News & Updates

  • 8 Nov 2018 4:28 PM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments courtesy of Matt Zavadsky

    Mixed issues here – on one hand, limited access to primary care may exacerbate health issues in this population, potentially resulting in more acute care use, including ambulance.  On another hand, this may lead to an acceleration of Medicaid potentially paying for EMS-Based MIH services for prevention and patient navigation as a way to meet the Triple Aim®.

    The inclusion of non-emergency ambulance transportation has been undetermined in this policy.  Some officials have indicated it was not, but other indicated it did include non-emergency ambulance transportation.

    CMS is developing a rule that could curtail Medicaid transportation access

    By Virgil Dickson  | November 7, 2018

    https://www.modernhealthcare.com/article/20181107/NEWS/181109932  

    The CMS is drafting a proposed rule that would make it easier for states to stop paying for non-emergent medical transportation for Medicaid beneficiaries, a move that could drastically cut into providers' revenue.

    While details of the potential rulemaking are scarce, a notice on the White House's Office of Management and Budget website said the regulation is projected to be released in May 2019.

    Just the suggestion that states could cut Medicaid transportation to medical appointments already has providers on edge. Annual Medicaid spending for these trips is around $3 billion, with roughly 103 million non-emergent medical trips each year, according to researchers.

    Medicaid enrollees already have a high no-show rate, and that could get worse if the CMS finalizes the rule, according to Dr. Theresa Rohr-Kirchgraber, a practicing pediatrician in Indianapolis and associate professor of clinical internal medicine and pediatrics at Indiana University.

    Many Medicaid enrollees lack access to vehicles due to their low incomes. There are also few public transportation options in Indiana, especially in rural areas, Rohr-Kirchgraber said.

    "Our feet are really held to the fire that we have high productivity in terms of the number of patients we have to see," she said. "We're the ones that are making the money for our institutions, and we can't we can't afford to keep our doors open if we can't get our patients in."

    Currently, states have to obtain a waiver from the CMS if they don't offer non-emergent transportation services. The Trump administration first floated the idea of changing that policy earlier this year in its 2019 budget proposals.

    Non-emergent transport to medical appointments has been a mandatory Medicaid benefit since the program's inception in 1965. 

    Iowa and Indiana are the only states with a waiver to opt out of providing transportation. Kentucky and Massachusetts have both asked the CMS for similar permission.

    It's unclear whether patients' health declines if Medicaid doesn't pay for rides to medical care. A February 2016 report from the Lewin Group said the impact of the transportation benefit waiver in Indiana has been minimal. Most beneficiaries could find other forms of transportation not paid for by Medicaid. Of the 286 beneficiaries interviewed, 11% cited lack of transportation as their reason for missing appointments. A report from Iowa had similar findings.

    But the Medical Transportation Access Coalition, a group made up of advocates, transportation providers and managed-care plans, noted that these waivers largely targeted adults who became eligible under Medicaid expansion and had not previously relied on the non-emergency transportation benefit.

    The group insists that making it easier for states to opt out of offering these services will harm access to care.

    Medicaid enrollees regularly use the benefit to get to dialysis, substance abuse treatments and chronic care visits for diabetes. A survey of Medicaid enrollees last summer by the coalition revealed that low-income patients found it critical to their day-to-day lives. 

    "Over half the trips taken today are for life-sustaining treatments," said Tricia Beckmann Faegre, an adviser to the coalition. "Some said that they would die or probably die if they didn't have transportation." Medicaid saved more than $40 million in hospitalization and other medical costs for patients receiving rides to dialysis and wound care treatments, according to a report by the coalition.

    It's unclear if the CMS has the authority to make this change to transportation benefits, according to Eliot Fishman, who oversaw 1115 waivers under the Obama administration and is now senior director of health policy at Families USA.

    "Making NEMT optional hasn't been tested in court," Fishman said. "If the administration goes in that direction, I expect there will be a legal challenge."

    The CMS does not comment on pending rulemakings, according to a spokesman.


  • 8 Nov 2018 7:56 AM | AIMHI Admin (Administrator)

    Longview News-Journal Source Article | Comments courtesy of Matt Zavadsky

    Hats off to our Texas neighbors!

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

    Longview starts pilot program to reduce EMS trips for high-volume patients

    By Jimmy Daniell Isaac

    Nov 7, 2018

    Emergency and mental health authorities are building toward a multiagency pilot program aimed at high-volume patients of local ambulance services.

    The program currently is unstaffed, but Community HealthCore is seeking grant funding with help from Longview health systems and the fire department’s Emergency Medical Services Division to pay for what is described as a proactive approach to patient care.

    The approach involves using in-home assessments to identify the needs of patients with the highest number of ambulance trips to local emergency rooms and other health centers — some who average more than 20 ambulance rides a month.

    “We had quite a few of those that use our ambulances quite often,” Longview EMS Section Chief Amy Dodgen said during a meeting Tuesday of the city’s EMS Advisory Board.

    The program targets people who call for emergency services with issues that can be served by a number of other agencies besides an ER visit, she said.

    EMS personnel will continue responding to 911 calls and transporting patients who need emergency room services, she said, but the goal of the program is to determine if the patient might, instead, need social, mental health or other services for issues not physical in nature. Those issues could be anxiety over where their next meal might come from or how they’ll pay a utility bill, which is why several social service agencies are involved in the program, Dodgen said.

    “We really want to solve their problems (and) what they’re needing, not just be a Band-Aid,” she said. “We have awesome people and awesome services in Longview. We’ve just got to connect people to them, and some people need assistance with that.”

    The EMS Advisory Board is made up of local hospital officials, health agents and first responders who advise the Longview City Council on matters dealing with EMS responsibilities such as financial and manpower investment priorities.

    Advocates hope to hear by the end of the year whether the Fort Worth-based Episcopal Health Foundation awards a grant to the local program — currently called the Gregg County Wellness Collaborative.

    Dodgen, a city staff liaison to the board, told members that a 270-page report of patients who used Longview ambulance services at least five times a month last year included one patient who took about 120 ambulance rides in one year.

    “That same patient is at 72 (trips) this year for 2018,” she said. “These patients, they’re the driving force behind the community health care medicine program that we’re wanting to start.”

    Community health care medicine programs have been tried in other cities and can be tailored to fit the Longview area’s specific needs, Dodgen said. It’s a partnership involving local hospitals and EMS agencies.

    “For Longview, the concept would be to take these high utilizers and go into their home with their permission and meet with them and see what we can do to mitigate their issues,” she said.

    A pilot program has been initiated with about five of the top ambulance users in Longview, including the highest user, who once averaged between 20 and 30 ambulance calls a month but has since reduced to about 10 times a month, Dodgen said, adding, “Although there were patient contacts with her, we didn’t transport her to the hospital as many times.”

    Advocates hope the program develops into a way to help patients who need assistance but do not need an emergency room visit.

    “Currently, EMS does not get paid if we don’t transport,” Dodgen said.


  • 8 Nov 2018 7:54 AM | AIMHI Admin (Administrator)
    HealthAffairs Source Article | Comments courtesy of Matt Zavadsky

    This is a nice summary of the possible healthcare implications post-election…

    What the 2018 Midterm Elections Means for Health Care

    Billy Wynne

    NOVEMBER 7, 2018

    Whatever you want to call the 2018 midterm elections – blue wave, rainbow wave, or purple puddle – one thing is clear: Democrats will control the House.

    That fundamental shift in the balance of power in Washington will have substantial implications for health care policymaking over the next two years. Based on a variety of signals they have been sending heading into Tuesday, we can make some safe assumptions about where congressional Democrats will focus in the 116th Congress. As importantly, there were a slew of health care-related decisions made at the state level, perhaps most notably four referenda on Medicaid expansion.

    In this post, I’ll take a look at which health care issues will come to the fore of the Federal agenda due to the outcome Tuesday, as well as state expansion decisions. And it should of course be noted that, in addition to positive changes Democrats are likely to pursue over the next two years, House control will allow them to block legislation they oppose, notably further GOP efforts to repeal the Affordable Care Act (ACA).

    Drug Pricing

    Democrats have long signaled they consider pharmaceutical pricing to be one of their highest priorities, even after then-candidate Trump adopted the issue as part of his campaign platform and maintained his focus there through his tenure as President.

    While aiming to use the issue to drive a wedge between President Trump and congressional Republicans, who have historically opposed government action to set or influence prices, Democrats will also strive to distinguish themselves by going further on issues like direct government negotiation of Medicare Part D drug reimbursement.

    Relevant House committee chairs, perhaps especially likely Oversight and Investigations chair Elijah Cummings (D-MD), will also take a more aggressive tack in investigating manufacturers and other sector stakeholders for pricing increases and other practices. Democratic leaders believe it will be easier to achieve consensus on this issue than on more contentious issues like single payer (more detail below) among their diverse caucus, which will include dozens more members from “purple” districts as well as members on the left flank of the party  

    Preexisting Condition Protections

    If you live in a contested state or district, you have probably seen political ads relating to protecting patients with preexisting conditions. As long as a Republican-supported lawsuit seeking to repeal the ACA continues, Democrats believe they can leverage this issue to demonstrate the importance of the ACA and their broader health care platform.

    A three-legged stool serves under current law to protect patients with chronic conditions: (1) the ban on preexisting condition exclusions; (2) guaranteed issue; and (3) community rating. Democrats will likely seek to bolster these protections with measures to shore up the ACA exchange markets. In the same vein, they will likely strive to rescind Trump Administration proposals to expand association-based and short-term health plans, which put patients with higher medical costs at risk by disaggregating the market.  

    Opioids

    Congressional Democrats believe that there were some stones left unturned in this year’s opioid-related legislation, especially regarding funding for many of the programs it authorized. This is a priority for likely Ways & Means Committee Chair Richie Neal (D-MA) and could potentially be a source of bipartisan compromise.

    Medicare for All

    While this issue could become a bugaboo for old guard party leaders, the Democratic base will likely escalate its calls for action on Medicare for All now that the party has taken the House. Because the details of what various camps intend by this term are still vague (some believe it is tantamount to single payer, others view it as a gap-fill for existing uninsured, etc.), we will likely see a variety of competing proposals arise in the coming two years. Expect less bona fide committee action and more of a public debate aired via the presidential primary season that will kick off about, oh, right now.

    Surprise Bills

    The drug industry is not the only health care sector that can expect heightened scrutiny of their pricing practices now that Democrats control the people’s chamber. Most notably, the phenomenon of surprise bills (unexpected charges often stemming from a hospital visit) has risen as a salient issue for the public and thus a political winner for the party. Republicans have shown interest in this issue as well, so it could be another source of bipartisanship next year.

    Regulatory Oversight

    Democrats believe they are scoring well with the public, and certainly their base, every time they take on President Trump. The wide range of aggressive regulation (and deregulation) the Administration has pursued will be thoroughly investigated and challenged by Democratic committee leaders, especially administration efforts to dismantle the ACA and to test the legal bounds of the hospital site neutrality policy enacted in the Bipartisan Budget Act (BBA) of 2015.

    Extenders

    While it instituted permanent policies for Medicare physician payments and some other oft-renewed ‘extenders’, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 left a variety of policies in the perennial legislative limbo of needing to be repeatedly extended. While the policies in the Medicare space have dwindled to subterranean, though not necessarily cheap, affairs like the floor on geographic adjustments to physician payments, a slew of Medicaid-related and other policies are up for renewal in 2019.

    For example, Medicaid Disproportionate Share Hospital (DSH) payments face a (previously delayed) cliff next year. That and the most expensive extender, ACA-initiated funding for community health centers, alone spring the cost of this package into the high single digit billions at least, driving a need for offsetting payment cuts and creating a vehicle for additional policy priorities.

    A likely addition to this discussion will be the fact that Medicare physician payments, per MACRA, are scheduled to flatline for 2020-2025 before beginning to increase again, albeit in divergent ways for doctors participating in the Merit-Based Incentive Payment Program (MIPs – 0.25 percent/year) and Advanced Alternative Payment Models (APMs – 0.75 percent/year). The AMA assuredly noticed this little wrinkle in the celebrated legislation but hundreds of thousands of doctors probably did not.

    Medicaid Expansion

    Of the variety of state-level health policy decisions voters made on Tuesday, perhaps the most significant related to Medicaid expansion. In there states where Republican leaders have blocked expansion under the ACA – Nebraska, Idaho, and Utah – voters endorsed it via public referenda. Increasing the Medicaid eligibility level in those three states to the ACA standard will bring coverage to approximately 300,000 people.

    Notably, voters in Montana rejected a proposal to continue funding the Medicaid expansion the state enacted temporarily in 2015 by an increase to the state’s tobacco tax. Their expansion is now scheduled to lapse in July 2019 if the legislature doesn’t act to maintain it. If they do not act, about 129,000 Montanans will lose Medicaid coverage.

    Finally, Democratic gubernatorial wins in Maine, Kansas, and Wisconsin will make Medicaid expansion more likely in those states.

    As they say, elections have consequences. While the Republican-controlled Senate and White House can block any Democratic priorities they oppose, the 2018 midterm elections assure a busy two years for health care stakeholders.


  • 1 Nov 2018 9:22 AM | AIMHI Admin (Administrator)

    Meet Matt Zavadsky, Chair of the AIMHI Education Committee.

  • 29 Oct 2018 9:09 AM | AIMHI Admin (Administrator)

    Congratulations to Sherry Willingham of Medstar Mobile Healthcare! Sherry was unanimously elected Chair of the AIMHI Reimbursement Committee on Friday. We thank her for her service!


  • 26 Oct 2018 9:31 AM | AIMHI Admin (Administrator)

    Source Article | Comments courtesy of Matt Zavadsky

    A very logical step being taken by the Pennsylvania legislature! 

    And, one that is currently in place for payers such as Anthem and the Medicaid programs in Arizona and Georgia.  Additional payers are looking to implement similar programs.

    Decoupling payment from transport helps enhance patient outcomes, improve the patient’s experience of care, and significantly reduce the down-stream cost of care. 

    The misalignment of incentives of only reimbursing ambulance TRANSPORT to an ED is a significant cost driver.  In 2013, Health Affairs published a RAND study that determined that 12.9 – 16.2% of Medicare ambulance trips to the ED could have safely and effectively been managed in an alternate setting, and giving EMS flexibility to navigate patients could save the Medicare program up to $560 million annually.

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

    Barrar's bill to reimburse ambulance companies heads to governor

    Digital First Media Oct 23, 2018

    WEST CHESTER—Legislation drafted by state Rep. Steve Barrar, R-160, that would require ambulance companies to be reimbursed for providing medical treatment, even if the patient is not transported to a hospital, was successfully voted on concurrence by the House.

    “The critical services provided by ambulance companies to Commonwealth citizens in their time of need will remain endangered, potentially to the point of extinction, if they aren’t reimbursed for their costs to render emergency care. My bill would entitle ambulance companies to payment when emergency medical responders treat and stabilize patients without a trip to the hospital,” Barrar said.

    Under current practice, EMS agencies can only be reimbursed by insurance companies if they transport the patient, even though time is spent, supplies are used and services are provided regardless of whether a transport takes place. This is a significant contributor to the financial challenges facing ambulance companies, especially when many are facing the grim reality of pending closures.

    House Bill 1013 would require reimbursement when transport to a facility does not take place as long as the following conditions are met: The Basic Life Support (BLS) or Advanced Life Support (ALS) unit must be dispatched by a county 911 center, and the EMS provider must have rendered emergency services even though the transport was declined.

    Also, the House approved legislation to close a loophole that PennDOT has been using to deny free emergency vehicle license plates to volunteer fire companies that also have paid employees.

    “Volunteer ambulance services all across the Commonwealth have been forced to pay for a plate that should have been given to them at no cost. It’s disappointing that PennDOT would take advantage of volunteer companies that save Pennsylvania so much money, but I’m pleased that I was able to influence the addition of an amendment on the bill to address this issue,” Barrar added.

    Both bills now advance to Gov. Tom Wolf for consideration.


  • 22 Oct 2018 8:03 AM | AIMHI Admin (Administrator)
    Health Affairs Source Article | Comments Courtesy of Matt Zavadsky

    Interesting analysis of the various initiatives to address out of network medical billing. 

    Recall that Health Affairs provided another analysis of legislative initiatives published by in September 2018.  Clearly this issue has the attention of federal and state lawmakers. 

    Of note to our EMS family is that once again, Health Affairs calls on the various legislative efforts to include ambulance services in the legislative language.

    Analyzing Senator Hassan’s Binding Arbitration Approach To Preventing Surprise Medical Bills

    OCTOBER 18, 2018

    Loren AdlerPaul B. GinsburgMark HallErin TrishBenjamin Chartock

    Another Senate bill to address the scourge of surprise out-of-network medical bills was newly released on October 12, the No More Surprise Medical Bills Act of 2018, this time introduced by Senator Maggie Hassan (D-NH) and cosponsored by Senator Jeanne Shaheen (D-NH). As we explained recently, surprise out-of-network medical bills can occur when a patient is unexpectedly seen by a physician who does not participate in their insurer’s provider network either in the course of emergency care or elective nonemergency care at an in-network facility, or when transported in an out-of-network ambulance.

    For enrollees in employer-sponsored health plans, the bill takes a largely similar approach to the recent bipartisan Senate bill, taking the patient out of the middle of the dispute and protecting patients in both emergency and nonemergency situations. The big difference is that, instead of prescribing a minimum payment rate from insurer to provider, Senator Hassan’s bill sets up a “binding arbitration” process to determine the appropriate provider payment rate in surprise out-of-network scenarios. And importantly, the arbiter would be instructed to consider Medicare and negotiated network rates, rather than artificially high provider charges, in making their rate determination.

    A companion bill introduced by Senator Shaheen would affect the individual market more broadly, capping the amount that out-of-network providers can charge in any situation (not just in situations we would define as a “surprise”) to enrollees in individual market plans (and also to uninsured patients). The bill allows states to choose among three options to set this out-of-network charge limit: 125 percent of Medicare fee-for-service (FFS) rates (with an allowance in rural areas to set payments up to 200 percent of Medicare rates), 80 percent of the “usual and customary rate” (UCR) based on provider’s billed charges, or the insurer’s in-network contracted rate for the service in question.

    While these provisions would not directly prohibit surprise bills in the individual market, they could considerably reduce the liability that patients potentially face in such situations by capping the amount that the out-of-network provider could charge. Moreover, by reducing the potential financial benefit to providers of remaining out-of-network, these provisions would likely also reduce the frequency of surprise bills by encouraging more providers to join insurers’ networks.

    The rest of this post focuses on the No More Surprise Medical Bills Act of 2018.

    No More Surprise Medical Bills Act Of 2018

    Senator Hassan’s legislation would protect group health plan enrollees from surprise out-of-network bills through the combination of:

    • Restricting the provider from charging the patient any more than what they would owe an in-network provider;
    • Requiring the insurer to count cost-sharing amounts for surprise out-of-network bills (which as just mentioned could not exceed in-network amounts) toward in-network deductibles and limits on out-of-pocket costs; and
    • Setting up a binding arbitration process to determine payment from insurer to provider in cases where they are unable to reach a resolution on their own.

    Provider Bills To Patients

    Hassan’s proposal would protect patients from surprise bills in both emergency situations and nonemergency situations at in-network facilities, when they are seen unexpectedly by an out-of-network clinician. An exception is allowed if the out-of-network provider provides an estimate of costs and obtains both written and verbal consent from the patient more than 24 hours in advance. If timely patient consent was not obtained, then the legislation’s surprise out-of-network billing protection automatically kicks in and the patient can be charged no more than what they would have paid if the service were performed by an in-network provider.

    Insurer Payment Of Providers

    Rather than prescribing the payment rate from insurer to provider for surprise out-of-network services, Hassan’s bill sets up a binding, “baseball-style” arbitration process to resolve payment disputes if the two parties are unable to agree on a payment amount. In this process, the insurer and provider each make a final offer and an independent arbiter contracted by government then chooses which of the two options it considers more reasonable. The theory behind this approach is that it incentivizes each side to make a reasonable offer or settle beforehand, because the arbiter is unlikely to choose an unrealistic offer. Making the results of these arbitration decisions public, as this bill would do (and as New Jersey’s new law does), further facilitates settlement before going to arbitration as both parties learn to anticipate what rate the arbiter would choose.

    The legislation provides guidance to the independent arbiter to consider the relevant Medicare payment rate and the local average in-network rate, in addition to the level of training of the physician and complexity of the service, when determining which offer to select. The bill makes no reference to provider billed charges, which tend to be extremely high and are largely untethered from market forces.

    Alternatively, Hassan’s legislation allows states to establish their own arbitration process, as New York, New Jersey, Illinois, and New Hampshire have done, as long as the state process is equally protective and the arbitration results are made public. Or states can elect a defined payment standard in place of the binding arbitration process, as long as it is no higher than 125 percent of the relevant Medicare rate or a comparable standard at the Secretary of Health and Human Services’ discretion.

    Senator Hassan’s bill improves options for states because currently they are unable to protect patients enrolled in self-insured employer health plans due to pre-emption by the Employee Retirement Income Security Act (ERISA).

    Representative Michelle Lujan Grisham’s Fair Billing Act of 2017 also proposes a similar arbitration approach, as did our 2016 white paper, which dives into significantly more detail.

    It is necessary to determine a limit on payments to out-of-network providers to provide comprehensive protections against surprise billing to patients without giving providers the unfettered ability to charge whatever they want. The advantage of the binding arbitration approach is that it encourages each side to submit reasonable offers, allows for some flexibility in the rate chosen for differing circumstances, and gives the involved parties more input into what that rate should be than a rate chosen by policymakers or regulators. On the other hand, the binding arbitration approach adds administrative burden to the process, although this could be mitigated over time as the arbitration decisions are made public, which provides more guidance for settlement. Nonetheless, it’s not necessarily clear that the arbiter will always choose the “right” rate or be any better at selecting an appropriate rate than lawmakers.

    Yale Professors Zack Cooper and Fiona Scott Morton have recommended an alternative approach. They suggest requiring hospitals to pay emergency and ancillary physicians directly, and to build those costs into their facility rate negotiated with health plans. This approach would more explicitly use the market to determine fair payment rates.                  

    Areas For Further Consideration

    The No More Surprise Medical Bills Act should be applauded for tackling an important problem in a thoughtful manner. As written, Hassan’s bill would nearly eliminate surprise out-of-network bills for enrollees in employer-provided health plans.

    As lawmakers work to refine this legislation, they should consider expanding protections to enrollees in individual market plans and for out-of-network ambulance services. One study found that roughly half of all ambulance rides were billed out-of-network.

    Additionally, the notice and consent exceptions in the bill are arguably both too broad and too narrow in parts. It is unclear that out-of-network physicians at nonparticipating hospitals should have to obtain patient notice and consent for nonemergency care before billing out-of-network. And on the flip side, for patients at in-network facilities, it may be inappropriate to ever permit out-of-network billing for ancillary services (e.g., anesthesia, radiology, pathology) because there is too great a risk that patients will sign any such consent forms without true understanding or consideration of reasonable alternatives.

    Author’s Acknowledgement:

    This analysis is part of the USC-Brookings Schaeffer Initiative for Health Policy, which is a partnership between the Center for Health Policy at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings. Through a grant from the Laura and John Arnold Foundation, Brookings is working to critically evaluate the prevalence, drivers, and policy implications of surprise medical billing, as well as develop potential nonpartisan policy solutions.


  • 3 Oct 2018 8:54 AM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    Interesting continued coverage of activities related to balanced billing for air ambulance, including the perspective of the anonymous consultant regarding the payment amount vs. costs

    Congress angles for air ambulance cost transparency

    BY SUSANNAH LUTHI 

    OCTOBER 2, 2018

    Last November, a fully insured North Dakotan was dispatched on an 84-mile medical air transport from Langdon, N.D., to Grand Forks. When the charges came in at more than $66,000, out-of-network insurance covered just $16,000.

    The patient was left with a $50,000 bill balance from Valley Med Flight. The tab far exceeded the $29,000 to $30,000 average price for a cross-country charter flight on a private midsize jet from Virginia to Oregon—according to an informal estimate by the charter company EvoJets.

    According to tallied complaints lodged with the state's insurance department and provided by Blue Cross and Blue Shield of North Dakota, surprise charges for various medical flights from the past four years ranged from $26,000 to nearly $534,000—although the latter number is a major outlier. Most charges fell between $30,000 and $88,000, with the average hovering around $60,000.

    One North Dakotan had a lien placed on their home. Another had wages garnished. Families have gone into bankruptcy.

    "They have health insurance, but no control over who picks them up," said Jeff Ubben, the state's deputy insurance commissioner.

    Like other states, North Dakota has tried to curb the unexpected bills. In 2015 the Legislature passed a law to split the medical air transport companies into two call lists. To make it on the primary call list, the company would have to be in-network with at least 75% of the state's health insurance contracts. All others would have dropped to a secondary call list and would only have been able to respond if none of the companies from the primary list picked up.

    In 2016, a federal judge struck down the law after Valley Med Flight sued, just as federal judges around the country have struck down similar state measures for violating the Airline Deregulation Act of 1978. This federal law bans states from regulating rates, routes or services of commercial airlines and continues to overrule state efforts to rein in air ambulance charges.

    Valley Med Flight is one of North Dakota's largest medical transportation companies, re-branded this year as Guardian Flight. As a subsidiary of Air Medical Group Holdings, which is owned by the global investment firm KKR, it is one of several sister air ambulance companies operating in the U.S.

    Air Medical Group Holdings did not respond to requests for comment.

    In 2017, North Dakota tried to tackle air ambulance billing again from a different angle, this time limiting out-of-network insurance reimbursements for these claims. If a person is transported by an out-of-network air ambulance, the transport company must accept the rate of an in-network carrier.

    Guardian Flight sued, but the case is still pending in federal court in Bismarck. Ubben told Modern Healthcare his office hasn't received consumer complaints since it went into effect in January of this year.

    But Congress would need to change the law to allow states to regulate the charges. Sen. Claire McCaskill (D-Mo.) pushed a bill this year to clarify that the 1978 statute could not prevent states from regulating the medical costs from air ambulances.

    Provisions from her proposal made it into the latest Federal Aviation Administration reauthorization bill expected to clear Congress this week, but ultimately lawmakers dropped the crucial measure that would allow states to address the consumer cost question.

    The final compromise provision requires the U.S. Transportation Department and HHS to convene an advisory committee of stakeholders to examine transparency measures, consumer education about insurance options for air transport and protections from excessive charges.

    Air ambulance companies would also need to list the Transportation Department's complaint hotline and website address on all bills. The Transportation secretary would have to set an industry oversight plan and write guidance for states on how to refer billing complaints.

    The provisions concur with some 2017 recommendations from the U.S. Government Accountability Office, which called for greater price transparency and better handling of consumer complaints.

    Insurers, insurance commissioners, patient advocates and the medical air transport industry herald the measure as "a step in the right direction," but it's unclear just how significant that step will be.

    The Transportation Department already oversees and handles consumer complaints on air transport, but close observers of the balance billing issue say the current process doesn't support patients stuck with tens of thousands of dollars of debt.

    "The Department of Transportation has regulatory authority and can determine whether the practices of any airline are fair or unfair, but they don't have expertise on medical billing practices," said Julie Mix McPeak, president of the National Association of Insurance Commissioners and Tennessee insurance commissioner. The association has been working on the issue for the past three years. "However, the department has yet to take action, and states are barred legally from doing so."

    The Association of Air Medical Services, or AAMS, the lobbying group for air ambulance companies, supports the final provision as a balanced approach.

    "We believe the formation of the advisory committee of stakeholders tasked with solving the complex issue of balance billing is a definite step in the right direction," the group said in a statement. "AAMS advocates for any effort to increase transparency to ensure our patients are not burdened by a bill that they did not expect and cannot afford."

    But ultimately the trade group blames the high balance bills on what they deem as inadequate Medicare reimbursements. The AAMS compares the air transport companies' net financial position with that of rural hospitals serving mostly government-insured or uninsured patients.

    The AAMS wants Congress to look at recalculating the air ambulance Medicare reimbursements, claiming it's "the only lasting solution" to protect air medical services, especially in rural areas.

    Both the House and Senate have introduced bills that would launch this effort, which are supported by the AAMS.

    Medicare's base pay for a single helicopter transport is $4,624, then an additional $31.67 per mile. According to data from the CMS, Medicare reimbursement for a typical 61-mile trip is about $6,556.

    The AAMS says that based on an independent study by the consulting firm Xcenda, Medicare covered 59% of actual costs in 2015.

    But one consultant, who spoke on condition of anonymity, pushed back on companies' claims that their charges correlate to their Medicare reimbursements. He said that the Medicare fee schedule, which moved reimbursements for air ambulances from Medicare Part A to Part B, favored the air ambulance industry when they were set in the early 2000s.

    He argued that the industry's claims about compensating for Medicare rates through high commercial and balance bill charges "are more related to underutilization and overcapacity."

    "In 1997 there were about 350 helicopters doing this," he said. "Today there are over 1,100."

    He estimated that Medicare pays for about one-third of these flights, commercial plans pay another one-third and Medicaid covers roughly 20% of the rest.


    "When two-thirds of customers paid at a rate that's favorable, the companies tripled the number of helicopters," he said, adding that the industry's ability to spread its fixed costs over a large number of transports is reduced because there are too many transports.

    "The problem is not that operating costs have dramatically increased; rather, companies cannot spread those costs over a reasonable number of flights," he said. "The industry then attempts to use this self-inflicted situation as justification for their extravagant billed charges."

    Aaron Todd, CEO of the operator Air Methods Corp., acknowledged in a 2015 investor earnings call that the number of transports may exceed market need.

    "And if you ask me personally, do we need 900 air medical helicopters to serve this country, I'd say probably not, maybe 500, 600 could do well, but it's an open market, these are—we don't have certificate-of-need restrictions," Todd said, according to the call transcript.


    One insurance lobbyist, who characterized the air ambulance market as "the wild West," complained of the sometimes aggressive ways companies find patients in the limited pool.

    "I've seen air ambulances following the police radio and showing up at the scene of an accident," the lobbyist said. "They have all sorts of tactics to get called."

    Analysis of one company's data shows the number of medical air transports per base has declined as those bases have proliferated. 

    According to numbers gleaned from past annual reports by Air Methods Corp.—one of the largest providers and publicly traded until a private equity firm bought the company last year—69 bases sent out about 39 transports each per month in 2005. In 2013, 179 bases each sent out about 25 transports per month. The company's annual number of total transports during that period increased from nearly 32,000 to just over 53,000.

    Rising operational costs for the air transport companies were the result of business decisions, the consultant said. "No one forced it; they just did it by themselves."

    He also said transport services develop relationships with the providers who dispatch patients from one facility to another for care. About 80% of transports send a patient from one facility to another, rather than airlifting a person from the scene of an accident.

    Even if they don't have a referral relationship with the air transport company, the consultant added, hospitals don't necessarily watch out for the patients' wallets since it isn't their money.

    "Again, you don't have a market where buyers or sellers are agreeing to buy some quality or quantity," he said. "None of this is a market situation."

  • 2 Oct 2018 9:26 AM | AIMHI Admin (Administrator)

    NYT Source Article | Comments Courtesy of Matt Zavadsky

    Another example of the ‘value’ challenge of traditional “EMS”. 

    Recall that Dr. Elisabeth Rosenthal (now the Editor in Chief of Kaiser Health News) also did an article in the NYT about the value of EMS, and she also did a video interview on the same topic…

    Contrast the message in recent media reports in publications, such as the NYT and Washington Post, extolling the value of “EMS 3.0” MIH services such as community paramedicine, alternate destinations and 9-1-1 nurse triage. 

    These vastly different perceptions of ‘value’ are likely why many EMS agencies are implementing MIH services, and many payers are moving quickly to pay for EMS patient navigation as opposed to being paid simply as a conveyance mechanism!

    Tip of the hat to Jonathan Washko from Northwell Health for sending along yesterday’s NYT article!

    Uber, Lyft and the Urgency of Saving Money on Ambulances

    ‘Don’t reflexively call an ambulance,’ a Harvard researcher says. In many cases, a cheaper way makes sense.

    THE NEW HEALTH CARE

    By Austin Frakt

    Oct. 1, 2018

    An ambulance ride of just a few miles can cost thousands of dollars, and a lot of it may not be covered by insurance. With ride-hailing services like Uber or Lyft far cheaper and now available within minutes in many areas, would using one instead be a good idea?

    Perhaps surprisingly, the answer in many cases is yes.

    The high cost of an ambulance isn’t really for the ride. It comes with emergency medical staff and equipment, and those can be very important, of course, even lifesaving.  But they are not things you always need, although you (and your insurer) pay for them with every trip.

    “Don’t reflexively call an ambulance,” said Anupam Jena, a physician and researcher with the Harvard Medical School. “Ambulances are for emergencies. If you’re not having one, it’s reasonable to consider another form of transportation.”

    The cost of ambulance rides adds up. In 2011, the United States spent about $14 billion on ambulance services, $5.3 billion of which Medicare paid for. Many of those trips might not have required an ambulance. Estimates of inappropriate use vary, but most are around 30 percent.

    Although it’s not always clear when an ambulance is warranted, there is evidence of waste and fraud in the industry.

    Last year, ambulance companies collectively billed Medicare improperly for at least $700 million.

    In 2014, employees of a Philadelphia-area ambulance company received prison sentences for fraudulent bills. That same year, the owners of a Tennessee company were convicted of fraudulent ambulance billing. A 2015 O.I.G. report found that half of questionable billing of Medicare by ambulance companies is from four metropolitan areas: Philadelphia, Los Angeles, Houston and New York.

    Other recent evidence from New York suggests a substantial number of ambulance rides are taken for non-emergencies. Scholars from Georgia State University and the University of Colorado Denver studied ambulance rides in New York before and after the Affordable Care Act’s coverage expansion. After the expansion, dispatches for minor injuries rose considerably while those for more severe ones did not.

    By 18 months after the expansion, ambulance dispatches for minor injuries were up 150 percent.  An explanation for the results is that a person’s insurance coverage tends not to affect a decision about calling an ambulance in a real emergency. But for minor injuries, people are more likely to call an ambulance if they have coverage than if they do not, even if they don’t really require that level of care.

    Using an ambulance also diverts attention and resources from true emergencies. Response times are longer than they could otherwise be if ambulances were used only when needed. One study found that the Affordable Care Act, by expanding coverage and financial access to ambulance rides, slowed ambulance response times by 19 percent.

    Uber and Lyft can’t disobey traffic laws the way ambulances can to speed people to a hospital in urgent situations. But they can broaden transportation options for patients and could disrupt the ambulance market. Both have announced new services to provide rides to medical appointments. This kind of non-emergency medical transportation is something many health plans already provide, but Uber and Lyft may be able to do it more cheaply, with better customer service and less waste.

    Uber Health would allow health care providers to order rides for their patients. As of March, over 100 health care organizations were using the service. Lyft Concierge is similar and already being used by a number of organizations that arrange rides for people in need of care.

    Of course, patients can request Uber or Lyft rides on their own, instead of an ambulance. And these services could help patients avoid missing appointments because of lack of affordable transportation. They may also help patients receive care in more appropriate and lower-cost settings, like a doctor’s office instead of an emergency department. One study found that Uber’s entry into a city reduced ambulance use by 7 percent.

    An advantage of arranging your own ride is that you can direct it to a hospital or doctor’s office of your choosing. In contrast, ambulances take patients only to hospitals — and typically to the nearest one, whether the patient would prefer that or not.

    This can actually degrade care. Evidence suggests that patients who return to the hospital where they received major surgery have a lower risk of mortality than if they go to another hospital. With an ambulance, there is no guarantee you’ll return to the same hospital.

    Although lack of affordable transportation is one barrier to care, it isn’t the only one. A randomized study of Medicaid patients at two Philadelphia-area clinics found that offering Lyft rides did not change missed appointment rates. Patients may miss appointments for other reasons, such as being unable to get off work or to obtain child care.

    “We often use higher-intensity care more than necessary throughout our health system,” Dr. Jena said. “Ambulance rides in non-emergencies is just one example.”

    For some, the financial setback of an ambulance trip can be immense. An alternative choice for non-emergencies could save a person thousands of dollars and help reduce waste in a system rife with it.

    Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health.


  • 2 Oct 2018 9:14 AM | AIMHI Admin (Administrator)

    Health Affairs Source Article | Comments Courtesy of Matt Zavadsky

    Interesting counsel from the authors, and, interesting reference to the transport policies in Philly…

    When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply?

    Sara F. Jacoby  Elinore J. Kaufman  Therese S. Richmond  Daniel N. Holena

    OCTOBER 1, 2018

    https://www.healthaffairs.org/do/10.1377/hblog20180926.69826/full/

    At the University of Utah Hospital last October, a nurse was arrested when she refused to draw blood from an unconscious patient for a police officer who was lacking a legal warrant. Surveillance footage of her arrest and rough treatment drew national media attention. As a consequence, the police officer involved was fired from his job, and the hospital issued a policy that now bans law enforcement activities in patient care areas of its medical center. The Utah Legislature responded as well by passing a bill to outline conditions under which police can obtain blood samples from patients for investigative purposes. 

    This case may have been extreme, but conflicts between clinicians and police are not uncommon. Emergency departments are arguably an epicenter of opportunity for this kind of conflict. It is in these clinical settings that intersections between health care and law enforcement activities are most frequent, for example, when police respond to medical emergencies or seek information to inform emerging criminal investigations. The challenge of these interactions is that clinicians and police have distinct professional priorities, and there is notable ambiguity in how best to interpret guiding policy and ethics. 

    Clinicians And Police Have Intersecting But Potentially Conflicting Responsibilities 

    Traumatic injuries, such as gunshot wounds or motor vehicle crash injuries, are conditions that attract both health care and law enforcement responses. In these circumstances, clinicians and police share a mandate to protect injured people and public safety. However, the police mission to initiate an investigation and solve crimes may compete with the urgency of emergency health care, which is built on protocol-driven systems for rapid diagnosis, medical stabilization, and triage. 

    Injured people, themselves, are rarely in a position to advocate for their own medical and legal needs during emergency care. Traumatic injuries can cause physiologic and psychological alterations that limit the ability to fully consent to medical procedures and legal interrogation. Once a person is transported from the scene of an injury and into a health system, health care ethics and laws obligate clinicians to offer help and guardianship. This includes protection of privacy over health information and patients’ autonomy in decisions that affect health and well-being. 

    A Complex Policy Landscape With No Clear Oversight 

    To date, there are no universal cross-disciplinary policies from which to outline clear expectations for interactions among trauma patients, clinicians, and police in health care institutions. The American College of Emergency Physicians published a statement in 2010 that reinforces the primacy of patients’ rights, dignity, and interests when law enforcement activities take place in health care institutions. Members of the emergency medical community have subsequently advocated for the creation of explicit policy guidance for these activities and offer a sample policy for implementation. Enacting, operationalizing, and auditing compliance to these policies is/would become the responsibility of individual health care systems. This is not necessarily a simple pursuit. In doing so, health systems will need to consider and integrate their own institutional policies and practice norms with relevant but potentially inconsistent federal, state, and local policies. 

    The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 prohibits clinicians from releasing information about patients to police without consent or a court-ordered warrant. Exceptions are made when: required by law (that is, state-mandated reporting), where criminal conduct is suspected (as a cause of a patient’s death or during medical care), or to avert a serious threat to public health or safety.

    In addition, a 2003 US Supreme Court ruling affirmed the constitutionality of police seeking testimony for a criminal investigation during emergency medical care when an injured non-Mirandized patient was suspected of a crime. 

    State laws may actually necessitate interactions between clinicians and police after a traumatic injury, but the conditions for mandated interactions can vary from state to state. In most states, clinicians are required to report evidence of child and elder abuse. In several but not all states, clinicians are also required to report any suspicion of assault, domestic violence, or drunk driving associated with an injury. 

    At a local level, municipal policies can influence the ways that clinicians and police interact in response to injuries. In Philadelphia, Pennsylvania, for example, where the rate of violent injuries outpaces the resources available for emergency medical systems, the city permits police to provide direct transport to the nearest accredited trauma center. As a result, a substantial proportion (more than 50 percent in recent years) of patients with penetrating wounds such as gunshot injuries arrive at Philadelphia trauma centers in police vehicles. Across national trauma systems, police transport has been shown to be as effective as ambulance transport and is believed to be a lifesaving intervention for cities with high rates of injuries and proximity to the resources of trauma centers. At the same time, this practice creates opportunities for police to question patients en route to a hospital and offers a direct pathway for law enforcement activities within trauma center emergency departments. 

    Lack Of Clear Policies Can Put Patients And Clinicians In Vulnerable Positions 

    The danger of the current policy landscape is that any interpretive ambiguities can result in ad hoc negotiations for when, where, and how law enforcement activities take place in health care institutions. This may lead to unintended, informal, and even illegal access to patients and disclosures of their health information to police. It can also promote interprofessional conflict and negative clinical outcomes. If, for example, patients can’t differentiate between questioning in the service of law enforcement and questioning in the service of medical care, they may be reluctant to communicate essential information to their health care team. Our recent research describes how black patients in a Philadelphia trauma center express conflicted interpretations of their interaction with police during emergency injury care. Some perceived police to be acting in their best interest by offering security and expediting transport to the hospital. Others found police questioning as an added stressor and disruption to the medical interventions they felt were essential for their survival. Victims of gun violence in Chicago describe similar impressions of their interactions with police in the aftermath of their injuries. 

    The diversity of federal, state, and local polices make it difficult to imagine a singular rule of conduct for all law enforcement activities in health care settings. Professional trauma surgery and nursing societies, however, have the opportunity to articulate the need for boundaries and necessary considerations when law enforcement activities take place within US trauma centers. One pathway toward leadership in this area would be for entities such as the American College of Surgeons Committee on Trauma, which accredit US trauma systems, to mandate and audit compliance to individual institutional policies. Not only would this present the opportunity to better protect injured patients, clarify professional role expectations, and prevent conflict, it would also better prepare legal counsel and ethical consult teams to support clinicians in cases of difficulty in policy interpretation. 

    Balancing Patients’ Rights And Health With Clinicians’ Rights 

    As institutional policies are developed, the process should ideally integrate multiple stakeholders including community members, police, and a full range of health system actors. There may also be benefit to bringing multiple institutions and sectors together with the leadership of city or state health departments to consider policy interventions that guide intersections between emergency health care and law enforcement that can account for local needs, resources, and environments. Although institutional context may vary, we recommend three core policy goals: 

    1. Policies that guide law enforcement activity in health care institutions should make patient health the first priority. Except in extreme cases of public safety risk (active shooter threats, terrorist events, and so forth), law enforcement officers should not interview patients until they are medically stabilized as determined by treating clinicians. Health care institutions and law enforcement agencies should also work together to clearly define how patients who are under arrest or incarcerated are managed in the emergency department to permit clinicians the opportunity to provide the same standard of medical treatment as would be offered to any patient in their care.
    2. Patients’ rights are the next priority. Therefore, except as above, law enforcement officers should not interview patients until they are mentally ready to understand and participate (stable, not overly sedated or narcotized). Patients should also have access to appropriate legal counsel at all times, even if this delays questioning. Hospitals and local law enforcement and legal communities should set up systems to facilitate representation.  
    3. Although health care personnel are not legal experts, they have a responsibility to protect patients’ health and rights and should be educated about guiding policies and feel empowered to step in as needed. Following the example of University of Utah Hospital, health care institutions need to put into place structures and processes to accomplish these goals. 

    Programmatic crossroads between law enforcement and injury and emergency care will likely continue to increase in response to looming public health threats. The Stop the Bleed campaign to prevent death after trauma and Naloxone distribution to prevent the consequences of opioid overdoses are two prominent examples in which health care and law enforcement providers are interacting to promote public health priorities outside of the hospital. While challenging, developing policy to extend cross-disciplinary collaboration within emergency department settings in a way that protects the rights and well-being of patients, health care providers, and the public is an ethical imperative. 

    Authors’ Note

    All authors are senior fellows of the Leonard Davis Institute (LDI) of Health Economics at the University of Pennsylvania. Support for this work was provided by the LDI Policy Accelerator Program.


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