News & Updates

  • 17 Apr 2019 7:49 AM | AIMHI Admin (Administrator)

    DCEO Healthcare Source Article | Comments Courtesy of Matt Zavadsky



    The Potential Impact of Blue Cross Blue Shield’s Medical Centers

    04/16/2019by Will Maddox 

    Last week, Blue Cross Blue Shield of Texas announced its entry into the provider space with 10 clinics opening near Dallas and Houston next year. The clinics will include primary care, urgent care, lab and diagnostic imaging services, care coordination, and wellness and disease management programs, and were framed as part of the insurer’s desire to advance value-based care in the medical space – but other providers see the clinics as direct competition.

    Value-based care is growing in popularity as the industry transitions away from fee-for service, where providers are paid based on the number of procedures or tests that are performed. By focusing on value, providers are held accountable for the outcomes of their practice, which should lead to lower overall healthcare costs and reduce unnecessary medical care.

    BCBSTX will be partnering with Sanitas USA, a branch of the Spain-based provider that has several clinics in Florida, New Jersey, and Connecticut. The clinics will be in Irving, Las Colinas, Mesquite, and Richardson in Dallas County, and be exclusively for BCBSTX plan holders. “Our partnership with Sanitas is another example of collaborating with health care providers to deliver the best possible care and support to our members,” said Dan McCoy, M.D., president of BCBSTX via release. “We believe that this partnership will advance primary care services and is an effective approach to providing quality health care outcomes, improving member engagement and experience, and lowering costs for our members, including populations that may have difficulty accessing care.”

    The healthcare industry is seeing segments expand into new territory in an attempt to consolidate marketshare and mitigate risk. BCBSTX is far from the first insurer to enter the provider marketplace. Optum, one of the largest physician groups in the country, is owned by UnitedHealthcare. Pharmacy behemoth CVS has opened clinics in their locations, and physicians are lobbying for a bill in the Texas legislature to be able to distribute common medications in their clinic.

    Employers have their own clinics and health systems have their own health plans.

    But some area primary care providers in BCBSTX’s network don’t necessarily see the new clinics as something to be celebrated. Chris Crow is President of Catalyst Health Network, which is made up of independent primary care physicians who focus on value-based care. He says the new clinics are competing directly with physicians, and an intrusion into the provider space. “It’s a stay in your lane moment,” he says.

    Crow is concerned that clinics that are owned by BCBSTX will receive better treatment than other offices. “The insurance company is choosing to directly compete with you, even though you contract with them to be in network. It might benefit those guys differently,” Crow says.

    BCBSTX Chief Medical Officer Dr. Paul Hain, says locations for the clinics were chosen based on their analysis of areas where their members were having trouble accessing primary care and aren’t meant as competition. “We looked at where we are hearing about our members getting access in a timely manner. The reality is that we are always short of primary care doctors in Texas,” he says. “This is not an attempt to compete; it was an addition that was carefully thought out.”

    The impending shortage of primary care doctors has been well documented, though the greatest shortages have been in rural and small town communities. When I searched primary care physicians through the BCBSTX Find a Doctor site, 40 family practice, internal medicine, and pediatric physicians were found in ZIP code 75038, which surrounds North Lake College in Las Colinas, one of the areas for a future Sanitas/BCBSTX clinic.

    Crow wonders why BCBSTX didn’t decide to partner with a local primary care provider rather than an international company. “You would have wish they would have partnered with someone local,” he says. “None of them (local providers) received calls or were notified until two weeks before the announcement.”

    Hain says that Sanitas was chosen because of their experience with value-based care in other states. While many local providers have some level of value-based care, Hain says they wanted to “move fast as possible to full value-based arrangement, with upside and downside risk on patients.” Sanitas was ready to deliver with that model, where they would be held accountable if they didn’t meet certain quality and cost standards.

    While the Sanitas clinics will provide primary care for patients, they will only be available for BCBSTX patients. Because most families get their insurance through their employer, a job change that results in a new insurance company will mean those patients won’t be able to keep their Sanitas primary care doctor.

    “Life expectancy goes up if you have a primary care physician,” Crow says. “If the continuity of care is important, insurance or employer clinics based on where people work can be very disruptive to the relationship that is really important in your life.” Crow says they could have worked with local providers who were already providing care. “Wouldn’t that be a good place to start rather than opening up your own?”

  • 15 Apr 2019 8:49 AM | AIMHI Admin (Administrator)

    MassLive Source Article | Comments Courtesy of Matt Zavadsky

    Nice comments from Scott Cluett – his new role at the state is similar to other state EMS offices, such as Georgia, who are implementing MIH specialists in their departments.

    Tip of the hat to Kolby Miller of Medstar Ambulance (Michigan) for forwarding this article.

    Massachusetts ambulance services urged to launch preventive health programs that could reduce ER trips


    By James F. Lowe

    NORTHAMPTON — The state is urging local ambulance services to branch out into preventive health programs that could reduce trips to hospital emergency rooms.

    That includes assessing fall risks in seniors’ homes, ensuring safe disposing of syringes used by diabetics and heroin users, performing mass vaccinations and more.

    “There are some great opportunities for EMS companies to start doing some point-of-care testing,” said Scott Cluett, manager of the state’s Mobile Integrated Health program. For instance, EMTs could screen patients for asthma, or make referrals to a primary care physician.

    The Community EMS program is meant to get ambulance services working collaboratively with local public health officials and related organizations. Since the state started taking applications in October, six EMS providers in the eastern part of the state have already been approved to launch programs, including in Boston, Fall River and Brockton. Cluett hopes there will be 40 to 50 such programs proposed across the state by July.

    Cluett was the featured speaker Thursday at the annual meeting of Western Massachusetts Emergency Medical Services, a nonprofit support organization for fire departments and private ambulance companies in the four western counties.

    “Community EMS, especially for our smaller, more rural towns, it’s a perfect fit,” said Deborah Clapp, WMEMS executive director. “EMS are trusted providers. They’re already in people’s homes.”

    One benefit of Community EMS programs could be aiding public health nurses, who have limited time and resources. Community EMS could also bring health services to people without transportation or limited mobility.

    Clapp said her organization is working with two consultants to assess needs in Western Massachusetts and develop programs in areas like fall prevention and opioid education.

    Many first responders already carry nalaxone, a drug that can reverse the effects of opioid overdoses. Mark Miller, director of the state Office of Emergency Medical Services, said changes in federal regulations could allow first responders to supply nalaxone to family members of opioid users to safeguard against future overdoses.

    Community EMS program proposals must be reviewed and approved by the state, and must be recertified every two years, Cluett said. High-value categories the state hopes EMS providers will address include opioid abuse, housing stability, mental health and disease control.

    Cluett said Community EMS programs will benefit public health and save money for the health care system as a whole.

    As things stand today, ambulance services are reimbursed by Medicare only when they transport patients to an emergency room. But Cluett said the federal Centers for Medicare & Medicaid Services is rolling out a new model that would reimburse EMS providers for treatment in the field and transportation to alternative destinations like urgent care centers — something he called a “game changer.”

    Thursday’s WMEMS meeting and luncheon was attended by about 75 people and included an award ceremony recognizing 12 people who helped save the life of Linwood Clark of Haydenville, who stopped breathing Jan. 31.

    They were: Daryl Springman, Jason Connell and Alex Kassell of the Williamsburg Fire Department, Robert Reinke and Mitchell Cichy of the Williamsburg Fire Department, Drew Morse, Kim Dresser, Maryellen McQueston and Keith Cotnoir of Highland Ambulance, first responder Tim McQueston and dispatcher Wendy Pariseau of Northampton Control.

    Clark’s wife, Karthyn Warner, was also credited for dialing 911.

    “Her calling was what saved his life,” said Highland Director Michael Rock.

  • 8 Apr 2019 6:01 PM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    This may me an area where an EMS-Based MIH program that assists with a ‘safe landing/safe transition’ program might demonstrate value. 

    BCBS of New Mexico, and other similar programs that deploy community paramedics to check in on recently discharged patients, have shown promise.


    CMMI seeks feedback on pay bundles for post-acute care


    April 8, 2019 

    The top deputy for the Center for Medicare and Medicaid Innovation told hospital leaders on Monday he is eying a bundled payment model for post-acute care.

    Innovation Center Director Adam Boehler told the audience at the American Hospital Association's annual meeting that he's seeing a flood of interest from industry, and he called for ideas on how a new approach could save money while improving care.

    "We've heard a lot of comment there, and I think we are interested in the concept of acute-care bundles," Boehler said. "Now is the time to raise ideas there."

    After the speech, the CMMI director declined to give a timeline for a prospective model other than there's nothing coming imminently. For now the the agency is in "listen mode," he added.

    "Post-acute care is an area where we can improve quality and save money," he said. "From that perspective we like it. The devil's in the details on how to set up the models correctly."

    This expensive segment of the healthcare industry has been drawing investment both from private equity firms and big hospital systems as they buy up nursing homes.

    Hospitals are increasingly reluctant to release patients to skilled-nursing facilities if they can send them home, citing quality reporting issues. This is supported by an October report from Welltower that said the post-acute provider world will shrink in the face of changing regulations and a shift to new payment systems.

    And, as evidenced by ProMedica's $1.4 billion acquisition of the bankrupt nursing home operator HCR ManorCare last year, health systems have the infrastructure and financial position to invest in a population poised to grow as baby boomers age. The number of 80- to 85-year-olds is slated to grow at about 5% per year over the next decade, and to more than double within the next 20 years.

    On the rural healthcare front, Boehler is also mulling new payment ideas as momentum continues to try to avert more hospital closures. In Monday's speech he echoed last year's discussions on Capitol Hill about global payment models as a way to give those hospitals time and space to figure out how they can reconfigure their operations.

    "We're thinking about the opportunity to say, 'Hey, let's give people the cover of night for a little bit, let's kind of freeze things for a while,' " Boehler said.

    He gave the example of a hospital reducing its number of inpatient beds while expanding its ambulatory clinics and telemedicine offerings, as well as incorporating more behavioral health into its treatment.

  • 8 Apr 2019 12:03 PM | AIMHI Admin (Administrator)

    WLOS Source Article | Comments Courtesy of Matt Zavadsky

    Interesting call volume changes referenced in the report.


    Cost of Growth: Agencies work to combat growing 911 call volumes

    by Lauren Brigman

    April 4th 2019

    As the population in Western North Carolina continues to climb, so does the number of 911 calls in some mountain counties.

    Local emergency officials are using various approaches to combat growing call volumes.

    In McDowell County, some paramedics practice house calls as part of the Community Paramedic Program.

    They visit patients like Richard January, who were frequently making trips to the emergency room. January said he suffered seven heart attacks in 30 years, and chest pains prompted his calls for help until the community paramedics stepped in.

    “What we’re really trying to focus on is getting down to the grassroots of the problem,” community paramedic Lt. Chad Robinson said.

    He said the program focuses on patients who regularly utilize 911.

    “To me, it’s all about getting to know the patient,” Robinson said. “We found out a long time ago that we were transporting for the wrong reason. It’s all about getting them to the right place at the right time."

    911 calls like January’s were climbing in McDowell County. County Emergency Services coordinator William Kehler said in 2007 they began seeing growth at 5% to 8% per year.

    Since the launch of the Community Paramedic Program in summer 2014, the numbers have dropped.

    “We are down almost 10 percent in our call volume for EMS ambulances,” Kehler said.

    That means fewer patients are going straight to the emergency room.

    Kehler added, “Every 911 call for service is not an emergency. It's estimated about 30 percent of our (McDowell County’s) calls could be better served if we sent a community paramedic."

    Community paramedics are helping to keep ambulances available for true emergencies, while building relationships with those they serve.

    In Buncombe County, EMS officials report that 911 calls have increased more than 11% since 2014.

    In response, within the last month, four additional paramedic positions were added, and the county has contracted a private ambulance company to help take on emergency calls.

    In Henderson County, 911 calls have climbed more than 22% since 2014. 

    A new emergency services center in the county is providing resources to meet growing needs. Henderson County EMS manager Mike Barnett said it’s helping to expand staff and training needs.

    "Over five years, we've added two new EMS stations and 15 full-time staff,” Barnett said.

    Henderson County EMS also utilizes the county’s rescue squad for assistance in responding to non-emergency transports.

    Emergency officials in Buncombe and Henderson counties said they are keeping an eye on programs like the one in McDowell to see if it could be sustainable there.

    News 13 reached out to emergency officials across the mountains and found that Haywood and Macon County EMS also have community paramedic programs.

    In Buncombe and Jackson counties, there are similar programs carried out through hospitals to help decrease the likelihood of patient re-admittance.

  • 6 Apr 2019 11:55 AM | AIMHI Admin (Administrator)

    JEMS Source Article | Comments Courtesy of Matt Zavadsky

    Excellent collaborative education by NAEMSP, IAFC and NAEMT.  This is part 1 of a 2 part article series. 

    The next article will answer the FAQs from the webinar. 

    There are several good figures and examples in the on-line version at the link below.


    Thinking About Applying for CMS’ New ET3 Model?

    Here’s what you should be considering now!

    Thu, Apr 4, 2019 

    By Brent Myers, MD, MPH, FACEP, FAEMS , Pete Lawrence , Matt Zavadsky, MS-HSA, NREMT

    The EMS community has been buzzing since the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) announced the Emergency Triage, Treat and Transport (ET3) Model. CMS has conducted a national press conference and three webinars explaining the model. Although many aspects of the program are still in development, the main tenets of the model have been well articulated and ambulance services will likely become eligible to apply by mid to late summer. Given the ambitious timeline communicated by CMS, it’s not too early to begin thinking about considerations if you are evaluating whether or not to apply for this voluntary Alternate Payment Model (APM).

    We couldn’t be more pleased that CMMI has announced the ET3 project, as we believe this to be a patient-centered initiative that will undoubtedly improve patient care and create efficiencies for EMS and hospital systems.

    On March 25, 2019, the National Association of Emergency Medical Technicians (NAEMT), the International Association of Fire Chiefs (IAFC) and the National Association of EMS Physicians (NAEMSP) conducted a webinar sponsored by ESO Solutions and FirstWatch, to begin educating agencies on what they should be considering now if they plan on applying for the ET3 APM.

    The salient points of that webinar are outlined in part one of this two part article series. The next article will provide responses to the most frequently asked questions regarding the ET3 model.

    (To view a recording of the ET3 webinar, go to

    Clinical Considerations

    First, let us begin by stating and offer the following for EMS physicians to consider as the application for—and implementation of—ET3 pilot programs progresses:

    Assurance of Quality and Patient Safety:

    The EMS physician or physicians who serve as medical directors for EMS systems have traditionally been responsible for credentialing personnel who function within the system. The ET3 pilot contemplates allowing on-scene telemedicine as well as transportation to alternative sites. Our first priority is to do no harm as we work to assure patient safety; we would, therefore, be strongly in favor of utilization of the traditional credentialing pathways for any clinician or provider who seeks to participate in the ET3 program. In this way, reporting of outcomes, assurance of availability, and performance improvement activities can be readily implemented. The absence of such a defined and practiced credentialing process could result in a situation where clinicians and providers unfamiliar with EMS scope of care are rendering medical opinions, leading to less than ideal outcomes for patients. Obviously, we support a public and transparent process for this credentialing such that there is not an undue restriction of markets or overly burdensome processes.

    Appropriate Differentiation of Traditional EMS vs. ET3 Utilization:

    Many EMS and EM physicians participate routinely in online medical direction for a host of critical patients, as well as those who are refusing transport. In many cases, these patients may be better served by telemedicine, inclusive of two-way video communications. At what point would a high-risk refusal patient in the traditional EMS sense become an ET3 telemedicine encounter? These and similar issues identify concepts that should be considered prior to program initiation.

    Appropriate Accounting for Actual and Perceived Conflicts of Interest:

    Whether the telemedicine provider is an EMS physician or provider in another facility, there undoubtedly will be patients who have an ET3 telemedicine encounter who may be appropriately referred for transport by EMS or as a follow up at some point in the future. We must assure appropriate alignment of incentives and transparency to prevent unintended consequences.

    Appropriate Performance Metrics:

    We are all keenly interested in patient safety, quality of care and cost accounting. The ability to track and report metrics and measures that demonstrate safety, experience of care, effectiveness and efficiency will be crucial. Assure you have processes in place that can evaluate and report key performance metrics. In the early discussions with CMS and CMMI, we provided examples of metrics such as:

    • Treatment in an ED within 6, 12, or 24 hours of an ET3 encounter, inclusive of outcomes from the second encounter (Patient Safety Measure);
    • Repeat EMS visit within 6,12, or 24 hours of an ET3 encounter, inclusive of outcomes from the second encounter (Patient Safety Measure)
    • Patient satisfaction and/or family satisfaction (Patient Experience Measure);
    • Total task time for EMS for non-transport, alternative transport and ED transport (Operational Efficiency Measure);
    • EMS personnel and other clinician and provider satisfaction scores (Practitioner Satisfaction/Balancing Measure); and
    • Pre- and post-implementation transport ratio (Economic Efficiency Measure).

    Operational Considerations

    Currently Licensed Ambulance Providers:

    Eligibility for this model is limited to ambulance providers and suppliers that are currently licensed and are participating with the Medicare program, as evidenced by the agency having a National Provider Identification (NPI) number with Medicare. Participation in this model means you will be eligible for Medicare reimbursement for providing treat in place, or transport to alternate destination services to Medicare Fee For Service (FFS) beneficiaries. Reimbursement eligibility for either of these two patient outcomes only applies if an ambulance responds to a 9-1-1 call for EMS assistance. A first response unit only, even if the first response agency is the same provider as the ambulance, will not be a reimbursable service under this model.

    Telehealth Required for Treat in Place:

    CMS articulated many times that any beneficiary who calls 9-1-1 should have the opportunity to be seen by a qualified healthcare practitioner (QHP). In Medicare terms, a QHP is a person or entity that is eligible for reimbursement for telemedicine or telehealth services, such as a physician, physician assistant or nurse practitioner. CMS has previously defined telehealth services as an interactive audio and video telecommunications system that permits real-time communication between the QHP and the beneficiary.1 The QHP will be eligible for Medicare reimbursement for services provided to Medicare FFS beneficiaries under the ET3 model. This means that to be eligible for reimbursement under an approved ET3 model, you will need to have the technology and processes in place to facilitate real time audio and video communications from the scene of the ambulance response. To assist the reimbursement process for the ambulance agency and the QHP, it’s likely there will need to be some process that links the patient encounter by the ambulance crew with the telehealth services provided by the QHP.

    No Telehealth Requirement for Alternate Destinations:

    Ambulance transport to alternate destinations will not require a telehealth intervention, meaning that this patient outcome could be “protocolized” to the level that your agency’s medical director authorizes. For example, a protocol that includes a list of inclusion, and more importantly, exclusion criteria for alternate destination could be established by your medical authority.

    Dispatch Agency Reimbursement:

    Under the proposed ET3 model, select dispatch centers operated by local governmental authorities that provide medical triage services will also be eligible for funding. This will be limited to dispatch agencies that provide dispatch services for an ambulance agency that has been approved and enrolled in the ET3 model under the alternative destination or telehealth programs. CMS hasn’t yet identified the financial model the reimbursement would follow and understands that reimbursing only for FFS beneficiaries may not provide enough funding to fully implement call triage in all dispatch centers.

    Financial/Community/Regulatory Considerations

    Is This Allowed in Your Operating Area?:

    Some state or local regulations may not allow ambulances to transport to alternate destinations from 9-1-1 responses. Similarly, there may be local or state rules that preclude the ability for EMTs and paramedics from offering alternate dispositions. Knowing whether or not an ET3 model is even legal in your area is a crucial step early in the ET3 model implementation evaluation process. If it’s not, begin conversations with those who can either change the rules, or in some cases, have the ability to grant a special waiver to facilitate the implementation of an ET3 service delivery model.

    Financial Triage:

    EMTs and paramedics generally don’t engage in extensive financial eligibility discussions on the scene of a 9-1-1 call. Since reimbursement for ET3 services will be limited to Medicare FFS beneficiaries, agencies will need to determine the best way to educate field crews how to identify eligible patients. Our advice (and CMS’ desire) is that agencies attempt to work with other payers in their service area (e.g., Medicare Advantage, Medicaid, commercial) to adopt similar models. This will make it easier to implement the model in larger patient populations, perhaps all patients, regardless of payer source. A great way to start this process is to get a payer report from your billing department, identify your largest payers, and begin those discussions. It is also possible that multi-payer integration for ET3 services will be an evaluation criteria for ET3 model approval.

    Partner Engagement:

    There are numerous stakeholders who may be impacted if your agency is approved for the ET3 model. Hospitals may be concerned about a reduction in Medicare or other payer beneficiaries coming to the ED by ambulance. Have conversations with them early to explain the model and seek their input. Under the ET3 model, you need a network of alternate destinations to transport, or refer patients to—without this referral network, success could be elusive. Engagement by community clinics, urgent care centers and large physician practice groups will be crucial to the ET3 model. Finally, due to the potential patient care and economic risk of the model, assure your medical director and governing body are appropriately involved during this crucial step.

    Demonstration of Value:

    The bottom line to this model is to prove to CMS and other payers that we can safely navigate patients to care locations other than an ED. It may be advisable for you to take a deep dive into your current transport ratio and the types of patients that fall into the payer categories who might be eligible for dispositions other than a transport to the ED. For example, if your transport ratio is already low because you have an operating MIH-CP program that includes protocols that facilitate enhanced alternate destinations, getting the ratio lower may be a difficult task. Further, if you have a unique patient demographic with an appropriately high transport ratio, it may be similarly difficult to safely reduce that ratio.

    These are very interesting times for EMS and the patients and communities we serve. The ET3 model is something many of us have been advocating for years, even decades. Appropriately implementing the model in your service area is absolutely essential to change the value proposition for EMS.

    In the next article in this series, we will attempt to provide guidance on some of the most frequently asked questions regarding implementation of the ET3 model.


    1. Medicare Learning Network. (January 2019.) Telehealth Services. Centers for Medicare and Medicaid Services. Retrieved April 4, 2019, from

  • 5 Apr 2019 7:49 AM | AIMHI Admin (Administrator)

    Source BMJ Supportive & Palliative Care PDF | Comments Courtesy of Matt Zavadsky

    Nice study about the Northwell MIH program…  Nice convergence use of the AMPDS dispatch system and Community Paramedicine!

    Congratulations Jonathan Washko and team!


    Community paramedics treat high acuity conditions in the home: a prospective observational study

    Abrashkin KA, et al. BMJ Supportive & Palliative Care 2019;0:1–8.

    doi:10.1136/ bmjspcare-2018-001746


    Objectives As the US population ages and healthcare reimbursement shifts, identifying new patient-centred, cost-effective models

    to address acute medical needs will become increasingly important. This study examined whether community paramedics can evaluate and treat, under the direction of a credentialed physician, high acuity medical conditions in the home within an advanced illness management (AIM) practice.


    A prospective observational study of an urban/suburban community paramedicine (CP) programme, with responses initiated based on AIM-practice protocols and triaged prior to dispatch using the Advanced Medical Priority Dispatch System (AMPDS). Primary outcome was association between AMPDS acuity levels and emergency department (ED) transport rates. Secondary outcomes were ED presentations at 24 and 48 hours post-visit, and patient/caregiver survey results.


    1159 individuals received 2378 CP responses over 4 years. Average age was 86 years; dementia, heart failure and asthma/chronic obstructive pulmonary disease were prevalent. Using AMPDS, most common reasons for dispatch included ‘breathing problems’ (28.2%), ‘sick person’ (26.5%) and ‘falls’ (13.1%). High acuity responses were most prevalent. 17.9% of all responses and 21.0% of

    high acuity responses resulted in ED transport. Within 48 hours of the visit, only 5.7% of the high acuity responses not initially transported were transported to the ED. Patient/caregiver satisfaction rates were high.


    Community paramedics, operating within an AIM programme, can evaluate and treat a range of conditions, including high acuity conditions, in the home that would typically result in ED transport in a conventional 911 system. This model may provide an effective means for avoiding hospital-based care, allowing older adults to age in place.

  • 2 Apr 2019 3:34 PM | AIMHI Admin (Administrator)

    D Healthcare CEO Source Article | Comments Courtesy of Matt Zavadsky

    Interesting perspective. 

    For the recommendations highlighted below, EMS-based Mobile Integrated Healthcare/Community Paramedicine programs are demonstrating significant improvement in patient outcomes, enhancement of patient experience of care and reduced healthcare expenditures. 

    This is being accomplished by appropriately triaging 9-1-1 callers with low acuity medical issues and navigating them to the best location for their medical care, collaborating with community resources to proactively manage super-utilizers, partnering with healthcare stakeholders to reduce preventable readmissions, and working with home health and hospice agencies to reduce preventable hospital visits for hospice and palliative care patients.

    CMS’ recent announcement of the EMS ET3 alternative payment model is an excellent step toward providing coordinated care, even when people access healthcare through the 9-1-1 system.

    TMF, a CMS QIO has launched a Learning Action Network for MIH programs – click here to learn more.


    Expert Opinion: How to Fix the Cost of Care Dilemma

    04/1/2019by Jason Signor

    Like most Americans, I am worried about the rising cost of healthcare, but the terrible news is that the real healthcare cost problem hasn’t even arrived yet. And like many people, I’m tired of our health insurance premiums going up. As a business owner, for the last few years I’ve had to make the tough decision of raising premiums on our employees, increasing deductibles, or having our company absorb the increase. Unfortunately, our company’s health premiums have gone up an average of 17% each of the last four years while maintaining the same benefit plan. A 67% increase in insurance premiums over a four-year period is not sustainable.

    Elderly Care is the Root of the Issue

    According to the U.S. Bureau of Economic Analysis, in 2012 the United States spent $2.37 trillion on healthcare expenditures. That same year, Centers for Medicare & Medicaid Services did a study on the usage of healthcare by age class and found that $190 billion of the expenditures were for people over the age of 85. Given the U.S. Census estimation that there were 5.8 million Americans over the age of 85 in 2012, that translates into $32,411 we spend per year or $88.80 per day to treat each American over the age of 85. Additionally, 34.5 percent of the total healthcare spending occurs for individuals over the age of 65, even though they represent only 13.7 percent of the population. With the increase in healthcare expenditures, the amount per person has only gone up since 2012 and is continuing to rise faster than our economic growth.

    Source: Healthcare Expenditures Benchmarked to 100 in 2000, Federal Reserve Bank of St. Louis (Courtesy of Caddis).

    The Real Problem is Coming

    What’s interesting is that the compounded annual growth rate of the 85-plus population has been declining the last several years and is expected to actually drop below the overall US population growth in 2019 before rising dramatically.

    The reason is the first Baby Boomer was born in 1946 and will not turn 85 until 2031. The much smaller Silent Generation (think Baby Boomer parents) are the age group currently in the 85-plus category, but once the Baby Boomers hit the age of 85, we will have a crisis on our hands. Between now and 2060, the US population is expected to grow 27 percent, but the 85-and-older population will grow 201%. There will not be enough healthy people to subsidize the sick and elderly.

    What can we do to fix the problem? We need to start thinking about the cost of healthcare as end of life care and work to decrease the cost of care on a daily basis for our senior citizens. Reducing the average healthcare consumption to below $89 per day seems like an achievable goal. As a professional in the healthcare space, I think our industry can make an impact in lowering our societal cost.

    Here are some examples of ways our industry can make an impact:

    • Reduce the number of unnecessary prescription drugs
    • Have a preference for older, proven healthcare treatments in lieu of newer, more expensive ones
    • Increase education on palliative care and its benefits
    • Create a more cost-effective way for people to have coordinated care
    • Provide alternatives to surgery for seniors over the age of 85 including rehabilitation therapy
    • Direct needed surgery to outpatient ambulatory surgery centers that utilize minimally invasive techniques and bill a lower reimbursement
    • Reduce the length of stay and readmissions in acute or skilled nursing settings by improving best practices in senior housing and other lower cost providers

    Caring for the sick and elderly taxes society. Since we all pay for it one way or another, shouldn’t we all take ownership for reducing its burden? 20 percent of the population is causing 80 percent of the costs. We should automate processes and integrate patient records, so any doctor the patient needs to see can access their full history. Third parties should be taken out of the middle of the process which diverts billions of dollars away from care of the patient and provide little to no value to the healthcare process. It can be done, we just need to get a better system going to offer everyone.

    The time to get this started is now.

  • 1 Apr 2019 9:26 AM | AIMHI Admin (Administrator)

    WHEC Source Article | Comments Courtesy of Matt Zavadsky

    Chief Allen does a great job on camera explaining a very complex issue – suggest viewing the 90 second video at the link below…

    Can’t wait to see what the station’s next investigative report uncovers regarding the direct payments to consumers that are not turned over to the provider.


    Ambulance services say governor's Medicaid cut plan could cause 'collapse of the ambulance industry'

    March 29, 2019 06:59 AM

    ROCHESTER, N.Y. (WHEC) -- Here's a tough pill to swallow for people in our community who are older and low income.

    Gov. Andrew Cuomo wants to stop paying for your ride in an ambulance and the people who operate the ambulances in our area gave News10NBC a dire warning about this. 

    They say this cut is going to put some ambulance services out of business. They say they're strapped for cash as it is. 

    First, let's explain what's happening. 

    If an ambulance crew got called to help a patient who was older and low income, the federal and state government pay for it. Medicare covers 80 percent. Medicaid pays 20 percent. 

    In his budget proposal, Cuomo wants to cut that 20 percent from Medicaid. 

    "So for our agency alone, it's $65,000 a year," Chief Reg Allen said. 

    Allen is the chief of CHS Mobile Integrated Healthcare. That's the ambulance for Henrietta, Chili, Scottsville and three other towns. 

    News10NBC Chief Investigative Reporter Berkeley Brean: "But if somebody is old and poor, you're still going to go pick them up?" 

    Reg Allen, CHS Mobile Integrated Healthcare: "Oh yeah." 

    Brean: "It's you that is not going to get the money?"

    Allen: "Right. It's a revenue loss so like any other business you have to figure out how to absorb lost revenue."

    Allen says he would have to cut a full-time and part-time EMT. He says smaller, rural ambulance services might have to cut everything. 

    "Now, they've lost revenue. Now, they go out of business," Allen said. "Now, there's nobody to cover them."

    It's not just Chief Allen saying this.

    The New York American College of Emergency Physicians says the Medicaid cut "puts patient health and safety at risk."

    The United New York Ambulance Network warned it would cause the "collapse of the ambulance industry."

    But one of the governor's policies is to control spending. 

    Here's what he's facing. 

    In 2017, one out of every three New Yorkers was eligible for Medicaid. That year, New York state spent $40 billion on Medicaid payments. That's more than Pennsylvania, Vermont, Massachusetts, New Jersey, Connecticut, Michigan, and Ohio combined. 

    So, the governor wants this Medicaid cut. The state legislature does not.

    Here is Assembly Speaker Carl Heastie at a rally last month. 

    Speaker Carl Heastie: "It is not lost on the members how important this is. We are hearing from the healthcare community throughout the entire state and it will not be lost to us. This is one of our highest priorities to restore the cuts that the governor has proposed in his 30-day amendments."

    News10NBC asked the governor's office to explain why it wants to stop paying ambulances for helping older, low-income patients. 

    Here is the statement from the governor's budget director: 

    "The state has been standardizing payment practices across the health care industry including updates to Medicaid billing methodologies. In situations where Medicare pays an appropriate amount, Medicaid should not pay more than it ordinarily would for any other patient. These changes are not anticipated to have any adverse impacts on availability of transport services. The Executive Budget also includes an increase in ambulance reimbursement rates and several new EMS workforce development efforts are underway." 
    Brean: "Why is this happening?"

    Allen: "I don't know. It's a cost-cutting measure and you would think they wouldn't try to cut costs for people that are typically the most in need. You're talking about low-income elderly."

    The state budget deadline is Sunday. 

    This isn't the only money problem for ambulances.

    News10NBC is investigating why insurance companies send some ambulance reimbursement money to patients who end up pocketing the money.

    Watch for that investigation next week. 

  • 1 Apr 2019 9:01 AM | AIMHI Admin (Administrator)

    Kaiser Health News Source Article | Comments Courtesy of Matt Zavadsky

    Interesting approach to a problem that vexes most communities – wonder how an MIH program using trained community paramedics could help medically clear psych patients for appropriate navigation to these types of resources.

    Stanislaus County, California has arguably the most successful model for this – the outcomes are excellent!


    She Was Dancing On The Roof And Talking Gibberish. A Special Kind Of ER Helped Her.

    With mental health beds in short supply, emergency rooms increasingly have become the care of first and last resort for people in the grips of a psychiatric episode. Now, hospitals around the country are opening emergency units that calmly cater to patients with mental health needs.

    By Anna Gorman   MARCH 25, 2019

    For decades, hospitals have strained to accommodate patients in psychiatric crisis in emergency rooms. The horror stories of failure abound:

    Patients heavily sedated or shackled to gurneys for days while awaiting placement in a specialized psychiatric hospital, their symptoms exacerbated by the noise and chaos of emergency medicine. Long wait times in crowded ERs for people who show up with serious medical emergencies. High costs for taxpayers, insurers and families as patients languish longer than necessary in the most expensive place to get care.

    “If you are living with schizophrenia or bipolar disorder, that is a really tough way to begin that road to recovery,” said Dr. Jack Rozel, president of the American Association for Emergency Psychiatry.

    In pockets across the country, hospitals are trying something new to address the unique needs of psychiatric patients: opening emergency units specifically designed to help stabilize and treat patients and connect them to longer-term resources and care. These psychiatric ERs aim to address the growing number of patients with mental health conditions who end up hospitalized because traditional emergency rooms don’t have the time or expertise to treat the crisis.

    The rate of ER visits involving psychoses, bipolar disorder, depression or anxiety jumped more than 50 percent from 2006 to 2013, according to the federal Agency for Healthcare Research and Quality. Roughly 1 in 8 emergency department visits now stem from mental illness or substance use disorders, the data show.

    The psychiatric ERs, staffed with nurses, social workers and psychiatrists, work to treat and release patients in under 24 hours, much as traditional emergency rooms handle physical ailments. Those who are well enough to go home get discharged, while those who need more treatment are admitted to the hospital or transferred to an inpatient facility.

    There are now roughly 100 such units across the country, said Dr. Scott Zeller, vice president of acute psychiatry at Vituity, a physician-led organization that provides staffing and consulting services to medical centers nationwide.

    Zeller pioneered the approach while working as chief of psychiatric emergency services at John George Psychiatric Hospital in Alameda County, Calif. Over time, he transformed the center from a traditional ward where restraints were common into one that treated patients in a more supportive, living-room like setting. The results — in terms of both patient outcomes and cost-savings — made Zeller a believer.

    He is helping design 10 new units, including in California, Florida, Illinois and Tennessee. Each is distinct, accepting patients in somewhat different circumstances and offering a slightly different range of services.

    Patients who arrive at an emergency room for psychiatric or substance use disorders are more than twice as likely to be admitted than other patients, federal data show. And yet about 80 percent of the time, Zeller said, patients’ mental health crises can be resolved without a costly inpatient hospital stay. A patient may be having a psychotic episode because he fell off his medications, for example, or having drug-induced hallucinations.

    “We need to treat people at the emergency level of care,” he said. “The vast majority of psychiatric emergencies can be resolved in less than 24 hours.”

    Nowhere To Hide

    Wearing a hospital gown, Rachel Diamond lay back in her recliner in a spacious room in a relatively new ward at Providence Little Company of Mary Medical Center San Pedro, a hospital near the Port of Los Angeles. Nearby, a few patients slept on identical recliners, draped in soft blankets. Others communed at a kitchen table over microwaved meals. A nurse walked through the locked unit with a rolling cart, dispensing medications.

    Except for a nursing station in the middle of the room, the unit didn’t look much like a health care facility. The room was divided into men’s and women’s sides, with separate TVs. A few smaller rooms — where patients could meet with a psychiatrist or social worker — lined the unit’s edge.

    Anya Price, interim clinical supervisor and a nurse, said the unit was designed to feel more like a home than a hospital.

    “We’re operating from an understanding that they’re coming here to get better,” Price said.

    The open design of the unit, known as the “Outpatient Behavioral Health Center,” allows patients to move freely. Staff said it also helps reduce problems because they can quickly spot a patient who may be getting agitated. Dr. Herbert Harman, a psychiatrist and medical director for the facility, said violence and the need for restraints are rare.

    The unit is in a building a short walk from the medical center emergency room. It opened in 2017 and accepts patients from emergency rooms across Los Angeles County once they are deemed stable medically. So far this year, its staff has treated about 400 patients, Price said.

    One recent morning, the patients included a man in his 40s found on the railroad tracks after an alcohol binge, and a woman with a history of schizophrenia who said she was seeing spirits. Some were there on involuntary holds because authorities had decided they were at risk of hurting themselves or others because of their illness.

    Diamond, 30, said she has been diagnosed with depression and anxiety and has landed in multiple ERs over the past decade when her symptoms spiked out of control. During those stays, she said, she often felt isolated and in the dark about her treatment. Doctors typically numbed her with medications and consigned her to a guarded room. “No one really talked to me,” said Diamond, who lives in Torrance, Calif. “It was like I was a caged animal.”

    She had been living in a car and fighting with her boyfriend in late February when she decided she wanted to end her life. She tried jumping out of a moving car, and when that didn’t work, she grabbed a bottle of pills. She gets help for her mental health issues, but sometimes, she said, the stress becomes too much. This time, she was taken to a hospital emergency room in Torrance before being transferred to the San Pedro unit.

    During her time in the behavioral health center — about 26 hours — she slept, received medications and met with nurses, a social worker and a psychiatrist. She said it was calmer than a regular ER, and the staff had time to talk, listen and help her through the worst of the crisis.

    “I genuinely feel better enough to leave,” she said. “I haven’t been able to say that in a while.”


    A Return On Investment

    Zeller argues that the use of emergency psychiatric clinics is both humane and cost-effective. Research on the Alameda County model found such units can dramatically reduce how long patients spend in medical emergency rooms, and that about three-quarters of patients treated in the units can be discharged to the community rather than to inpatient care. That, Zeller said, can lessen the overwhelming demand for inpatient psychiatric beds and preserve available spots for those who truly require them. The model saves money for hospitals in part because the patients spend less time in emergency care.

    “The return on investment is exponential,” he said.

    In Montana, the Billings Clinic opened a psychiatric stabilization unit last April across the street from the traditional ER. Dr. Eric Arzubi, psychiatry department chair, said nearly 10 percent of the visits in the Billings Clinic emergency room involve people in psychiatric crisis. Since the new unit opened, wait times for psychiatric patients have dropped from about 10 hours to four hours, and fewer patients are being admitted to the inpatient unit. Arzubi said his staff isn’t trying to cure people of their mental illness but rather stabilize them and get them the care they need.

    “Just like in the emergency room, you don’t get comprehensive care,” Arzubi said. “But you can stop the bleeding, you stabilize the patient and get them to the right level of care.” In some cases, that means a transfer to an inpatient facility.

    Staff at the San Pedro unit decided soon after Chantelle Unique arrived that she would be one of those patients. Unique, who is 23, has been diagnosed with bipolar disorder and schizophrenia. She had been dancing on the roof and speaking gibberish when her mother called 911.

    Unique said she has had a hard time in regular emergency rooms. “There are a million people,” she said. For most of a morning at the San Pedro facility, she sat calmly watching TV, talking to nurses and eating spaghetti. But at one point, she started pacing and yelling at other patients. Nurses and security guards quickly surrounded her and persuaded her to return to her recliner and take additional medication.

    Finding an inpatient bed for a patient like Unique with more progressed mental illness is not always easy, said clinical social worker Mark Tawfik. But he’s committed to finding a way. “We have to make sure we find them adequate resources,” he said. “Otherwise, they will come right back.”

    For Price, the clinical supervisor, even when a patient requires a transfer for more intensive care, there’s satisfaction in knowing that person is headed in the right direction. If Unique hadn’t been brought in, Price said, she would have been out in the community, lost to her delusions, putting herself at risk of accident or arrest.

    In the unit, staff made sure she was safe, Price said, in addition to providing “a warm bed, some food and some compassion.”

  • 27 Mar 2019 11:03 AM | AIMHI Admin (Administrator)

    Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

    Very interesting discussions related to the balance billing issues…


    Analysts, some legislators want regulation of contracts to stop surprise billing


    March 23, 2019

    As Congress eyes legislation to end surprise medical bills, policy experts are lining up behind an idea to regulate hospital contracts with emergency physicians. The idea is that emergency physicians could no longer bill on top of the hospital charges, and it has already raised red flags for hospitals since it would essentially force them to include emergency physicians’ pay in the facility fee they charge patients.

    Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the leaders of the Senate health committee, have sent a model of the idea, among others, to the Congressional Budget Office for financial analysis, The Hill newspaper reported. A Senate aide told Modern Healthcare that the committee is still reviewing “a number of different options” and lawmakers are “still in the preliminary stages.”

    Hospitals and insurers already have been publicly tangling over two different ideas: using rate-setting or binding arbitration to resolve pay disputes between the two types of stakeholders. But advocates for the contract-reform approach argue it’s a far less invasive way for lawmakers to deal with a political linchpin problem.

    “What makes the most sense is to look at the root cause of the problem, which is the group of physicians you don’t choose and can’t avoid, as part of a wider package of services,” said Zach Cooper, associate professor of public health and economics at Yale University. “The simplest and easiest solution is for the groups of physicians that aren’t chosen by patients to be part of a package of care that a hospital sells.”

    Policy analysts have been discussing the idea on Capitol Hill, and it was included in a recent paper from the Brookings Institution.

    Furthermore, a new white paper by Benedic Ippolito of the American Enterprise Institute and David Hyman, professor of law at Georgetown University Law Center, contended this approach would “prevent surprise bills in the first place.”

    Still it’s far from clear which policy Congress, under pressure from the White House, will ultimately opt for in the legislation expected to come up this year amid intense industry lobbying. Molly Smith, vice president for coverage and state issues at the American Hospital Association, has urged lawmakers simply to ban balance billing and let insurers and hospitals work out the rest.

    Some people working on policy are wary about contract reform, however. 

    Jane Bayer, senior health policy adviser to the Washington state insurance commissioner, warned an audience at the Brookings Institution on Friday that the model could shift costs, particularly in concentrated health systems. 

    “I would respectfully say that I don’t think having a hospital bundle all the rates is separate from the market dynamics that we have around market concentration in hospital systems,” she said. “I think it’s the example of, if you squeeze the balloon in one place it pops up in another.”

    While both the Senate health committee and the House Energy and Commerce Committee are still in the early stages of legislating, Sen. Bill Cassidy (R-La.) has led a bipartisan effort in the Senate. Cassidy sits on the health committee and is consulting with Alexander, but he plans soon to release his own new bill, co-led with Sen. Michael Bennet (D-Colo.). Sen. Maggie Hassan (D-N.H.), who dropped a proposal last fall to require insurers and providers to settle balance billing issues through binding arbitration, is also part of the effort.

    The insurance and hospital industries have publicly focused on the policy ideas offered by Cassidy and his group, who have solicited industry data and feedback.

    In a letter last week to congressional leaders, a coalition including America’s Health Insurance Plans urged lawmakers to steer clear of the arbitration approach and instead advocated for rate-setting—which hospitals adamantly oppose. The coalition advocated that lawmakers protect consumers by passing legislation that would include “setting reimbursement rates that will not increase premiums or impact access for consumers by basing amounts on market rates determined by reasonable, contracted amounts paid by health insurance providers to similar doctors in a geographic area or a percentage of Medicare.”

    Hospitals immediately responded in a joint statement from American Hospital Association CEO Rick Pollack and the Federation of American Hospitals CEO Chip Kahn. “Not only is it a dangerous precedent for the government to start setting rates in the private sector, but it could also create unintended consequences for patients by disrupting incentives for health plans to create comprehensive networks,” Pollack and Kahn said. 

    This month, Cassidy said in an interview that he was leaning toward the arbitration approach although he hadn’t decided yet. He cited New York as a reason to opt for that model. The state was an early adopter of its own curbs to balance billing within its individual market. “If the states are laboratories of democracy, we can see a laboratory experiment which seems to be worked,” Cassidy said. 

    But the model of using a national system of arbitration is drawing a range of skepticism from the consulting policy world. Ippolito and Loren Adler of the USC-Brookings Schaeffer Initiative for Health Policy contend New York’s system could lead to general inflation of healthcare costs since the benchmark for the state arbitration is tied to a percentile of regional charges.

    Benjamin Chartock, associate fellow at the Leonard Davis Institute of Health Economics at the Wharton School, has found in his ongoing research on New York’s system that the state’s final arbitration agreements have so far tracked with that benchmark. This has stayed consistent even though people have the perception that arbitration is fairly flexible, Chartock said. “Arbitration doesn’t loosen it up completely,” he added. “There’s only a narrow window in which the arbitrator can wiggle around.”

    Cooper, whose research found that in-network rates in New York have declined since the state adopted its arbitration law, doesn’t believe the benchmark rate inflates cost. Still, he is wary about whether the arbitration method could work if it’s rolled out nationwide.

    “Arbitration is tough to do on a national level—for one thing, who are the arbitrators?” he said. “Do you have mass lines of people lining up to seek remediation?”

    He also noted that since New York already had fairly low out-of-network rates, it doesn’t necessarily serve as a model for other states, and warned physicians could lobby regulators or arbitrators on the state level and eke out higher rates.

    Contract reform, however, has already sparked sharp hospital industry criticism.

    Kahn, of the Federation of American Hospitals, said in an interview last month that he finds it a “terrible idea” that undermines the way hospitals currently staff physicians. “You can’t own your medical staff in that way,” he said. “I think it’s a very problematic.”

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