News & Updates

FierceHealthcare Source Article | Comments Courtesy of Matt Zavadsky

Interesting summary in Fierce Healthcare about the study published in JAMA.

May highlight the importance of safe care transitions from hospital to home – a role an increasing number of EMS agencies are providing in mobile integrated healthcare partnerships with hospitals and health systems.

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Link between readmission rates, mortality rates back under scrutiny

by Matt Kuhrt | 

Jan 2, 2019 7:20am

A new study shows a statistically significant correlation between lower readmission rates and higher mortality rates for patients with heart failure and pneumonia, renewing questions about the efficacy of the Center for Medicare and Medicaid Services' Hospital Readmissions Reduction Program (HRRP).

The new study, published in JAMA, looked specifically at changes in mortality rates in the 30- and 45-day periods after discharge for patients suffering from heart failure, heart attack or pneumonia. The 30-day data showed accelerated mortality rates for those with heart failure or pneumonia, though the 45-day data did not.

The HRRP has come under previous scrutiny for potentially raising mortality rates by offering hospitals a perverse incentive to reduce admissions in ways that don’t necessarily meet the patient’s best interest, such as discharging them after emergency room treatment or placing them in a temporary observation unit rather than readmitting them. In other studies, however, the program’s success at reducing overall readmissions has been hailed as broadly effective.

While the study’s limitations don’t necessarily indicate a causal relationship between the HRRP and the higher mortality rates, it does raise some potential red flags, according to Rishi Wadhera, M.D., a cardiology fellow at Brigham and Women’s Hospital and the study’s lead author.

Wadhera notes that the increase in mortality rates comes amid troubling context. While post-discharge deaths for heart patients with heart failure had already begun to increase in the years prior to the HRRP, the trend actually accelerated after the program was established. At the same time, the increase in mortality rates for pneumonia patients followed a period of stability in the years prior to the HRRP. Those conditions also saw significant decreases in the number of readmissions after discharge.

Whether hospitals are acting in ways that don’t necessarily benefit patients remains an open question, but Wadhera sees important lessons in the lack of clarity around how the program actually functions.

“I think one of the issues is we really haven’t done a deep dive into how physicians and hospitals have responded to the HRRP,” he said. “All we’ve really observed are the decline in admission rates and we’ve assumed that that was due to improvements in quality of care, but we don’t actually know that.”

Given the potential for unintended harm, Wadhera believes policymakers should slow down and take a more measured approach. “Our takeaway from the findings is that the HRRP should not be expanded to all hospitalized conditions, which is what some policymakers have advocated for recently, and that we should be more cautious before widespread expansion of the program.”

The findings also offer useful lessons for developing nationwide incentive-based quality programs in the future, Wadhera said. 

At the very least, he recommends more limited pilot programs or randomized studies before rolling programs out nationwide. In cases where that’s not possible, he recommends specifying analyses to identify potential unintended consequences before implementation, and monitoring after implementation with well-defined stop-loss thresholds if that analysis uncovers a signal of harm.

“The HRRP teaches us about the importance of evaluating policies rigorously before we implement them nationwide, and I think CMS and specifically the Centers for Medicare and Medicaid Innovation, which have some leeway to test policies, could really take the lead on evaluating policies before they’re implemented nationwide,” Wadhera said.

D Magazine Source Article | Comments Courtesy of Matt Zavadsky

Interesting outcome that may have implications across the country for emergency medical care providers.  Another signal that we should be partnering with payers on payment models that bring enhanced value to the patient, the provider, and the payer.

For our EMS brethren, note the reporter’s use of the term ‘emergency medical services’ to refer to the care received in the ED. 

NHTSA and the Red Flash Group are embarking on a project seeking input on terms that most accurately reflects the services provided by out-of-hospital medical care providers working on ambulances and First Response vehicles. 

NEMSAC and some professional organizations have recommended use of the term “paramedicine” as the services we provide, whereas “EMS” in its purest sense was originally intended to represent a ‘system’ of care, including pre-hospital, inpatient and post-hospital care.

We encourage all who are invited to provide input into this project to do so.

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Judge Dismisses Blue Cross Lawsuit Over Low Reimbursement Rates

12/21/2018| by Will Maddox|

A federal judge has dismissed a lawsuit against Blue Cross Blue Shield of Texas by 49 physician groups that claim the insurer is not paying enough for emergency medical care.

The groups argue  there are 250,000 claims where Blue Cross’ reimbursement rate for out-of-network providers violates Texas insurance laws and regulations.

In an emergency, patients are brought to the nearest hospital, which might not always be in network. “As out-of-network providers, the Provider Entities are not contractually bound to accept discounted rates of payment for the emergency medical services they provide to BCBSTX Members and instead expect to receive their billed charges for these services,” the lawsuit reads.

The 49 complainants, who come from all over the state, say that there have been hundreds of thousands of out-of-network claims where Blue Cross has underpaid. “Rather than pay the true and accurate bill generated by the Provider Entities, BCBSTX has knowingly lowered the reimbursement rate allowed for ‘out-of-network’ care to levels below what member plans and applicable regulatory authority require. BCBSTX paid most of these claims at a net payment rate that is significantly less than what the Provider Entities are entitled to receive as out-of-network providers.”

The lawsuit also highlights past action taken against Blue Cross by the Texas Department of Insurance. “TDI found that Blue Cross set its allowable amounts for out-of-network providers at ‘unreasonably low rates that are less than the amounts billed by facilities and also less than the rates paid to BCBSTX contracted facilities.’ TDI also stated that Blue Cross’s “reimbursement rates are so low as to violate Texas insurance laws and regulations.”

Judge Karen Gren Scholer of the U.S. District Court for the Northern District of Texas dismissed the case without explaining the decision, and the physicians have 60 days to file a new complaint with additional support. Due to the appeals process, Blue Cross Blue Shield of Texas had no comment.

60 Minutes Source Article | Comments Courtesy of Matt Zavadsky

For those of you who may have missed it, 60 Minutes aired a very interesting story about an attorney taking on the opioid manufacturers and distributors.  He’s the same attorney who won the big tobacco settlement and the BP gulf oil spill settlements.

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Opioid Crisis: The lawsuits that could bankrupt manufacturers and distributors

The attorney behind a multibillion-dollar tobacco settlement in 1998 has turned his attention to the opioid epidemic. And he wants drug companies to pay

December 16, 2018

Mike Moore says he's, "just a country lawyer from Mississippi." But this country lawyer has engineered two of the most lucrative legal settlements in American history. As Mississippi's attorney general, he engineered the historic 1998 settlement under which Big Tobacco paid billions to address smoking-related health issues. In 2015, he convinced BP to settle multibillion-dollar lawsuits over its huge oil spill in the Gulf of Mexico.

Now Mike Moore has taken aim at the manufacturers and distributors of opioid painkillers, claiming they should pay for the epidemic of addiction and death that has swept this nation. As you'll hear in a moment, he has powerful new evidence that he says proves that states like Ohio, among the hardest-hit by the opioid epidemic, should collect billions from all the companies he's suing.

Mike Moore: If we try the Ohio case, if we win a verdict against these manufacturers and distributors there, it could bankrupt them. It'd put them outta business.

Bill Whitaker: Truly? These are huge, profitable--

Mike Moore: Huge.

Bill Whitaker: --wealthy companies.

Mike Moore: Well, you know-- they can be as profitable as they want to. But-- Ohio is losing $4 billion or $5 billion a year from the opioid epidemic. And they're losing 5,000 or 6,000 people a year from overdose deaths. So when a jury hears the evidence in this case, they're not gonna award just a couple hundred million dollars. It may be $100 billion. And whoever amongst these companies thinks they can stand up to that? Good luck.

Attorney General Mike DeWine: We are hurting now in Ohio. We need help now in Ohio.

Ohio's Republican attorney general Mike DeWine, who will be sworn in next month as governor, hired Mike Moore as soon as he decided to file suit against opioid manufacturers and distributors.

Attorney General Mike DeWine: They flooded the State of Ohio with these opioid pills that they knew would kill people.

Bill Whitaker: They knew would kill people.

Attorney General Mike DeWine: If they didn't know it the first couple years, they clearly would've seen it after that. You can't miss it. When one year we had close to a billion-- a billion pain meds prescribed in the state of Ohio, you know, 69 per man, woman, and child in the state. And that lies at the feet of the drug companies. They're the ones who did that.

Ohio is one of four states Mike Moore formally represents, but he's coordinating with 30-plus states that have filed suit, and with many of the local governments, nearly 1,500 cities and counties that also are suing. He is the unofficial commanding officer of the army that's attacking the opioid industry.

Bill Whitaker: This is where your war room is located?

Mike Moore: That's right.

The unlikely "command center" for Moore's legal war is the sleepy town of Grayton Beach on Florida's panhandle.

Mike Moore: You know, in a place like this, you're not limited with a bunch of tall buildings, and coats and ties, and that kinda thing. You can think outside the box a little bit. So.

When we were in Grayton Beach, about a dozen lawyers from all around the country, some working on state cases, others on local lawsuits, had gathered for all-day strategy sessions, focused on an audacious goal.

Mike Moore: Success for me would be that we would find funding to provide treatment for all the 2.5 million opioid-dependent people in this country.

That would take many billions of dollars, of course, but remember, Mike Moore has done it before.

Mike Moore: Look, when I filed this tobacco case in 1994 there was nobody that thought that we had a chance to win. We showed up for our first hearing, and in our first hearing, so there was three of us there. On the courtroom on the other side they had 68 lawyers.

Despite that early mismatch, within four years Moore had all 50 states lined up against Big Tobacco. He did it partly by going to court, but mostly by going public.

Mike Moore: A case in court is a case in court, and that's fine. But there's also the court of public opinion. And the court of public opinion is sometime the most powerful court.

60 Minutes played an important and controversial role in the public case against Big Tobacco. Moore was interviewed for a segment that at first, CBS corporate lawyers refused to allow on the air.

Mike Moore: We're thinking to ourself, "Look, if 60 Minutes seems to be afraid of these guys for whatever reason, then what about us?" (LAUGH)

60 Minutes finally aired the segment in early 1996 after The Wall Street Journal ran a story featuring the same tobacco industry whistleblower.

Bill Whitaker: You said this in that 60 Minutes story, "This industry," talking about this-- the tobacco industry, "in my opinion is an industry…

Mike Moore in 1996: …who has perpetrated the biggest fraud on the American public in history. They have lied to the American public for years and years, they've killed millions and millions of people and made a profit on it."

Bill Whitaker: Those are pretty strong words.

Mike Moore: Well, it-- they were true. Those words were true.

Bill Whitaker: And you finally got big tobacco to cry uncle.

Mike Moore: That's right.

Bill Whitaker: They ended up paying, what, over $200 billion?

Mike Moore: $250 billion, yeah.

Bill Whitaker: So when you look back on what you did what has been the impact?

Mike Moore: We reduced smoking rates to a place that nobody ever thought was possible. So the number one cause of death in America has been reduced dramatically. That's pretty powerful.

"The distributors are saying things like, 'We're just truck drivers. We didn't know where the pills went.' Of course, they did"

Now, going after the opioid industry, Mike Moore is using the same playbook he used against tobacco and more recently against BP for the Gulf Oil Spill: build legal and public pressure until the companies see no choice but to settle, and fork over billions.

Mike Moore: Here's the deal. There's a huge pill spill in this country. It's huge.

Bill Whitaker: Pill spill?

Mike Moore: Pill spill. Huge pill spill. It never should've occurred. Everybody's got some fault. But we have 72,000 people dying every year. Let's figure out a way to resolve this thing. You guys made billions of dollars off of this. Take some of that money and apply it to the problem that you helped cause.

He's a long way from convincing the drug industry to do that, of course, that's why all the lawsuits. The first targets are opioid manufacturers like Purdue Pharma, which makes oxycontin, the pill that fueled the opioid epidemic.

Mike Moore: Purdue Pharma created an environment so that opioid use was okay. So if you prescribe your patients this drug, there's less than 1 percent chance they'll get addicted. That was a lie, a big lie.

Bill Whitaker: Can you prove that in court?

Mike Moore: Absolutely.

Purdue Pharma declined our request for an interview, but said in a statement that when the FDA approved oxycontin in 1995 it authorized the company to state on the label that "addiction to opioids legitimately used is very rare." But as evidence of abuse mounted, the company admitted in federal court in 2007 that it had misled doctors and consumers about just how addictive oxycontin can be.

Mike Moore: The Purdue Pharma case is an easy case. I hate to say it, but it's an easy case to prove. You can prove that they told the lies that they told.

It has been considered tougher to build a case against Mike Moore's other targets, the huge drug distributors who've made billions delivering opioids from manufacturers to pharmacies.

Mike Moore: The distributors are saying things like, "We're just truck drivers. We didn't know where the pills went." Of course, they did. There's a Controlled Substance Act. Controlled Substance Act. You're supposed to control these pills. And when you don't, you have a responsibility for it. It-- it's real simple.

"The stories that you've heard from some of the DEA investigative agents concerning the large volumes of pills going into certain parts of our country are absolutely true."

It's also simple why Moore is going after the biggest players in drug distribution: because they have much deeper pockets than the manufacturers. Purdue Pharma, for example, had less than $2 billion in revenue last year. Distributor McKesson, by contrast, had $208 billion in revenue.

Mike Moore: McKesson, you're the sixth largest company in this country. You're telling the American public you didn't have systems in place to adhere to the Controlled Substance Act? Seriously?

Mike Moore and his allies now have what they characterize as devastating evidence proving that distributors knew what they were doing. A huge confidential DEA database called ARCOS tracks all transactions involving controlled substances. This spring, a federal judge in Cleveland who is hearing many of the local lawsuits ordered all that data to be handed over to the plaintiffs' lawyers.

Burton LeBlanc: And I can actually tell you which distributor distributed to which particular pharmacy, by year, by volume, and where the pills came from.

Burton LeBlanc is a Louisiana lawyer who regularly huddles with Mike Moore in Grayton Beach. His firm represents hundreds of cities and counties in their opioid lawsuits, and his team has taken the lead in analyzing the ARCOS data.

Burton LeBlanc: In terms of the wholesale distributor's duty to report suspicious orders, we can immediately look at volume and detect patterns with the data that we currently have.

Bill Whitaker: So, you can see that for every pharmacy in the-- in the country?

Burton LeBlanc: I have it for every transaction in the United States.

Bill Whitaker: What's the most important thing that it has shown you?

Burton LeBlanc: That the stories that you've heard from some of the DEA investigative agents concerning the large volumes of pills going into certain parts of our country are absolutely true.

One of those stories concerned Kermit, West Virginia, a town of just 400 people, where nine million opioid pills were delivered in just two years to a single pharmacy.

Bill Whitaker: Did the companies have access to this information?

Burton LeBlanc: It was their data.

That data has now been shared with state attorneys general, including Ohio's Mike DeWine.

Attorney General Mike DeWine: I'm not allowed to talk about the specifics. But I will simply tell you it's shocking.

Anyone who was looking at those numbers, as those middlemen were, as these distributors were, clearly, clearly should've seen that something was dramatically wrong.

"If they cared enough, maybe we would not have lost 500,000 lives from this problem."

Like Purdue, drug distributors declined our request for an interview, but in a statement from their trade association, said, "it defies common sense to single out distributors for the opioid crisis… distributors deliver medicines prescribed by a licensed physician and ordered by a licensed pharmacy." But Mike Moore insists that does not let the companies off the legal hook.

Mike Moore: If you've got walking around sense and you care, you're gonna check before you send nine million pills to a little, bitty county in West Virginia or Mississippi or Louisiana or Ohio. You're gonna check if you care.

Bill Whitaker: You think they don't care?

Mike Moore: I don't think they cared enough. And if they cared enough, maybe we would not have lost 500,000 lives from this problem. It's-- it just-- it appalls me.

Trial dates have been set for next year in a few of the state and local cases. But rather than go to trial, and just as he did with tobacco, Mike Moore hopes to force a mega-settlement to fund drug treatment, prevention, and education.

Bill Whitaker: You had to have thought about how much money you would need to do the projects that you foresee?

Mike Moore: Oh, I've seen all the models. To be effective, we need at least $100 billion to start off with.

Bill Whitaker:  And I know you've heard the criticism, that with all these lawyers involved, that this is just a bunch of trial lawyers looking for a great, big payday.

Mike Moore: Right. I don't care one whit about any money in this case. Not one whit whatsoever about it.

Bill Whitaker: Nobody's gonna believe that the attorneys are not going to make any money.

Mike Moore: No, no, no. No, no, and I'm not saying that. I was talking about-- all I can speak for is me.

Bill Whitaker: You made money off tobacco.

Mike Moore: Nope, not a penny.

That's because for all the years of the tobacco litigation, and many years after, Moore was working for a modest state salary as Mississippi attorney general.

Bill Whitaker: You made money off of BP spill.

Mike Moore: I made some money on helping resolve the case, yeah.

Moore has made enough money to be comfortable. At age 66, this may be his last big case, and he believes the ARCOS data gives him the ammunition he needs to demolish the opioid industry's argument that it should not be blamed.

Mike Moore: Nobody in the world's gonna believe that. And-- and don't go try to tell that to 12 jurors in Mississippi or Ohio who've lost people from this. You know what-- (LAUGH) you know what those jurors are gonna do? They're gonna go in the back room, they're gonna spend about 30 minutes thinking about it, gonna come back out and bam.

Produced by Rome Hartman. Associate producer, Sara Kuzmarov.

By Wayne C. Harbour, NRP , Matt Zavadsky, MS-HSA, NREMT  

Ask EMS professionals to define “quality in EMS” and you may get a tip of the head and an answer like, “Well, I’m not sure, but I know it when I see it.”

In today’s healthcare environment, demonstrating quality is crucial. Payers are increasingly linking payment to outcome and quality, and becoming less interesting in paying for services that don’t add value or are quality-based.

Read the full article in JEMS>

Modern Healthcare Source Article | Highlights by Matt Zavadsky

Health insurer, employer groups call on Congress to end surprise billing

By Shelby Livingston  

December 10, 2018

Nine groups representing health insurers, employers and consumers on Monday called for federal legislation to protect patients from surprise medical bills from out-of-network providers.

Surprise medical bills may arise when a patient unintentionally visits a doctor or healthcare facility that does not contract with the patient's health insurer. This sometimes occurs when patients are taken to an out-of-network emergency department during a crisis. Surprise billing is common, with 4 in 10 insured adults reporting they received a surprise medical bill in the last year, a Kaiser Family Foundation poll found in September.

The groups—which include powerful lobbyists like the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the National Business Group on Health, and Consumers Union—called on Congress to prohibit providers from billing patients for costs not covered by the health plan when the out-of-network visit isn't the patient's fault. But they also said Congress should ensure any policy enacted doesn't increase premiums or discourage providers from joining a health plan's network.

The other organizations involved include the American Benefits Council, The ERISA Industry Committee, Families USA, the National Association of Health Underwriters and the National Retail Federation.

While the groups committed to keeping patients informed about which doctors and facilities are out of network, they ultimately pinned the blame for surprise billing on providers. 

"When doctors, hospitals or care specialists choose not to participate in networks, or if they do not meet the standards for inclusion in a network, they charge whatever rates they like," the groups wrote. "The consequence is millions of consumers receiving surprise, unexpected medical bills that can often break the bank." 

The CEOs of the American Hospital Association and the Federation of American Hospitals quickly hit back in a joint statement, saying health plans' inadequate provider networks for emergency care are one of the "root causes" of surprise medical bills.

While some states, including California, Connecticut, Florida, Illinois, Maryland and New York, have passed comprehensive consumer protection laws to protect patients from surprise out-of-network medical bills, the federal government has yet to tackle the issue. That may change soon. In August, a bipartisan group of senators introduced the Protecting Patients from Surprise Medical Bills Act, which would protect patients from large out-of-network charges if they were being treated at an in-network facility.

Source Article | Comments courtesy of Matt Zavadsky

Kudos to Chief Lyman and his team at Greeley Fire!

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Colorado Fire Department Reduces 911 Calls By Helping Frequent Callers

By MICHAEL DE YOANNA • DEC 4, 2018

MICHAEL DE YOANNA / KUNC

The Squad 1 crew makes their way to their truck at a downtown Greeley fire station. They're walking, not running, and once their truck is on the road, there are no flashing lights.

"We hardly ever use the siren," says driver Darren Conradson.

This is the Greeley Fire Department's solution to a vexing problem: 911 calls that simply aren't emergencies. 

Instead of sending a big engine with several firefighters -- and possibly police officers and paramedics -- Squad 1 may take the call instead. None of the crew members are firefighters. Conradson is a community paramedic. The other crew members include a crisis intervention counselor and experts at helping people navigate the complex world of social services.

Their truck is red, but it's an ambulance. It comes to a stop at Paul Villa's small house. He's 89 and used to work in the fields and then at the local meat plant.

His goal is to keep living in his home, but he's had to resort to 911 several times for help -- but not always for what the fire department would consider an emergency.

Proactive steps, like this simple check-in, aim to prevent those non-emergency calls, Conradson said.

"So are you still good on your test strips?" Conradson asked Villa.

"Yeah," Villa replied. "I'm OK."

"And glucometer?" Conradson asked.

"M-hmm," Villa said. "Good."

 

Five people, 200 calls to 911

This proactive approach, mixed with Squad 1's triaging of 911 calls as they come in, represents a major shift in culture and thought for the fire department.

"We're very traditional," Chief Dale Lyman said with a laugh. "We like to send lots of people and big trucks to things."

The department is set up to respond to fires, life-or-death medical emergencies, hazardous materials situations and rescues. Yet too many 911 calls, Lyman said, are more along the lines of personal emergencies, like people who couldn't get to a doctor's appointment or can't find a way to pick up their prescription.

"So they get to a point where, 'Well, I'll call 911 and maybe somebody can help me,'" Lyman said.

 

"There is a segment of our population in our community that doesn't -- I'll just say it -- they don't have access to health care like you or I would."

For years, firefighters have exchanged anecdotes about such calls. That inspired Lyman to dive into the department's 911 data to learn more.

First, the obvious: 911 calls to the Greeley Fire Department are up significantly. Since 2001, they have risen by more than 160 percent thanks, in large part, to the city's growing population.

Yet Lyman uncovered another driver of the calls: social ills.

"The data, once we started looking at it, proved it," Lyman said. "There is a segment of our population in our community that doesn't -- I'll just say it -- they don't have access to health care like you or I would."

He also identified what he calls "super utilizers," people who call the department often, posing a big challenge for the

increasingly-stretched department. In 2016, just five people generated more than 200 of the department's 911 calls.

One of them was a homeless person and chronic alcohol abuser who called 86 times, prompting 86 trips to the emergency room.

Another one, with mental health problems, made 26 of the calls and took 20 trips to the ER.

"It was insanity," Lyman said. "We're sending this highly-trained expensive crew -- fire apparatus, equipment -- for legitimate big-scale problems just over and over again to these things that don't need that. (…) It was a vicious cycle that needed to be stopped."

When Squad 1 hit the streets in a pilot last year using one of the station's old Chevy Suburbans, the frequent callers didn't just stop. But once the crew started securing long-term services and/or substance abuse help for the group, the number of 911 calls they made dropped significantly.

 

Squad 1 in action

After saying goodbye to Paul Villa at his house, Squad 1's crew gauge what they can do for him. Team member Meredith Munoz is also a coordinator with the nonprofit North Colorado Health Alliance and the Community Action Collaborative.

"He's afraid if he goes and gets care because they're going to say you need to go to a nursing home or something," she said. "His wish is to die in this house so he's very reluctant to even leaving."

That concerns Jayme Clapp, a mental health therapist with the nonprofit North Range Behavioral Health.

"I'm assessing his loneliness and if he's had contact because that can lead to a lot of physical problems," she said. "We want to make sure he doesn't lose contact with somebody who is checking to see."

Lyman said Squad 1 has the potential to make a positive dent on the homeless community. He told the story of one man who was linked to counseling and services through the crew and has since found a job.

"That's huge," Lyman said. "That's one less person that might be out on the streets or sleeping in the park because of substance abuse or whatever the case may be."

Greeley isn't alone in trying the concept. Departments in Colorado Springs and at least two other states -- New Mexico and Arizona -- have similar units and other departments around the country are studying the idea.

 

A growing need

So far this year, more than 12,700 calls have been made to 911. Squad 1 began operating in Feb. 1, and since then has run more than 350 of those calls.

 

"That's one less person that might be out on the streets or sleeping in the park because of substance abuse or whatever the case may be."

Yet the number of calls the squad is potentially needed for is much higher -- two, maybe even three, times as high. The squad only has funds to run 40 hours a week, not round-the-clock, meaning firefighters are still responding to non-emergency 911 calls.

But before Squad 1 existed, Lyman said, firefighters weren't always able to help people facing a personal crisis. That led to frustrations, he said, because firefighters want to be helpful. Now, firefighters can refer cases to the squad's crew for follow-up.

He said he's seeking additional streams of funding to cover more hours for the unit.

The existing funding is from the nonprofits that participate and, on the department's side, carved out of a savings the squad helped create. Because of Squad 1, the department hasn't had to send out his big engines to respond to as many 911 calls.

"Less miles," Lyman said. "Less wear and tear. Less fuel."

Beckers's Source Article | Highlights Courtesy of Matt Zavadsky

BCBS of Texas beats physician lawsuit alleging ER underpayments

Written by Morgan Haefner

December 05, 2018 

A lawsuit filed by 49 physician groups against Blue Cross Blue Shield of Texas was dismissed Dec. 3, according to Bloomberg Law.

The physicians' lawsuit accused BCBS of Texas of underpaying 250,000-plus claims for emergency medical care. Earlier this year, the health insurer announced a new discretionary ER policy, under which a medical director hired by the insurer reviews claims after the ER visit to determine the reason a patient opted for the ER and if they could have received treatment in a less expensive setting.

In the original lawsuit, the physician groups said BCBS of Texas reimburses out-of-network providers at a rate that violates state law and regulations. The judge's two-page order did not explicitly explain why the case was dismissed, according to Bloomberg Law. The physician groups have 60 days to submit a new complaint with additional supporting facts.

Anthem launched a similar policy in multiple states and has faced harsh criticism as well as numerous lawsuits. A recent report from Sen. Claire McCaskill, D-Mo., found the insurer denied 12,200 claims from members in three states during the second half of 2017 on the grounds the ER visits were "avoidable." However, when patients challenged the denials, Anthem proceeded to reverse itself and pay the claims most of the time.

Modern Healthcare Source Article | Highlights courtesy of Matt Zavadsky

Fewer hospitals earning Medicare bonuses under value-based purchasing

By Maria Castellucci  | December 3, 2018

Roughly 1,550 hospitals will receive a bonus from Medicare in fiscal 2019 under the Hospital Value-based Purchasing Program, according to the CMS. The results are slightly worse than last year when more hospitals earned bonuses.

About 55% of hospitals earned Medicare incentive payments in fiscal 2019 compared with fiscal 2018, when 57% of the hospitals did, or just under 1,600.

The program, which kicked off in 2012 as mandated under the Affordable Care Act's efforts to move away from fee-for-service, ties hospitals' Medicare reimbursement dollars to how well they perform and improve on various quality measures.

The CMS imposes a 2% reduction to base diagnosis-related group payments for about 2,800 hospitals paid under the Inpatient Prospective Payment System. Medicare redistributes that money to hospitals that receive high scores in four areas: clinical care; safety; person and community engagement; and efficiency and cost reduction. Each domain accounts for 25% of the total hospital score. 

Similar to last year, about $1.9 billion will be awarded to hospitals in the form of value-based payments in fiscal 2019. The program is paid through a 2% reduction in all payments and is budget-neutral, meaning the highest-performing hospitals can earn back bonuses greater than the payment reduction, while others may receive small or no payment increases.

For about 60% of the hospitals, the changes to their DRG payments will be small, in the range of plus or minus 0.5%. The average net payment adjustment is 0.17%. The highest-performing hospital in fiscal 2019 will receive a payment increase of 3.67% while the lowest-performing hospital's payment will be cut by 1.59%, according to the CMS. 

Even though slightly fewer hospitals received bonuses, the average performance scores across all the hospitals in fiscal 2019 improved from last year. The average total performance score was 38.1, a slight increase from fiscal 2018 when the average score was 37.4.

JAMA Source Article | Comments Courtesy of Matt Zavadsky

Interesting study, and even more interesting (concerning) potential causes from the study authors.  The accompanying editorial attempts to offer alternate reasons for the response time differences that are at least slightly more logical.

**Special Note: some of the terminology used relates to ambulance response time, but the average “EMS Response Time” indicated in the article of 37.5 minutes indicates this is the total EMS time – including transport to an ED.  This is evident in the study, but not clear by the study title and editorial headline**

There seems to be two important take-a-ways from this research:

1. There still appears to be an illogical assumption that faster ambulance response times equate to improved patient outcomes, something that has been refuted in numerous studies published in peer-reviewed journals. 
   • This study only looked at cardiac arrest cases, which represent a small % of overall EMS volume and a condition in which numerous factors other than ambulance response time has an impact (bystander CPR rates, AED use, 1^st Responder response times, etc.)
     

1. Many progressive EMS systems use the philosophy of on-scene stabilization prior to transport due to evidence-based research supporting this treatment modality. 
   • The researchers in this study do not seem to take that into account in the time analysis.
     

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Poor communities wait longer for ambulances, causing health disparities

By Steven Ross Johnson  | November 30, 2018

Patients that experience heart attack in low-income neighborhoods tend to wait longer for emergency medical services to arrive than those living in more affluent communities, a discrepancy that could drive health disparities between the groups.

Ambulances took an average of four minutes longer to handle calls from low-income areas than high-incomes neighborhoods, according to an analysis published Friday in JAMA Network Open that looked at more than 63,000 cases of cardiac arrest. The study marks the first national study evaluating disparities in 911 responses for cardiac arrest in high-income and low-income neighborhoods.

Researchers measured the time it took ambulances to arrive at a patient's location after it was dispatched, how long it took an ambulance on the scene to depart, how long it took to transport a patient from the scene to the hospital, and the total emergency medical services time. 

The study found communities where the annual median income was between $57,000 and $113,000 had an average overall emergency response time of 37.5 minutes compared to 43 minutes in ZIP codes where the median income ranged from $20,250 to $42,642. Researchers also found EMS responses were more likely to meet nationally recognized benchmarks of arriving within eight minutes to a like-threatening event.

Study lead author Dr. Renee Hsia, professor of emergency medicine at the University of California San Francisco and an emergency physician at Zuckerberg San Francisco General Hospital and Trauma Center, said the findings help to show one of the many inequities that have contributed to the widening gap in health outcomes between poorer and wealthier Americans.

Research published in 2017 in Health Affairs found that 38% of people living in households with annual incomes of less than $22,500 reported to be in poor to fair health between 2011 and 2013 compared to just 12% of individuals making more than $47,000 a year. 

"We've been talking about disparities for decades in the United States and a lot of time people think it because physicians might be biased, but this shows that there are systemic issues that we can do something about," Hsia said. "It's not just about training providers to be more culturally competent there are system-level biases that exists, and this is one of them."

Hsia said there were a number of potential factors that could contribute to the disparity in ambulance wait times. 

She said it was possible that the spate of hospital, emergency department and privately-owned ambulance company closures in recent years could be a contributing factor for the longer wait times. Previous research has found EDs tend to have a higher closure rate in hospitals that regularly receive a high proportion of uninsured patients due to the low reimbursement they receive. 

A 2014 Health Affairs study also authored by Hsia found the number of EDs in the U.S. decreased by 6% between 1996 and 2009. That study found one-quarter of hospital admissions between 1999 and 2010 occurred near an ED that had closed, which led to a 5% increase in the odds of mortality at those hospitals.

The study surmised closures could have led to longer EMS times because of the added strain it put on existing emergency departments that become more overcrowded, and lead to diverting ambulances more often to other facilities that increases transportation times.

But Hsia said another factor for the disparity in wait times could be related to the increase in recent years in the number of privately-owned ambulance companies that are contracted by local governments to provide services to their communities. More cities and towns have turned to for-profit ambulance providers to save money since those companies tend to bill commercial and public insurers or the patient directly for their services.

Hsia said it was possible that the shift in who's answering those emergency calls could be contributing to the disparity since companies would likely try to position their resources to better meet the needs of communities that are more likely to give the best returns.

Hsia said government EMS directors might benefit from looking more closely at whether the response times of ambulance providers they consider contracting with are distributed evenly across poorer and richer communities.

"I think that it's important policymakers realize that as there are these shifts going from publicly-funded entities that are providing these services to privately-funded entities that there may be different incentives that underlie their provision of these services," Hsia said. 

Evidence has shown delays in ambulance response times can have a large impact on mortality rates. A 2001 study published in the medical journal BMJ concluded reducing ambulance response times to five minutes could almost double the survival rate for cardiac arrests.

Source Article from KRWG | Comments courtesy of Matt Zavadsky

Kudos to Paul Ford and his team at Las Cruces Fire Department!

Las Cruces Fire Department: Mobile Integrated Healthcare

By CASSIE MCCLURE • NOV 30, 2018

Firefighters walk not only into flames, but into the homes of citizens. It’s in these homes that the Las Cruces Fire Department (LCFD) has seen a new need it can provide to the community - connecting citizens with resources that may aid in the quality of their lives.

For the last two years, LCFD has provided the Mobile Integrated Healthcare program to the resident of Las Cruces. It came first from the recognition that there was a gap in healthcare for those residents who want retain their independence in their homes, but who had been depending on LCFD fulfilling their needs.

“The challenges are anywhere from transportation-related to as simple as having durable medical equipment fail and repairs not being covered by their insurance or Medicaid,” said Paul Ford, LCFD Mobile Integrated Healthcare coordinator. “Since we’ve started the MIH program, and investigating their needs, we’ve seen a profound drop in those who would call the fire department at least once a day, by almost 90 percent.”

Ford, along with part-time staff, focuses on finding the barriers between residents and resources within the Las Cruces community to manage their care for example helping them get their medications or being able to repair their walkers or even let them know about reduced- price transportation for seniors in Las Cruces.

“We understand that many people do not want to lose their independence,” said Ford, “and when we knock on their door, they are usually more willing to open up and let us see the real situation they are in. Sometimes all it takes is to get their permission to call their children to let them know that their parent needs more help.”

LCFD works with both Memorial Medical Center (MMC) and MountainView Regional Medical Center (MVM) to invite physicians and social workers to join them on visits, bridging the gap between what a provider may see at a clinic to the condition that patients may face at home.

Dr. Roberto Aguero, a second-year medical resident at MMC, “I think every doctor in primary care should have this experience. It lets you see the harder aspects of what patients have to deal with to get to their doctor appointments and be on medications and get medications and what happens if they can’t get to follow-up appointments. Some can’t get out of the door or have literacy issues.”

Aguero explains that what happens with an emergency transport is not only not the best care for a patient long term, but also isn’t the best for the community. “Ending up in the emergency department is the worst place to get your care.

It’s the most expensive and the least effective,” said Aguero. “Something like the MIH program can get into their homes and see what their needs are and gets them out of the hospital; it pays for itself 10 times over.”

He recalled a patient in Silver City who would benefit from a program like MIH. “She has schizophrenia and a hypothyroid, but when she forgets to take her medicine, she quickly decompensates,” said Aguero. “For a 20-year-old lady who is trying to stay in school and get ahead, very disabling to her and threatens her success in life.”

LCFD also reached out to New Mexico State University to create a partnership where graduate students from its social work program work with MIH to fill gaps, especially with case management. Mendy Fowler, in her last year in the graduate program, was the first student who rode along with Ford on patient visits.

“We get to have the boots-on-the-ground experience,” Fowler said. “We can evaluate the resources that the community has to offer, and find the gaps, especially for transportation.”

“But there are so many barriers, not just transportation,” said Fowler. “Other things are an issue, too, like food and housing insecurity, and even problems with heating and cooling. We are working to lessen some of the health disparities that the community faces by lessen barriers and make those connections to the community.”

If you are interested in knowing more about the MIH program, or would like to make a connection between the program or a business that may be a new resource for the MIH program to the community, please contact Paul Ford at (575) 528.3473 or pford@las-cruces.org.