise unaddressed health needs in communities,” Mr. McGinnis says.

    Among the nonemergency calls that paramedics often respond to: shortness of breath, weakness and fatigue from dehydration, cuts and abrasions, abdominal pain, low-grade fevers, cold-like symptoms, urinary problems and minor falls in the home.

    Dovetailing with efforts to align EMS workers more closely with core health-care delivery, EMS organizations in a draft report released last month called for “an EMS system that maximizes value to the community by providing new and essential services.” Extending EMS responsibilities to helping people navigate the health-care system, coordinating care and better educating patients, the report said, can “ultimately lower cost and improve the quality of patient care.”

    The report cited big hurdles, including a highly fragmented national EMS system and payment policies which generally reimburse EMS providers only when they transport patients to a hospital. That could change as private insurance companies and the federal Medicare and Medicaid programs continue in their transition from a fee-for service model to one linked to the quality of care provided and measurable patient outcomes.

    According to a 2013 study in the journal Health Affairs, if Medicare would reimburse EMS for services other than transporting patients to an ER, it would improve the continuity of care and save the federal government as much as $560 million a year. If private insurance companies followed suit, the study added, overall savings could be twice as large. The Centers for Medicare and Medicaid Services is now funding several programs testing new models that would reimburse for such alternative models.

    Many EMS services are financially strapped due to the hospital-transport-only reimbursement policy, says Kevin Munjal, director of prehospital care at the Mount Sinai Health System in New York. In smaller communities and rural areas, the model is too low-volume to support paid staff, so EMS is provided by volunteers. That, in turn, puts their ability to respond in a true emergency at risk.

    By creating a system that reimburses EMS professionals to do things like treat patients at home, move them to other health-care providers and check on them after they leave the hospital, “we could unleash innovative new models of care that meet unmet needs, while making emergency response more reliable,” says Dr. Munjal, who is leading a nationwide EMS innovation project. Otherwise, he warns, “many would argue that EMS’s ability to be there in emergencies is under threat.”

    Treating more patients at home

    Meanwhile, several pilot programs are working on ambulance services whose job is to not take people to the hospital.

    Mount Sinai and a local ambulance company have established a community paramedicine program in which specially trained paramedics respond to calls from patients enrolled in the program or in Mount Sinai’s visiting doctors program. The paramedics visit and examine the patients in their homes, and consult with doctors at the hospital via telemedicine, or two-way video, on what to do next. Out of 36 patients who called the service over a six-month period, only five were transported to the hospital, for an estimated savings of about $1,400 per encounter, Dr. Munjal says. The pilot program was started with a grant from the Centers for Medicare and Medicaid Services and is supported by private foundations.

    In a similar pilot program in Mesa, Ariz., dispatchers in the Mesa Fire and Medical Department talk to patients who call the 911 center. For many whose problems are not deemed an emergency, nurses offer medical advice, or send a community-medicine unit to the caller’s home. The units include firefighter paramedics, nurse practitioners or physician assistants, or behavioral-health counselors from local fire departments and health-care providers and a hospital. A test of 983 patient encounters from August 2012 to February 2013 showed a cost savings of over $1 million, according to Mesa Deputy Chief Steven Ward. In 2014, the Mesa program also received a grant from the Centers for Medicare and Medicaid Services.

    Caring for patients at home has advantages for everyone—when it’s possible. Tony Lo Giudice, the Mesa department’s community-care grant administrator, says that out of 55,000 calls a year, about 40% are low-acuity, “and it can be can be very expensive to place everyone in an ambulance and take them to the ER.” The community-care units also visit some hospital patients after discharge that are at higher risk of being readmitted, to offer preventive-care measures and make sure the patients are following discharge instructions. Paramedics are then able to identify those that might need follow-up services such as a social worker or physician referral, says Mr. Lo Giudice.

    Susie Jackson, who lived in Gilbert, Ariz., says the community unit was a big help when her mother, Nancy Long, 80, cut her arm badly. Ms. Jackson called 911 and jumped in her car to get to her mother, expecting to spend the day in the ER with her. Instead, a physician assistant with the community-care unit stitched up the wound in her mother’s home. “It put my mother at so much ease that she didn’t have to leave home to be taken care of,” says Ms. Jackson.

    A national emergency network

    New information systems under development could make it far easier to share information in an emergency. First responders currently rely on thousands of separate and incompatible networks during emergencies, and often can’t easily communicate and work together. A 2012 federal law created the First Responder Network Authority, known as FirstNet, an independent authority that is developing a high-speed, nationwide, wireless broadband network dedicated to public safety. EMS teams would be able to transmit live video and images from car crash scenes, for example, even in rural areas with limited coverage.

    In another national effort, known as Next Generation 911, states are upgrading antiquated 911 systems, which can only receive phone calls, allowing callers to send video and pictures to dispatchers. A growing number of states have recently added 911 text messaging.

    With such advances and mobile apps designed for EMS services, first responders could use smartphones to share information that is now often lost or incomplete when they hand over patients at the ER, saysBenjamin Schooley, an assistant professor of integrated information systems at the University of South Carolina. His design of a mobile system that allows paramedics to transmit video, pictures and other information to hospitals from car crashes has been tested in Idaho and Montana.

    So far, Dr. Schooley says, EMS has only started to scratch the surface of what it can do with patient data in real time.

    When less care is more

    Counterintuitively, perhaps, researchers are finding that some patients may benefit from less intervention by paramedics. Studies have shown that in cases of penetrating trauma, such as gunshot or stab wounds in the torso, chest, abdomen or upper arms of legs, so-called advanced life support methods including providing IV fluids and inserting breathing tubes don’t improve survival rates.

    Ambulance crews around the country are using new techniques and testing new missions.

    PHOTO: ISTOCKPHOTO/GETTY IMAGES

    Temple University Hospital in Philadelphia is embarking on a five-year study that will randomly group patients who are shot or stabbed. One group will receive advanced life support. The other group will be brought immediately to the hospital with only basic life-support therapy such as an oxygen mask if needed. The hospital has been meeting with city residents to explain the study and provide wristbands for those who want to opt out.

    Zoe Maher, a trauma surgeon and researcher for the study, says that while the procedures can help in rural areas where trips to the hospital are long, in a city they might not help—and could hurt patients who are shot or stabbed and bleeding to death. For example, administering IV fluids can dilute the blood’s clotting ability, and putting a tube down the victim’s throat can increase pressure in the chest cavity and decrease the amount of blood coming back to the heart.

    “Sometimes we think of innovation as adding more treatment, but innovation here means doing less,” says Amy Goldberg, chair of Temple’s department of surgery. “We need to embrace this just as we would a new device or a new technology.”

    Ms. Landro, a Wall Street Journal assistant managing editor, writes the Informed Patient column. Email: laura.landro@wsj.com.

    Original article can be accessed here.

  • 19 Sep 2016 12:00 PM | AIMHI Admin (Administrator)

    September 2016

    If there is one issue confronting our health-care system on which just about everyone agrees, it’s this: Unnecessary emergency room visits are a significant driver of costs. But getting the people who most abuse emergency services under control has been an uphill battle.

    Now a new approach is showing promise in reducing visits to the ER by what the Centers for Medicare and Medicaid Services calls “super-utilizers,” typically defined as those who use emergency services four or more times a year. The National Conference of State Legislatures estimates that up to 27 percent of all visits to ERs are for nonemergencies. But so-called community paramedic programs are finding new ways to manage these frequent flyers.

    Minnesota has been a pioneer in community paramedicine. Under its program, a hospital will typically identify four or five super-utilizers who need a managed care approach. Then community paramedics will go into those people’s homes to look not only at their overall health issues but also at factors like safety precautions and nutrition. Through the program, Minnesota has seen ER use by super-utilizers decrease by 60 to 70 percent.

    Community paramedics are generally more seasoned emergency medical services personnel who have undergone training to help them identify community-based health needs. “We’re not asking them to do a brain transplant,” says Jim Dunford, the EMS director for San Diego, which has a community paramedicine program that’s part of a state-launched pilot covering nine cities. “The majority of issues that confound our health-care system are social ones. We need to be teaching our patients to connect the dots.”

    San Diego’s program uses data to help determine whether a community paramedic should show up at a scene where 911 has been called. “All of the data that resides in these 911 systems gives us the ability to identify individuals who have been using services in the last week, the last six months, the last year,” says Dunford. “We can look at factors like: Do they have co-occurring illnesses? Are they over 65?”

    Some of the big insurance players involved with government health-care programs are starting to get in on the action as well. Blue Cross and Blue Shield of New Mexico has begun pilot programs for its Medicaid patients in a few of the state’s more urban areas. The company says a group of patients identified in one of the programs has cut its ER use by 60 percent. One former super-utilizer hasn’t been to the ER in the 11 months he’s been enrolled in the program, says Kerry Clear, the company’s manager of community social services.

    In setting up its program, Minnesota included legislation that allows the state’s Medicaid program to reimburse community paramedic services. But most of these programs are either subsidized by ambulance companies operating under fixed-price contracts or funded by grants from foundations or the federal government. In San Diego, whose program is funded through an ambulance service, Dunford is optimistic that the results from the pilot will encourage lawmakers in Sacramento to follow Minnesota’s lead.

    The success of the community paramedic model has many EMS directors encouraged that this could be the future of emergency care. On the federal level, U.S. Sen. Al Franken of Minnesota has introduced legislation advocating for community paramedicine nationwide. That’s an idea that appeals to people like Clear. With the number of primary-care physicians at an all-time low, he says, “we all know prevention is key to keeping our communities healthy.”

    Original article can be accessed here.

  • 19 Sep 2016 9:00 AM | AIMHI Admin (Administrator)

    September 17th, 2016

    If unnecessary hospital readmissions are, as some suggest, the low-hanging fruit in the pursuit of better healthcare, hospitals should get ready to pluck less and less.

    Hospital administrators have had years—four since Medicare’s Hospital Readmissions Reduction Program took effect, and six since the Affordable Care Act spurred a slew of other initiatives to improve healthcare value—to scrutinize and cut down on unnecessary readmissions. And in those years, the U.S. has largely managed to do so, new numbers from the CMS show.

    From 2010 to 2015, readmission rates among Medicare beneficiaries fell in Washington, D.C., and every state but one, the CMS reported. That drop translates to about 565,000 avoided readmissions for Medicare beneficiaries since 2010, including 100,000 in 2015 alone.

    That momentum could soon slow. That’s not necessarily a bad sign, because not all readmissions are preventable. But it also means hospitals and other providers will have to work smarter to keep making progress on readmissions.

    A bevy of CMS initiatives have taken aim at improving healthcare quality while holding down or even trimming costs, with the ambition of tying 90% of traditional Medicare payments to quality or value by 2018. Unnecessary hospital readmissions, regarded as an indicator of poor quality care, play a burgeoning role.

    The idea that hospitals can avoid readmissions by providing better follow-up care once patients are discharged is at the heart of the Hospital Readmissions Reduction Program. Under it, those that fail to curb excess readmissions lose out on a portion of their Medicare reimbursements.

    The program took effect Oct. 1, 2012, and has imposed increasingly hefty financial penalties on hospitals whose avoidable 30-day readmission rates for a limited list of conditions exceed the national average. For fiscal 2017, which starts Oct. 1, the CMS will penalize more than 2,500 hospitals, saving the agency about $538 million.

    Readmissions targeted by the Medicare program are for a narrower set of conditions than the 30-day all-condition hospital readmission rates published by the CMS last week, but the CMS said the program was one factor in reducing avoidable readmissions.

    But some providers and policy experts are concerned that imposing financial penalties to drive down excess readmissions could move hospitals to take measures that go too far.

    “I think we’re going to reach a point of diminishing return, where to reduce readmissions further is eventually going to be perceived as underdelivering care and almost being cruel,” said Dr. Martha Radford, chief quality officer at NYU Langone Medical Center in New York. “Not all readmissions are preventable, and it’s kind of tough to know which ones are and which ones aren’t, particularly in advance.”

    Hospitals can still do more to reduce the unnecessary ones, said Dr. Eric Coleman, a professor at the University of Colorado, where he also heads the healthcare policy and research division. “But the relative return on investment going forward will be less,” Coleman said.

    Medicare views hospital readmission rates as an important indicator of the quality of care because they reflect the breadth and depth of care a patient receives. If hospitals fail to treat a patient fully or ensure that the patient has a feasible discharge plan, that patient could end up coming back to the hospital for care. Unnecessary readmissions are also expensive, costing the U.S. $25 billion annually, by one estimate.

    More tightly coordinated care and better communication between hospitals and post-acute providers have indeed helped hospitals prevent readmissions and improve the quality of patient care, Coleman said.

    “This is a fairly dynamic process, where we believe that what we’re doing is reducing modifiable risk,” Coleman said. But, he warned, “There certainly are people whose risk may not be so modifiable. They really do need to be readmitted. We don’t want to deny care on that end.”

    One unintended consequence of Medicare’s focus on readmissions, according to some critics, is that hospitals are keeping patients in outpatient observation status rather than admitting them.

    “It has been the case that the hospitals have been gaming the system in extraordinary ways,” said Ross Koppel, a sociology professor at the University of Pennsylvania who conducts healthcare research.

    A Wall Street Journal analysis of Medicare billing data late last year concluded that hospitals were indeed gaming the system by classifying patients as being on observation status. Two months later, HHS researchers countered in the New England Journal of Medicine that the small increase in observation claims couldn’t explain a more substantial drop in readmissions.

    Providers and their advocates argue that it’s often better for patients to be held for observation rather than admitted. “Observation status helps ensure that the most appropriate setting of care is where the patient ultimately receives their care,” said Lorraine Ryan, senior vice president of legal, regulatory and professional affairs at the Greater New York Hospital Association. It gives a provider more time to evaluate patients before deciding if they should be formally admitted.

    And other challenges remain. Despite the progress by hospitals and post-acute care providers, the quality of care that patients receive after they’re discharged still leaves much to be desired. Improving it will require grappling with thorny issues such as insurance coverage and weak healthcare infrastructure in many parts of the U.S.

    The reasons for gaps in care as patient’s transition out of the hospital and back home vary from the financial and logistical to the socio-demographic.

    Some hospitals, especially safety net providers, care for disproportionate numbers of lower-income patients who live in communities without other healthcare services and resources essential for follow-up care, such as primary-care physicians and pharmacies. As a result, no matter what the hospital does, some patients might not be able to get the follow-up care they need.

    “The strategies that hospitals are using, a lot of them are some of the same,” said Akin Demehin, director of policy for the American Hospital Association. “But certainly the challenges that they may face in their own patient population, in their own communities, in their own space, could look a little bit different.”

    In other cases, patients or families are given instructions for care after discharge. But that doesn’t mean they can, or will, follow them.

    “A lot of folks go home and just feel unprepared and start to panic,” Coleman said. Preventing avoidable readmissions “really is about preparing patients and families to be able to feel confident in their own self-care.”

    And sometimes, a patient’s insurance will not cover the post-acute care services he or she needs, or will pay for only a portion.

    “We’ve tried a lot of things—we make sure people have a follow-up appointment, we do arrange for visiting nurses, we’ll place them in some sort of chronic-care facility if possible. Often, it’s not,” said Radford, of NYU Langone. “The payment models don’t help here. Some people don’t have coverage for that type of thing.”

    Of the 49 states where readmissions fell from 2010 to 2015, 43 saw decreases of more than 5%, and rates fell by more than 10% in 11 states. The one state where Medicare’s 30-day, all-condition hospital readmission rate rose was Vermont—from 15.3% in 2010 to 15.4% in 2015, which the CMS described as “virtually unchanged.”

    And according to hospital leaders there, the state may be seeing what others throughout the country are about to experience: doing well on readmissions means lower rates of improvement.

    “While Vermont’s readmission rates may not have changed drastically, they remain lower than in more than half of other states,” said Jeffrey Tieman, CEO of the Vermont Association of Hospitals and Health Systems. The state’s rate in 2010 was 1.3 percentage points below the median, according to CMS data.

    “Our hospitals recognize that it can be hard to make progress on these types of measures when your state is already a strong performer,” Tieman said. “But they are focused on continuing to reduce readmissions even further by improving the way we coordinate and integrate care.”

    Original article can be accessed here.

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