News & Updates

EMS agencies should pay close attention to the potential Medicaid and Medicare changes proposed in this bill that will likely impact reimbursements to EMS agencies. Specifically:

Medicaid – 

- Reduces the number of Medicaid beneficiaries through work requirements and other eligibility limitations.
- Bars states from using State Directed Payments to require Medicaid HMOs from reimbursing more than 100% of Medicare reimbursement for similar services, or 110% of Medicare in non-Medicaid expansion states.
- Mandates cost-sharing up to $35 for services provided to Medicaid expansion enrollees with incomes above the federal poverty level, which is $15,650 for a single person.
- Limits retroactive provider reimbursements for newly enrolled Medicaid recipients to one month instead of three.

Medicare – 

- Triggers Medicare cuts under the Statutory Pay As You Go Act of 2010 that could include reductions in provider reimbursements.

Also recall that CMS released a proposed rule last week, that according to the language in CMS' release, "would end states’ ability to exploit a health care-related tax loophole currently used by seven states to generate billions in federal Medicaid payments—without contributing their fair share or expanding care for Medicaid enrollees".

We recommend strong engagement with local and national EMS advocacy organizations and keeping abreast of these potential legislative and regulatory changes.
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What the 'One Big Beautiful Bill' does on healthcare

Michael McAuliff

May 22, 2025

https://www.modernhealthcare.com/politics-policy/big-beautiful-bill-medicaid-medicare-pbms

The House passed a sweeping tax-and-spending cuts bill Thursday that would dramatically reshape the healthcare system by slashing more than $1 trillion from Medicaid and other programs.

The majority Republican lower chamber voted 215-214 to approve the One Big Beautiful Bill Act of 2025 just before 7 a.m. EDT after an all-night floor debate. Attention now shifts the GOP-led Senate, which has not commenced public debate on its tax measure. Congress is scheduled to begin a recess Friday and will return to Washington on June 2.

The legislation was in flux all week as Republican leaders sought to balance the competing demands of hard-line conservatives who wanted deeper spending cuts and swing-district members pushing the other direction. As a consequence, the details changed, the final legislative language didn't emerge until late Wednesday, and the nonpartisan Congressional Budget Office and Joint Committee on Taxation couldn't keep up.

But the thrust of the package remained the same, even as the particulars and the numbers fluctuated. To partially offset about $3.8 trillion in lost federal revenue over 10 years from extending the tax cuts President Donald Trump enacted during his first term, House Republicans seek to reduce federal spending by hundreds of billions of dollars, according to the most recent CBO analyses. The largest source of those savings is Medicaid.

These are the key healthcare provisions from the One Big Beautiful Bill Act:

Medicaid

Establishes work requirements for adult enrollees who don't have disabilities or dependents that would begin no later than Dec. 31, 2026, and directs the Health and Human Services Department to issue guidance to states on this policy by the end of this year. Beneficiaries would have to document at least 80 hours a month of work or other qualifying activity, such as volunteering. The CBO estimated this would reduce spending by $280 billion based on an earlier iteration that wouldn't have taken force until 2029.

Bans new or increased state provider taxes and tightens standards for what provider taxes are legally permissible. The bill also bars most states from using state-directed payments to order Medicaid managed care companies to pay providers more than 100% of Medicare rates, but states that haven't expanded Medicaid under the Affordable Care Act of 2010 would be able to pay up to 110% of Medicare. Combined, these would cut federal spending by $197 billion, although the CBO analysis was based on a previous version of the bill that limited all state-directed payments to 100% of Medicare.

Orders states to maintain updated information on Medicaid enrollees, such as verifying addresses and removing deceased people from the rolls. This would save $17 billion.

Suspends a 2024 Centers for Medicare and Medicaid Services regulation designed to ease enrollment in Medicaid, the Children's Health Insurance Program and the Basic Health Program. Federal spending would be $82 billion lower under this policy.

Requires eligibility redeterminations every six months for adults covered under the ACA Medicaid expansion. This would cut spending by $53 billion.

Mandates cost-sharing up to $35 for services provided to Medicaid expansion enrollees with incomes above the federal poverty level, which is $15,650 for a single person. That is projected to reduce spending by $13 billion.

Limits retroactive provider reimbursements for newly enrolled Medicaid recipients to one month instead of three. That is projected to save $6 billion.

Reduces federal Medicaid funding to states that use their own money to cover undocumented immigrants through Medicaid. This would cut spending by $11 billion.

Cancels a regulation setting staffing minimums for nursing homes. This would reduce spending by $23 billion.

Eliminates extra federal Medicaid funding from the American Rescue Plan Act of 2021 intended to encourage states to expand Medicaid under the ACA. The provision is estimated to save $881 million.

Delays cuts to Medicaid disproportionate share hospital payments for three years. That would increase spending by $16 billion.

Medicare

Increases Medicare physician reimbursements 2% in 2026 and pegs future payment updates to the Medicare Economic Index. In addition, this provision would eliminate extra payments to physicians participating in alternative payment models. These policies would cost $8 billion.

Triggers Medicare cuts under the Statutory Pay‑As‑You‑Go Act of 2010 that could include reductions in provider reimbursements. Because the bill would increase the budget deficit by $2.3 trillion, the CBO projects the White House Office of Management and Budget would have to curtail Medicare spending by $45 billion in 2026 and $490 billion from 2027 to 2034.

Suspends a rule to facilitate enrollment in Medicare Savings Programs that cater to low-income people eligible for Medicare and Medicaid by pushing back the effective date to 2035. Savings are estimated to be $84 billion.

Expands rural emergency hospitals program. There was no cost estimate for this part of the bill.

Ends Medicare eligibility for some lawfully present foreign nationals who currently qualify by limiting the program to permanent residents who are green card holders, from Micronesia, the Marshall Islands or Palau, or, in certain cases, from Cuba. This would save $132 million.

Health insurance exchanges

Institutes stricter eligibility and income verifications for exchange customers and requires new checks for low-income enrollees with zero-premium plans. This would save $101 billion.

Shortens open enrollment period by one month.

Ends permanent special enrollment opportunity for people with incomes up to 150% of poverty and bars federal and state exchanges from establishing special enrollment periods linked to income.

Allows health insurance companies to demand premium payments before beginning coverage and to remove customers who are in arrears, regardless of income.

Ends automatic enrollment into Silver-level plans for low-income exchange customers with Bronze-level plans who qualify for cost-sharing reductions that can only be applied to Silver plans.

Those provisions combined would reduce spending by $101 billion.

Restores cost-sharing reduction payments to health insurance companies covering the lowest-income exchange policyholders, which Trump cut off in 2017. A CBO analysis from 2018 said that would reduce federal spending by $19 billion, in part because it would enable insurers to reduce premiums, which would decrease spending on premium tax credits. The bill also would withhold cost-sharing reduction payments for insurance plans that cover abortion.

Requires full repayment of excess premium tax credits regardless of enrollee income. Savings are projected to be $2.3 billion.

Expands ICHRAs — individual coverage health reimbursement arrangements — by permitting employees offered these plans to buy exchange coverage with pre-tax dollars. Creates tax credit for small employers that offer ICHRAs. This is projected to cut spending by $514 million.

Limits lawful immigrant access to unsubsidized exchange coverage and makes Deferred Action for Childhood Arrivals recipients ineligible for subsidies. This section would save $63 billion.

Bans gender-affirming care as an Essential Health Benefit under the ACA as well as Medicaid and CHIP coverage of these services. This would reduce spending by $830 million.

Pharmacy benefit managers

Requires greater transparency for PBMs in Medicare Advantage and Medicare Part D.

Orders PBMs to "delink" their compensation from the discounts they negotiate with drugmakers and instead charge set fees under Medicare Part D.

Those provisions combined would reduce spending by $402 million.

Bans spread pricing, a practice under which a PBM charges more for a medicine than the price it secured from the drug company. This would save $3 billion.

Health savings accounts

Relaxes rules governing HSAs, such as raising the annual contribution limit, declaring individual market Bronze and Catastrophic plans compatible with HSAs, and making gym memberships and some other sport and fitness costs HSA-eligible. These policies would result in $25 billion in lost tax revenue.

Two actions this week in DC may be signaling the future of GEMT programs.

First, CMS released a proposed rule Monday, that according to the language in CMS' release, "would end states’ ability to exploit a health care-related tax loophole currently used by seven states to generate billions in federal Medicaid payments—without contributing their fair share or expanding care for Medicaid enrollees". 

Second, the House Energy and Commerce Committee released their 160 page heath package for the Budget Reconciliation Act. The legislation would limit states’ ability to levy taxes on providers to finance Medicaid programs and changes Medicaid eligibility to reduce the number of Medicaid enrollees. 

The “Provider Tax” limitation language starts on page 64, line 19 of the document here.

News reports related to these two actions are below.

Recall that the CMS OIG is still auditing GEMT cost reports, and are due to release the results from their audits this year (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000786.asp),

The OIG initiated these audits following a notice from CMS to state Medicaid offices detailing their concerns about non-allowable costs being included in some GEMT cost reports (https://www.medicaid.gov/federal-policy-guidance/downloads/cib08172022.pdf).

Providers who are currently participating in GEMT programs, or are awaiting State Plan Amendment approvals from CMS, should monitor these development closely.

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CMS proposes crackdown on 'money laundering' provider tax policies
Bridget Early
May 12, 2025
 
https://www.modernhealthcare.com/policy/provider-tax-medicaid-requirements-cms
 
The Centers for Medicare and Medicaid Services is proposing to close what the agency dubs a "loophole" in an obscure form of Medicaid funding.
 
In a proposed rule released Monday, CMS seeks to tighten its oversight of state provider tax policies. The agency said it wants to ensure that states' provider taxes are either broad-based and uniform as required by law, or that states applying for a waiver from that requirement are qualified to receive one.
 
The proposed rule would also ban states from taxing Medicaid dollars higher than other payments and set deadlines for states to wind down existing provider tax policies the agency deems to be noncompliant with federal law.
 
States tax providers and insurers to help fund their share of Medicaid’s federal-state payment structure.
 
The system has garnered heavy criticism from spending hawks, who argue the dollars are returned to providers in the form of Medicaid payments down the line.
 
By law, provider taxes must be broad-based and uniform, meaning they need to apply to a vast swathe of products and services and they need to be applied at the same rate for all healthcare services within a category. States are also prohibited from reimbursing providers more than 6% of their net revenue.
 
In instances where states seek to levy a tax that doesn't meet the parameters, CMS must conduct a series of statistical tests to ensure the payments are permissible under statute. CMS can waive requirements that these taxes be broad-based and uniform in some instances — for instance, when regulators determine that a state’s tax would be generally redistributive, meaning revenue from taxes on non-Medicaid services would be used to fund the state's Medicaid share. 
 
Now, CMS is looking to tighten its oversight.
 
The agency says in its proposed rule that it has found loopholes in the statistical test it uses to determine whether states’ provider tax proposals are generally redistributive. Some waivers have passed the test but are not generally redistributive, particularly for taxes on Medicaid managed care organizations, the rule says.
 
In response, the agency proposes to ban states from effectively taxing provider revenue from Medicaid at higher rates than Medicare or commercial healthcare, even if a state's tax proposal passes the statistical testing required by law.
 
The agency estimates finalizing the rule would save more than $30 billion in the next five years, according to a fact sheet on the proposal, adding that the issues in its statistical tests represent “a Medicaid tax loophole exploited by states to inflate federal payments to states.”

“States are gaming the system — creating complex tax schemes that shift their responsibility to invest in Medicaid and rob federal taxpayers,” said CMS Administrator Dr. Mehmet Oz in a news release on the proposed rule.
 
CMS also proposes to ban “vague language” in states’ proposals that it says conceals taxes focused on Medicaid. The agency says it will closely assess “language that does not specify Medicaid explicitly, but appears to invoke it implicitly,” such as language identifying the providers and services that would be taxed.
 
All states except Alaska have some form of provider tax, according to a March analysis from KFF: 45 states tax hospitals and 46 tax nursing homes, while 20 states have provider taxes on managed care organizations.
 
If finalized, the rule would also set timing requirements depending on when a state’s waiver was last approved. States that have had a waiver approved within the last two years would not be eligible for a transition period, CMS proposes, but any states outside that window would have one year from the date of the final rule to come into compliance.
 
Some hospital groups are criticizing the proposal, which would come as yet another blow to the Medicaid program. Hospitals have been embroiled in a firestorm of lobbying to stave off sweeping funding cuts.
 
“While we are still reviewing the proposal, any effort to reduce provider taxes would harm long-term care facilities and hospitals’ ability to care for Medicaid patients. These taxes are essential to keeping state Medicaid programs afloat and enabling hospitals to continue providing critical health care services to their communities,” said Marie Johnson, senior director of media relations for the Catholic Health Association of the United States, in an email.
 
Republicans on Capitol Hill have set their own sights on provider taxes. Lawmakers are looking to curtail certain provider taxes and eliminate others in a sweeping reconciliation package released Monday as lawmakers look to generate substantial savings from the Medicaid program.
 
The CMS regulation was first listed in a December 2024 Unified Agenda published by the White House Office of Management and Budget in the final weeks of President Joe Biden’s tenure.
 
Comments are due in July.
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House Republicans release Medicaid cuts proposal
By: Jakob Emerson
5/12/25
 
https://www.beckershospitalreview.com/legal-regulatory-issues/house-republicans-release-medicaid-cuts-proposal/
 
House Republicans unveiled legislation May 11 that would introduce Medicaid work requirements nationwide and stricter eligibility requirements.

The 160-page bill, introduced by the House Energy and Commerce Committee as part of a broader budget reconciliation package, aims to reduce federal spending by hundreds of billions of dollars over the next decade, with Medicaid and ACA programs facing the majority of the proposed cuts.
 
The legislation calls for more frequent eligibility redeterminations and strict address verification processes to prevent duplicate enrollment across states, and managed care organizations would be required to relay updated address information to Medicaid programs.
 
A key provision mandates that able-bodied adults aged 19 to 64 without dependents work at least 80 hours per month or participate in community engagement activities to maintain their Medicaid coverage, with exemptions for pregnant individuals and certain other situations. States that fail to verify citizenship or immigration status among enrollees could lose federal funding for those individuals’ benefits. The proposal would also ban the use of Medicaid and CHIP funding for gender transition procedures for individuals under the age of 18.
 
The bill does not propose per capita caps or a complete overhaul of Medicaid expansion funding, but it does include provisions to penalize states financially if they provide Medicaid benefits to noncitizen residents by reducing their ACA expansion matching rate.
 
The GOP proposal would also shorten the retroactive coverage period under Medicaid from three months to one and eliminate federal reimbursement for benefits during the “reasonable opportunity” period in which applicants verify immigration or citizenship status, unless verification is completed.

The legislation would limit states’ ability to levy taxes on providers to finance Medicaid programs, which are typically imposed on hospitals, nursing facilities, and physicians.

The bill also includes provisions aimed at pharmacy benefit managers, requiring that contracts between states and PBMs adopt a transparent pass-through pricing model to limit payments for prescription drugs to the ingredient cost and dispensing fees. Additionally, any payments to PBMs for drugs must be fully passed through to pharmacies or providers. The bill would also ban the use of spread pricing within Medicaid programs.
 
Democratic lawmakers and hospitals have criticized the legislation, pointing to an analysis from the Congressional Budget Office indicating the bill could cut Medicaid and ACA spending by up to $715 billion over the next decade and result in at least 8.6 million people losing insurance coverage by 2034. Hospital and health system leaders have been outspoken about proposed cuts, warning that even without FMAP reductions or per capita caps, the cuts could still deliver a blow to hospitals and their patients.
 
“Congressional Republicans and President Trump rightly pledged to protect Medicaid benefits and coverage – this bill fails that test,” Federation of American Hospitals’ President and CEO Chip Kahn said. “It is imperative Republicans go back to the drawing board; too many lives depend on it.”
 
The bill is scheduled for markup in the Energy and Commerce Committee on May 13 and will need to pass in the narrowly divided House and Senate.

Many EMS agencies across the country are struggling financially, leading to challenges retaining and recruiting staff, resulting in service delivery challenges and even closures of EMS agencies.

PWW Advisory Group (PWW|AG), in partnership with EMS|MC, is launching a new EMS Financial Index: Driving Change Through Data and Best Practices.

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This inaugural report, with a foreword written by the Rob Lawrence, the President of the Academy of International Mobile Healthcare Integration (AIMHI), reveals data broken down by region of the country such as:

• Average Base Fee
• Level of Care Billed
• Dollars Collected
• Average Reimbursement by Payer Classification

The index report will be released quarterly, highlighting various benchmark revenue cycle data from the over 1,500 agencies serviced by EMS|MC across the U.S. and will focus on several consistent themes, as well as specialized content each period.

It is our hope that sharing benchmark data, along with best practice recommendations, will help EMS agencies assess their revenue cycle management (RCM) practices and outcomes to improve their financial health.

Click below to download this free report: 

Stay tuned for the next report in July, which will cover metrics including:

• Emergency call service mix (BLS, ALS ALS2, TIP)
• Commercial insurer claims, payer paid vs. patient paid
• Medicare FFS vs. Managed Medicare Reimbursement
• Payments for Treatment in Place (TIP) services

Is there national and regional data YOU would like to see included in future index reports? If so, click here and send us your request.

Nice to see the progressive leaders of an outstanding EMS agency implementing scientific, evidence-based system design changes to enhance patient care, improve employee morale, and reduce system costs!

An overview of the assessment that led to these changes, and how the KCEAA Team is implementing these them will be presented at the upcoming American Ambulance Association Conference and Trade Show in Lexington, KY June 22 - 24, 2025.

Response Reboot? Implementing Data Driven Decisions for System Sustainability – A Case Study

https://annual.ambulance.org/session/response-reboot/  

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KCEAA implementing changes to cut costs while improving service
by: Blake DeJarnatt
May 5, 2025
 
https://www.wowktv.com/news/west-virginia/kanawha-county-wv/kceaa-implementing-changes-to-cut-costs-while-improving-service/
 
CHARLESTON, WV (WOWK)- Leaders with the Kanawha County Emergency Ambulance Authority met Monday to discuss how they can tackle a $4 million deficit, while improving the quality of their medical care.
 
The way it works now is whichever ambulance is closest to an emergency call is dispatched, even if they aren’t best suited for the job. In partnership with Metro 911, they plan to implement “tiered responses,” a system that would ensure the best ambulance available for the situation would be dispatched, regardless of proximity to the emergency.
 
“Tiered response is basically taking the appropriate ambulance and dispatching it to the appropriate situation. So, if you have a cardiac situation, you need one level of staffing as opposed to, say, you have a sprained ankle, that kind of simplifies it. Taking advances in technology and making sure the appropriate ambulance, the appropriate equipment is being dispatched to the appropriate situation,” said Tom Susman, a spokesperson for KCEAA.
 
This system would ensure that Advanced Life Support (ALS) vehicles would be dispatched to dire emergency situations, like a heart attack or stroke. Basic Life Support (BLS) vehicles would be reserved for what would be considered minor injuries, like a sprained ankle or broken finger.

Susman says that this initiative could save costs when it comes to how to best utilize resources and cut back on overtime pay for paramedics. When a BLS squad is sent to a critical situation, they may take more time at the scene than an ALS squad would.
 
“I think you’d be able to save KCEAA money because you’d be able to do away with some duplication. It would be a more efficient use of resources. It’s also good for paramedics. The staff want to be able to dispatch to their level of training. So, for example, you don’t have a primary care doctor going to the cardiac unit, and conversely, you won’t have a cardiac doctor going to a primary care situation,” said Susman.
 
Susman says the KCEAA is also putting feelers out in having a third-party organization take over their billing operations. He says that they’re still waiting on the board of directors’ approval, but that having a third party take over could lead to a more streamlined and cost-effective billing process.
 
“Billing in medical services is becoming more and more complicated,” said Susman. “You need to keep your equipment up, ’cause insurance companies are tough to bill with. So, if you have somebody who does this for hundreds of thousands of people across the country, or millions of people, they have better systems than a stand-alone EMS agency might have. So, it’s really, it’s just trying to find out if there’s a way to do it that generates more resources and better use of the dollars.”
 
Susman says that some of the main reasons for the $4 million deficit are increased operating costs, offering competitive pay for their paramedics, and low reimbursement rates from insurance companies.
Susman says that they plan on implementing tiered responses in the next 90 days, but they won’t launch the new system until they are certain it will work the way they have planned. 

Interesting comments from the fire chief, and another example of the need for EMS and community leaders to implement evidence-based system design changes in EMS systems, such as:

• Effective, quality assured, medical director approved Emergency Medical Dispatch (EMD) to prioritize EMS requests based on acuity.
• Dispatch processes to navigate calls that can be effectively dispositioned from the PSAP, without sending an ambulance.
• Lengthening response times to low-acuity calls to maintain readiness/availability of resources to reduce response times for the 5-10% of high acuity calls.
• The use of a tiered deployment strategy (BLS and ALS units), as well as potentially single-resource Community Health units to respond to low-acuity EMS calls that have a low propensity for requiring transport to an ED.
• Stopping the ability for hospitals to violate EMTALA rules and rob community EMS resources by EMS agencies allowing hospitals to hold EMS crews at the hospitals..

5-7% of the patients EMS responds to require Potentially Life-Saving Interventions, and studies have shown that cardiac arrest patients have better outcomes if the time from time of call to CPR initiation is within 4 minutes, yet few EMS systems are designed to meet this goal, or track or report this important metric.

Effective community education is key to implementing these evidence-based system changes. View a recent webinar on "Expectations vs. Reality" with physician EMS leaders here: https://aimhi.mobi/ondemand/13420011 

Download a summary document of evidence-based patient outcome research and joint position statements on issues like response times, ALS utilization and performance metrics , with links to the source studies here:  References-Resources on Response Times - All ALS and EMS Performance Measures Updated 5-1-25.pdf

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A study finds long EMS response times in DeKalb. What are the reasons?

By Michael Doudna, WSB-TV

April 29, 2025

https://www.wsbtv.com/news/local/dekalb-county/study-finds-long-ems-response-times-dekalb-what-are-reasons/EVT4J3H5EJAQ3PW4Z7FAUPTHLQ/

DEKALB COUNTY, Ga. — When you call 911, you expect a quick response. In Dekalb County, a study found that EMS response times could be more than 20 minutes.

The recommended standard nationally for basic life support is usually between four and eight minutes.

The county conducted an EMS feasibility study, looking at five years of data between 2019-2023.

The study found that AMR, the county contractor, responded to EMS calls at 23 minutes in the 90th percentile. Dekalb County Fire was more than 10 minutes.

The study found the main problem was resources. Dekalb County Fire Chief Darnell Fullum told Channel 2’s Michael Doudna that he agreed resources were part of the problem.

Around 80 percent of the time an EMT crew was on the clock, they were on an emergency call. That means the system’s resiliency is impacted.

“That means there are fewer resources available for that next call that comes in,” Fullum said.

“Those 911 calls don’t stop, but they keep coming in and they keep stacking up,” said Chad Black, Chairman of the Georgia EMS Association.

Black says that lack of resources exacerbates issues from tiring out workers to putting them out of position.

He says EMT crews should be on a call about 50 percent of the time they are on the clock. That allows for enough resources to be on standby when those top-priority calls come in.

The study estimated it would cost Dekalb County between $12 to 16 million to get resources to around that level and have response times of eight to 12 minutes in the 90th percentile.

“More investment is needed ... but it’s not just money,” Fullum said.

According to Fullum, around 80 percent of 911 calls are not life-and-death emergencies. In nearly half of cases, an ambulance responds to end with no one being transported.

“There are calls we don’t need to be going to,” Fullum said.

“We need to educate the public on what is an emergency and what is not,” Black said.

Channel 2 did a ride along with DeKalb County EMTs Kentrick Wade, Brittney Witherby and fire Capt. Jason Daniels.

The first call came in just after 10 a.m., of a person feeling faint. The ambulance arrived five minutes later. Wade and Witherby rushed in and then came out with an empty stretcher.

“They felt like they were fine and didn’t need our services,” Witherby said.

“It happens more than you think,” Wade said.

The second call happened on our way back from the first one. The call came in about an accident with injuries after a hit-and-run near Spaghetti Junction.

It took 23 minutes to find the accident. When they arrived, the victim decided he wanted to get checked out at the hospital. That led to around a half-hour drive to Grady and then waiting at the hospital.

“The amount of time a patient will spend in an ambulance on our stretcher is the same as if they would go to the hospital and wait in a waiting room,” Witherby said.

Those waits, known as “wall times” can add up. The study found in the 90th percentile, Dekalb EMTs were spending more than 80 minutes at major metro hospitals. During that time, they are stuck, unable to go to new calls.

“You hear calls come through all the time on our walkie, whether it is a cardiac arrest or a breathing problem right down the street,” Witherby said. “While we have someone in our care at the hospital, we aren’t able to go on any other calls, regardless of what the priority is.”

DeKalb says they receive too many emergency calls that do not need an ambulance, hurting the availability of resources.

“Help us to make sure those resources are available. Know when to call 911, know when 911 might not be your best solution,” Fullum said. “That means changing sometimes the expectations. That means educating the public on when that ambulance needs to get there right away.”

The report found that except for cases like strokes and heart attacks, longer ambulance response times do not have a large impact on survivability.

Fullum says to reduce response times to the most important calls, the public’s help is needed to use limited resources.

He also pointed to services like nurse navigators, which do not take up EMS ambulances and instead divert some 911 calls to nurses, who can also provide a rideshare voucher to get someone to the hospital.

Dekalb County claims that after investing more than $4 million in the EMS system, response times are down, especially for top-priority calls, sitting around 8:43 on average.

Channel 2 did request to interview the Dekalb County CEO about future investment and the study’s recommendations, but repeated attempts were rebuffed.

An excellent news report in the trade publication for health insurers and others that may generate additional interest from payers to help financially sustain valuable EMS-based MIH programs!

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Why insurers may want in on mobile integrated healthcare

Diane Eastabrook

April 24, 2025

https://www.modernhealthcare.com/providers/mobile-integrated-healthcare-medicaid-costs

Health systems have been shouldering the cost of mobile integrated healthcare programs for at-risk patients, but some insurers may be ready to start picking up the tab as providers prove they can save money.

UMass Memorial Health, Geisinger, Prisma Health and others that operate these at-home care programs say the service saves millions of dollars by preventing emergency room visits and rehospitalizations of chronically ill patients. Government and private insurers have been covering little to none of the cost, but that could be changing as systems get information to prove the programs are effective.

Related: Hospital-at-home, emergency medical systems vie for paramedics

Mobile integrated healthcare is a 30-year-old model designed to provide on-demand and preventive care to patients who may not have a physician or reliable access to healthcare — especially those with chronic conditions such as diabetes and chronic obstructive pulmonary disease. It brings coordinated care where people live, including to those who are homeless. Patients receive examinations, medication and sometimes diagnostic services, mostly from paramedics.

The concept has taken off over the last decade, especially during the COVID-19 pandemic as providers tried to stem the tidal wave of patients flooding hospital emergency rooms, said Victoria Reinhartz, executive director of the National Association of Mobile Integrated Healthcare Providers.

Systems that looked at program results have found mobile integrated healthcare keeps high-risk patients out of the hospital and lowers overall costs.

For example, nearly 1,100 Florida Medicare Advantage members who received care for three months from a mobile integrated healthcare service operated by Nashville, Tennessee-based Envision Healthcare experienced a 21% decrease in emergency department visits and a 40% decrease in hospital utilization, according to a 2017 study.

Worcester, Massachusetts-based UMass Memorial Health released a study earlier this year that found 76% of patients who received care through its mobile integrated healthcare program from 2022 through 2024 avoided going to the emergency room within 30 days of an in-home visit.

Researchers from Worcester Polytechnic Institute this month estimated the program saved up to $1.8 million dollars in avoidable emergency service costs for the 550 unique patients who received approximately 1,000 home visits through the program during that time.

Savings generated by the program could be even greater, said Dr. Laurel O’Connor, director of Mobile Integrated Health at UMass Memorial Health.

“It does not take into account other costs that are associated with those acute encounters that end up in the ER, like hospitalization, because many of the patients that end up in the ER are hospitalized and that is extremely expensive,” O’Connor said. "They could also get COVID in the waiting room. So, there are a lot of potential downstream costs that patients will not suffer from if they are at home.”

While mobile integrated healthcare programs may help control the cost of delivering care to at-risk patients, most providers are not fully reimbursed for the service because Medicare, Medicaid and private insurance don’t typically cover care provided by paramedics that does not involve an ambulance trip to the hospital.

UMass Memorial Health supports its mobile integrated healthcare program mostly through grants, O’Connor said. She said Medicare and Medicaid cover telehealth visits that physicians provide and the health system’s hospital-at-home program — which is reimbursed by Medicare and Medicaid — pays for paramedics’ salaries.

Greenville, South Carolina-based Prisma Health also uses grant funding to support its mobile integrated healthcare program, which is expected to provide in-home care to more than 7,000 patients this year, said Aaron Dix, Prisma Health vice president of mobile health.

Dix could not estimate how much the six-year-old program has saved the health system. He estimates the cost savings are significant because many of the patients who receive care have severe chronic conditions that can escalate and lead to hospitalizations without the program's preventive care.

“You just have to take a small leap of faith that financially there is cost avoidance. It’s the uninsured and the underinsured population groups that the hospital systems are footing the bill for to control their health,” he said.

Some health systems pay third-party vendors out of pocket to provide mobile integrated healthcare to patients because it's less expensive than incurring penalties from Medicare when those patients bounce back to the hospital.

Hyannis, Massachusetts-based Estella Health provides the service to hospitals in New Hampshire and Massachusetts, including Beth Israel Deaconess-Plymouth in Massachusetts and Cape Cod Hospital in Hyannis, Massachusetts, said Estella Health Chief Operating Officer Brendan Hayden.

“They see the value because the visit decreases the overall cost of care for that patient, so it is money well spent to them,” he said.

Some health insurers are also beginning to see the value of paying for the home-based service, according to Hayden. He said he has received inquiries from a few insurers interested in piloting mobile integrated healthcare reimbursement.

“Insurance companies are at risk for every life they have covered and they are looking for strategies that will better manage patients in a more proactive way instead of reactive, which is very expensive,” Hayden said.

Blue Cross Blue Shield of New Mexico is one step ahead. The insurer piloted a mobile integrated healthcare program for some patients in Albuquerque in 2017 that resulted in a 61% reduction in emergency room visits, a spokesperson said in an email. She said the insurer has since expanded coverage to members living in three other New Mexico communities who are enrolled in Turquoise Care, a Medicaid managed care plan.

Some states are also considering Medicaid coverage of the service.

A bill before the Illinois General Assembly would require insurers to pay for all services provided under mobile integrated healthcare. Legislation introduced earlier this year in the Oregon House of Representatives would set up a registry for mobile integrated healthcare providers to participate in a state medical assistance program and establish billing codes for reimbursement under the state's Medicaid program.

Congress is considering Medicare coverage, as well. Legislation introduced in both the House and Senate would allow Medicare to reimburse for care emergency service providers offer in the home without requiring patients to be transported to the hospital.

O'Connor hopes the positive results from UMass Memorial Health can help move those coverage conversations forward and encourage insurers to begin reimbursing for mobile integrated health, as well as encourage other health systems to launch or expand similar programs.

“This is one program in one hospital in one state. We really wanted to say in this analysis that we saved a substantial amount of money in a very small, conservative way. Imagine if you took into account all of the things that we are preventing and scaled it up. It could be really impactful," O'Connor said.

Another example of the EMS staffing crisis effecting all provider types, including fire departments.

Public officials and EMS leaders should carefully evaluate evidence-based options for managing EMS system delivery such as staggered deployment based on response volume, tiered deployment(BLS and ALS ambulances), Emergency Medical Dispatch (EMD) to prioritize responses based on acuity level and alternate responses such as 1st response units only for low-acuity calls.

Tip of the hat to Rodney Dyche, one of the contributors to EMSIntel.org, for sharing this article

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City confirms ambulance shortage during fatal Landis Drive incident

By Tessa Noble,

Staff writer

April 17, 2025

https://www.beaumontenterprise.com/news/article/ambulance-shortage-confirmed-landis-dr-fatality-20279723.php

City officials have confirmed that no ambulances were available when a pedestrian was hit fatally hit by a car on April 9. However, had a unit been available, they don't believe the outcome would have changed.

Trey Guillory was hit by a car in the 8600 block of Landis Drive but was not taken to a hospital until about 45 minutes after the call came in. He was later pronounced dead at the hospital.

Since the incident, community members have expressed concern about the availability of ambulances in the city.

Ward II Council member Mike Getz recently took to social media to share more information about the issue, prompting an in-depth conversation in the comments.

“All of the city EMS units were tied up on other calls and not immediately available to transport this man, but a senior paramedic arrived on the scene within minutes and immediately began lifesaving efforts,” Getz said.

Records also confirm this. The Enterprise requested records showing when EMS department had reached "level zero" any time from April 3 to April 10." Level zero is the formal name for a lack of available ambulances. In response, the Enterprise received a list of 9-1-1 calls, including the call in question.

RELATED: City EMS response time questioned after pedestrian death on Landis Dr.

According to International Association of Firefighters Local 399 President Jeff Nesom, it took 30 minutes for an ambulance to arrive due to the “level zero” status. Getz stated in a Facebook post that even though units were tied up, the patient couldn’t have been moved faster.

“When a person sustains the type of injuries as in this case, you don't just scoop them up, load them in an ambulance and rush them off to the hospital. You immediately begin life-saving efforts at the scene and try to stabilize their condition,” Getz said. “That is what happened in this case. In fact, when the EMS unit did arrive, the paramedic was still working to stabilize the citizen, and it was a few minutes before the paramedic declared he was stable for transport.”

City spokesperson Tracy Kennick said Guillory was taken to the hospital within 45 minutes of the first 9-1-1 call.

Even with the additional information, Joey Hilliard, who is running against Getz for the Ward II seat, said on social media that the city failed its citizens.

“There is no excuse for the failures of current city management,” Hilliard stated. “Enough is enough.

Citizens and families like the man lost last night deserve better. Taxpayers are tired of 'level zero' service from bad politicians at City Hall and the Beaumont Fire Department fire chief.”

Nesom said the ambulance was due to a lack of staffing. The department is around 30 firefighters short and only running eight ambulances despite being licensed for nine. This number was increased in 2023 from five ambulances.

Some people in the comments of posts by Getz and the union expressed a belief that the department needs more than eight ambulances running at one time. Ward I Candidate Cory Crenshaw said they need more than two ambulances assigned to the West End of Beaumont. One citizen, Deborah Markham Rice, commented on Getz’s post that the city needs two more additional units.

RELATED: New software for Beaumont dispatch aims to streamline emergency response

When asked by Getz how many ambulances were needed, the union responded by saying, “Enough to be able to respond when citizens need our help.”

Robie Morris commented on the Union’s post, saying the city needs 17 ambulances.

“To be on par with the rest of the nation regarding the amount of times those med units spend only running calls (not to include daily unit inventory, supply inventory, monthly expirations which take hours, charting as many as three cardiac arrest reports that take 1-2 hours each, etc.) the city needs seventeen.”

The department also has a policy that allows them to transport a patient in a fire truck when no ambulances are available but a patient needs immediate transport. However, Nesom said this isn’t safe.

“You can't transport a patient that is that critical in the back of a fire truck; there's no way to secure a patient back there,” Nesom said. “There's no way to provide continuous care to a patient in the back of a fire truck, and his policy that he has on that is absurd.”

One citizen commented on Getz's post, agreeing that patients should be stabilized before transport.

“The level zero status explains the delay in response,” said Courtney Thompson. “It seems the patient was getting treatment until then by appropriate staff, so an immediate response by an EMS box doesn't mean you immediately transport to the ER. The patient has to be stabilized first. You can add more trucks, but who is going to staff it if they can't even staff what they have now?”

She also stated that another part of the issue must address the abuse of the 9-1-1 system for non-emergency calls.

“The entitlement of the public is atrocious,” Thompson said. “EMS isn't a taxi service, but they are treated as such. … There are some cities that are addressing the frequent flyer abuse, and I think Beaumont should consider the same.”

The city is working to implement two programs to target this issue, including the Good Sam software and partnering with RightSite Telehealth.

The Academy of International Mobile Healthcare Integration (AIMHI) Excellence in EMS Integration Awards celebrates and promotes high-performance, high-value EMS, its partners, and leaders.

Nominations for the 2025 Awards are open now through May 7, 2025.

Winners will be recognized at the AIMHI Board Meeting on June 21^st, 2025, during the American Ambulance Association Conference & Trade Show June 22 – 24, 2025. They will also receive recognition on the AIMHI website and social media platforms.

Please see below for criteria for each specific award category.

Excellence in EMS Integration Award

External Award | Integration with EMS Agencies | Organizational Recipient

This award recognizes a non-EMS organization that has developed and implemented a partnership with EMS organizations that have demonstrated enhancement of patient experience of care, improved patient outcomes, or reduced the cost of healthcare.

Award Philosophy

Awards should be based on measurable data that sets a benchmark for others to follow. These awards could be geared to best practices that support AIMHI’s mission of transforming EMS care. Award winners should demonstrate clear approaches to transformation, well deployed processes that demonstrated cycles of learning and benchmark results in the top decile of EMS agencies.

Eligibility

Integrated Healthcare Networks

• Payers
• Hospital Systems
• Home Health Agencies
• Hospice Agencies
• Other EMS agency partners

Entry Criteria

• Nominator demographics and contact information.
• Nominee demographics and contact information
• Description of program
• Date of implementation

Judging Criteria

• Number of patients/members enrolled
• Utilization change
• Patient experience scores
• Other criteria/outcomes
• Demonstrates a clear approach to change, with system-based deployment (of process, procedure, etc.) and benchmark results.

Winning agencies should be learning organizations that are willing to share best practices.

Nomination Link: https://forms.office.com/r/6g9zpqTkHs

Excellence in Public Information or Education

EMS Internal or External Award | Communications/PR/Public Affairs | Organizational Recipient

This award recognizes an EMS or non-EMS organization that has developed and implemented an effective public information or education campaign designed to encourage patients, members, or the public to develop or maintain healthy lifestyles, or to more effectively utilize healthcare resources.

Benchmark results demonstrating a significant change in how the public integrates with EMS practices. Agencies that have a clear approach to motivating the public to partner with EMS and local hospitals in obtaining outcome-based results.

Award Philosophy

Awards should be based on measurable data that sets a benchmark for others to follow. These awards could be geared to best practices that support AIMHI’s mission of transforming EMS care. Award winners should demonstrate clear approaches to transformation, well deployed processes that demonstrated cycles of learning and benchmark results in the top decile of EMS agencies.

Eligibility

•  EMS Agencies
• Integrated Healthcare Networks
• Payers
•  Hospital Systems
• Home Health Agencies
• Hospice Agencies
• Other EMS agency partners

Entry Criteria

• Nominator demographics and contact information
• Nominee demographics and contact information
• Description of program
• Date of implementation

Judging Criteria

• Estimated program reach (number of impressions)
• Cost of the campaign
• Any data on changes in behavior as a result of the campaign
• Demonstrates a clear approach to change, with system-based deployment (of process, procedure, etc.) and benchmark results. Winning agencies should be learning organizations that are willing to share best practices.

Nomination Link: https://forms.office.com/r/jHMvdKZki6

Excellence in Value Demonstration or Research

EMS Internal or External Award | Reporting/Data Analytics | Organizational Recipient

This award recognizes an EMS or non-EMS organization that created and implemented an analysis of data and/or research project to demonstrate the value impact of the services provided by the organization. Examples could include:

• Distributed analytics relating to the cost and outcomes from innovative EMS delivery.
• Study published in a peer reviewed journal that demonstrates improved patient outcomes, patient safety, or reduced cost of care as the result of a change to a protocol or process
• Benchmark improvement in efficiency that demonstrates a reduction in cost, and/or increase in patient safety with outcome-based metrics that exceed 90% of the national average for favorable results.

Award Philosophy

Awards should be based on measurable data that sets a benchmark for others to follow. These awards could be geared to best practices that support AIMHI’s mission of transforming EMS care. Award winners should demonstrate clear approaches to transformation, well deployed processes that demonstrated cycles of learning and benchmark results in the top decile of EMS agencies.

Eligibility

EMS Agencies

Entry Criteria

• Nominator demographics and contact information
• Nominee demographics and contact information
• Description of data distributed and method of distribution
• Submission of published studies that meet award submission criteria

Judging Criteria

• Value demonstration of data distributed
• Publication Impact Factor (IF) or Journal Impact Factor (JIF) of the journal publishing the research
• Demonstrates a clear approach to change, with system-based deployment (of process, procedure, etc.) and benchmark results. Winning agencies should be learning organizations that are willing to share best practices.

Nomination Link: https://forms.office.com/r/AR6jUsKs5R

Leadership in Integrated Healthcare Award

EMS Internal or External Award | Individual Recipient

This award recognizes an individual who has made significant impact on the integration of EMS, or the advancement of the integration of EMS into the healthcare system.

Award Philosophy

Awards should be based on measurable data that sets a benchmark for others to follow. These awards could be geared to best practices that support AIMHI’s mission of transforming EMS care. Award winners should demonstrate clear approaches to transformation, well deployed processes that demonstrated cycles of learning and benchmark results in the top decile of EMS agencies.

Eligibility

• EMS agency leaders
• Healthcare system leaders
• Leaders from payer organizations
• Leaders from EMS or Healthcare Associations

Entry Criteria

• Nominator demographics and contact information
• Nominee demographics and contact information
• Description of the initiatives/activities of the nominee
• Description of the impact the nominee’s initiatives has on EMS integration

Judging Criteria

• Effort of the initiatives undertaken by the nominee
• Outcomes of the initiatives of the nominee
• Demonstrates a clear approach to change, with system-based deployment (of process, procedure, etc.) and benchmark results. Winning agencies should be learning organizations that are willing to share best practices.

Nomination Link: https://forms.office.com/r/xrEHGtKN7W

Advocacy in Integrated Healthcare Award

EMS External Award | Individual Recipient

This award recognizes a legislator or regulator who has made significant impact on the integration of EMS, or the advancement of the integration of EMS into the healthcare system.

Eligibility

• Legislators and regulators from all levels of government

Entry Criteria

• Nominator demographics and contact information
• Nominee demographics and contact information
• Description of the initiatives/activities of the nominee
• Description of the impact the nominee’s initiatives has on EMS integration

Judging Criteria

• Effort of the initiatives undertaken by the nominee
• Outcomes of the initiatives of the nominee

Nomination Link: https://forms.office.com/r/yS9UXQgQnQ

While this Rand study highlights the crisis in America's emergency departments, many of the findings are equally true for EMS systems across the country.

EMS leaders should work with national and state associations to advocate for scientific, evidence-based system redesign to help assure EMS system sustainability.

Click the link below to view a recent AIMHI webinar on "Emergency Medical Services Delivery – Expectation vs. Reality".

https://aimhi.mobi/ondemand/13420011  

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Emergency departments risk closing over pay, overcrowding: Rand
Hayley DeSilva
April 06, 2025
 
https://www.modernhealthcare.com/providers/emergency-departments-closing-pay-rand
 
Emergency departments are in danger of closing without legislative intervention, according to a new report.
 
Increased violence towards providers, declining reimbursement from payers and higher volumes of complex patients are endangering the future of emergency departments, nonprofit research organization Rand wrote in a report on Sunday. Rand said policymakers must pass legislation to help hospitals navigate the challenges that have surmounted for emergency departments over the years.
 
"If we want [to maintain] this 24/7 service that we have right now, in the form that we have where everyone comes, and it doesn't matter if you can pay or not.. then we really have to proactively do something as a country," said Dr. Mahshid Abir, lead author of the report and senior policy researcher for Rand. "The current level of dependence on the [emergency departments], the value they offer [along] with the challenges they've faced, is not going to be sustainable." 
 
For the report, Rand used a combination of peer-reviewed research, interviews with emergency physicians, survey responses from emergency care leaders and two case studies of shuttered emergency departments. 
 
Here are five challenges facing emergency departments, according to Rand. 
 
1. Overcrowded emergency departments
Not only has the number of visits to the emergency room reverted back to pre-COVID-19 levels, but Rand researchers say a higher level of acuity and complexity among patients is overcrowding emergency departments. Researchers say a larger number of older adults, patients with mental illness, survivors of violence, veterans, unhoused individuals and undocumented immigrants are receiving care in the emergency department. 
 
As a result, emergency departments are providing more critical types of care. They've also been forced to board patients in hallways and waiting areas due to limited inpatient capacity in hospitals. 
 
Higher levels of complex patients can also put a significant strain on a department and hospital's finances. Rand researchers say policymakers should focus on offering financial incentives for hospitals to address emergency department boarding. They also recommend hospitals create flexible expansion areas for patient care and leverage efficient inpatient discharge strategies.
 
2. Increased violence towards clinicians
The result of emergency department overcrowding has led to frustrated patients. Several emergency department workers interviewed by Rand said they're facing more violence from patients. 
 
Physical and verbal abuse from patients has become more common and there are little standards in place to protect workers, said Rand researchers. One nurse interviewed for the report said emergency departments have become a high-risk environment. 
 
Researchers recommend state and federal legislators enforce anti-violence policies by instituting laws that will increase the legal consequences for violence against healthcare workers.
 
3. Burned out workers
Overcrowding and violence from patients has led to more doctors and nurses feeling burned out, said Rand researchers. Female clinicians are also facing increased levels of gender or sexual harassment, which is another reason for the rising attrition levels within the emergency department workforce. 
 
Pay is another contributing factor to burnout. The report highlights that physician pay per visit is down and has not kept up with inflation over the years. 
 
"I mean, if you're not paying people well to do this really difficult work, people who graduate from medical schools, maybe the better students, with the higher grades, they may not want to go into emergency medicine, and maybe then ERs are staffed with people who just are scrambling to just find some kind of residency," Abir said. 
 
4. Lack of funding for uncompensated care 
Emergency department are seeing a higher number of patients who are either uninsured or cannot pay for care. The Emergency Medical Treatment and Active Labor Act of 1986 compels emergency departments to treat these patients.
 
This mandate causes funding gaps and threatens the sustainability of emergency departments, said Rand researchers. Commercial, Medicare and Medicaid insurance payments are inadequate to cover the costs of providing care to those populations.
 
Rand recommends that lawmakers mandate that a certain percentage of commercially-insured visits are allocated to cover EMTALA-related care. They also recommend legislators allocate state and federal stipends for EMTALA-related care. Industry groups and healthcare organizations should institute uninsured and underinsured patient compensation benchmarks so that emergency departments are compensated based with the level of care they provide, Rand reports. 
 
5. Lower reimbursement rates from payers
Additionally, Rand researchers reviewed data from revenue cycle management companies and found that insurance administrators regularly underpay or deny payment for significant portions of what they're obligated to pay. The report found that 20% of all emergency physician expected payments go unpaid across all payer types, totaling roughly $5.9 billion per year of unpaid physician services.
 
Rand said its interview and focus group participants have seen a reduction in payments and insufficient reimbursement from public insurance programs. Also, emergency department facility fees, which cover overhead expenses, have gone up significantly in the last few years, researchers said. This has all led to budgetary challenges and in some cases, the closure of emergency departments. 
 
Researchers said policymakers should require a minimum emergency physician professional fee as a percentage of facility fees and mandatory commercial coverage for all emergency department visits at the level of services provided. 

Emergency Medical Services (EMS) play a critical role in public health and safety, yet their structure, funding, and effectiveness vary significantly across different countries. This webinar offers a comparative analysis of EMS delivery in the United States, Canada, and the United Kingdom, examining key differences in system design, response times, accessibility, and patient outcomes.
 
Join industry experts from the U.S., Canada and the U.K as we explore:
✅ Economic models and involvement of government oversight
✅ Response times and clinical metrics across the three countries
✅ Differences in 911, 999, and 112 emergency call systems
✅ Retention and Recruitment
✅ Formal recognitions of paramedicine as a profession
✅ Challenges and best practices in EMS coordination and innovation (MIH/CP)
 
Whether you're a healthcare professional, policymaker, or simply interested in how emergency care systems function globally, this discussion will provide valuable insights into the strengths and challenges of each approach.
 
Date: Tuesday, April 22, 2025
Time: 12n ET
Location: Zoom Webinar

Register now to gain a deeper understanding of how EMS systems operate and what lessons can be learned to improve emergency care worldwide!

Register in advance for this webinar:

https://us02web.zoom.us/webinar/register/WN__eTbdXdxSPC3Ryq1h7l05g

After registering, you will receive a confirmation email containing information about joining the webinar.