News & Updates

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.

AIMHI President Rob Lawrence presented Congressman Jason Smith (R-MO), Chairman of the House Ways and Means Committee, AIMHI's 2025 Legislator of the Year Award.

Rep. Smith, his staff and his committee have been exceptional advocates for EMS, introducing the Emergency Medical Services Reimbursement for On-Scene and Support Act (Medicare Reimbursement for Treatment in Place) and the Improving Access to Emergency Medical Services Act (Community Paramedicine funding bill).

His committee also hosted a field hearing on EMS and EMS reimbursement at an EMS facility where committee members heard 3 hours of testimony about EMS and the EMS reimbursement model.  Congressman Smith and his staff are ardent EMS advocates.

One of his key staff members, Ari Kirsh, accepted the award on behalf of Representative Smith. Ari has been the driving force behind much of the committee's EMS legislation work, and he attended, in full, the recent webinar on the results from the Ground Ambulance Data Collection System (GADCS) report.

Click here to see Ari's acceptance video message: https://youtube.com/shorts/GNPYN84Rbnw

Click here to watch the EMS segments of the March 2024 Ways and Means Committee field hearing: Ways and Means Committee Meeting EMS Focus 3 18 24

It’s unfortunate that there is so much focus on response times, when more evidence-based patient outcome data could be evaluated, such as those contemplated in the Joint Position Statement from 16 EMS, fire, public policy and patient safety organizations on EMS Performance Measures Beyond Response Times (https://www.tandfonline.com/doi/full/10.1080/10903127.2024.2375739).
 
Measures for clinical care, patient and provider safety, patient and provider experience and financial outcomes would provide a more balanced evaluation of provider performance.
 
Still, response times goals and measurements, when evaluated as an operational process measure, should be evidence-based, and tracked and reported from a patient-centric perspective, starting when the call is received by the dispatch center, and ending at patient contact.
 
Individual time durations such as call processing, activation, drive, and patient access can then be trended over time to identify opportunities for enhancement.

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Contract dispute with Sonoma County Fire District delays release of key ambulance performance data

County and fire district officials are locked in a dispute over how to calculate response times, a key component in evaluating how local ambulance service is performing.

March 29, 2025

https://www.pressdemocrat.com/article/news/sonoma-county-fire-discrict-ambulance-contract-dispute/

Three things to know:

• Sonoma County's contract with the Sonoma County Fire District for ambulance services is under dispute, affecting the timely release of performance data.
• The fire district is arguing the contract does not cover requirements for low-priority calls and wants them thrown out of 2024 performance data.
• The county argues that low priority calls make up 40% of all ambulance calls and removing them from the equation would erode public trust.

It’s been a year since Sonoma County Fire District took over the exclusive contract to provide ambulance service in the county’s central core. Those exclusive rights — worth $30 million annually for at least five years — come with response time standards and data reporting requirements.

That data is only now trickling out, and on the surface it shows the providers met response time thresholds during the last three months of 2024, which fire district officials say outperforms the previous provider’s “anemic” service.

But that may not tell the complete story.

Behind the scenes, officials and the district are locked in a dispute over the fundamental criteria used to calculate response times, a key component of the district’s performance evaluation.

That means the average Sonoma County resident may have no way of knowing for sure whether response times are better or worse than they were a year ago.

The disagreement, which started last May, has for months hamstrung the county’s ability to monitor and enforce the contract, which calls for periodic compliance reviews.

Compliance data is a critical information source both for the county officials, who are tasked with ensuring the district is meeting requirements, and district officials who need to make sure the system is operating efficiently. At the center are patients ― the public ― who are reliant on ambulances to reach them quickly.

“An EMS system is essentially bringing the hospital to a patient's door and making a lot of the interventions that would exist at a hospital available to you right there on the scene,” said Gabriel Kaplan, assistant director for the county’s health services department, which oversees the contract.

The dispute over compliance requirements is laid out in a series of letters exchanged between officials and attorneys and obtained by The Press Democrat through a public records request.

Feb 25 Letter from District Attorney to Solito.pdf

One of the key disagreements is whether the contract holds the district accountable for low priority calls, which amount to 40% of calls for ambulance services. Such calls, referred to as “Code 2,” are still considered urgent but do not require lights and sirens.

The county says it has always enforced standards for Code 2 calls, the terms of which are spelled out in the contract. Jennifer Solito, interim health services director, made that clear in the correspondence.

March 3 Letter from Solito to Fire District Attorney.pdf

“The County cannot and will not bend on this requirement because a lack of a response time requirement would erode public trust in both DHS and SCFD,” Solito wrote to Sonoma County Fire District Chief Mark Heine in a March 3 letter.

But the district says the contract is ambiguous and has accused the county of being “unreasonable” and risking “breach of contract.” In multiple letters, an attorney representing the district said the county’s stance “is unfairly prejudicial to SCFD by moving the proverbial goalposts.”

A representative of the county’s previous exclusive ambulance contractor pushed back on any attempt to loosen response time requirements.

Jason Sorrick, a spokesman for American Medical Response, locally known as Sonoma Life Support, said Code 2 calls may not require lights and sirens but still need urgent medical attention and require some type of performance measurement.

He questioned the fire district’s high marks.

“We believe that the system is likely 30% understaffed, and it is our opinion that the demands of the system were underestimated in the bid,” he said.

Disputed chart

When the Board of Supervisors approved the district’s contract in June 2023 after months of contentious debate, both county and fire district officials heralded their partnership as a significant step toward bringing ambulance services under public domain. The benefits would include transparency, accountability and enhanced emergency response.

Landing the contract was a major coup for the relatively new fire district, which was created in 2019 through a series of local fire agency consolidations. Its firefighting territory at the time included Windsor, Rincon Valley, Bennett Valley, Bodega Bay, Guerneville and Forestville.

The five-year deal provides exclusive rights covering the county’s most populated areas. On a single day in March 2025, for example, the county’s 911 dispatch system received more than 300 ambulance calls.

To help cover the significantly larger territory under the county contract, the fire district brought in a subcontractor, Vallejo-based Medic Ambulance.

This map shows Sonoma County Fire District’s newly expanded ambulance service area, covering most of Sonoma County. Service in the area shaded in pink begins Jan. 16, 2024. (Dennis Bolt/ For The Press Democrat)

The district’s contract took effect mid-January last year and offered a three-month grace period before penalties for failure to meet compliance standards kicked in.

In a single compliance period, the district must meet response times at least 90% of the time. The number of minutes an ambulance has to reach a patient varies depending on the severity of the call and whether the location is in a rural, semirural or urban area.

The contract outlines a sliding scale of penalties if the district is out of compliance in any of the six zones that make up the coverage territory.

A few months into the new contract, a dispute erupted between the district and county as officials began to review the district’s performance during the first three months of operation, according to a Feb. 25 letter an attorney representing the district sent to Solito.

“At that meeting, and in subsequent discussions, it became clear that the parties were interpreting the … response time standards tables differently,” the attorney, Andrew Schouten of Wright, L’Estrange and Ergastolo, wrote, referring to a May meeting.

The county and district disagreed on four points regarding how to calculate response times: when the clock starts during a call; how to measure calls that do not come through the 911 system; how to calculate response times for a call where the severity is downgraded over the course of the call; and ― the biggest point of contention ― whether the district should be held to Code 2 response time standards for its 2024 performance.

The Code 2 disagreement boils down to a single chart in the 134-page contract.

That chart outlines the response time thresholds broken down by the severity of the emergency and by the six coverage zones that make up the district’s territory. Its title includes a set of parentheses that includes only “Code 3.”

The district says there is no “Code 2” table in the contract.

The county counters that response times for Code 2 calls are clearly listed in the body of the chart.

The county has acknowledged in correspondence with the fire district that “(Code 3)” is an error, but maintain the contents of the table cover requirements for all calls, including Code 2.

“Our position is … that all calls have a response time requirement, including Code 2 calls,” Solito told The Press Democrat.

But the district has argued that the Code 3 label means the chart only applies to the higher acuity calls, even though the lowest acuity calls, called Alpha and Bravo, are listed in the chart with response times.

In letters to the county, Schouten, the attorney for the fire district, said that “ambiguity” could create an unsafe situation for responding ambulance crews, patients and the general public if calls that are considered Code 2, are tied to response times in the same Code 3 chart.

But in the Feb. 25 letter, Schouten also noted the district added the “Code 3” parenthetical to the first draft of the contract, which was negotiated over a six-month period.

“Given its silence during negotiations and acceptance of SCFD’s proposed language, SCFD reasonably believed County interpreted the response time standards charts to apply to Code 3 responses only,” Schouten wrote.

An oral agreement

Heine acknowledged there should be time standards for low priority calls and called it “good public policy,” but stressed that such requirements should be spelled out clearly in the contract.

“Where I have to draw the line is when you decide you don’t like what’s in the contract, or that it’s missing something, and you want to impose it upon us without successfully negotiating,” Heine said. “That’s a problem.”

Last summer, the district attempted to negotiate with the county on Code 2 response times, going back and forth over a few months.

Following a mid-August meeting, Heine believed the two parties had reached a resolution. He said former county health services director Tina Rivera, who was overseeing the contract, had agreed to extend the amount of time they are allowed to respond to low priority calls by seven minutes.

 

Not long after that meeting, Rivera left her post with the health services department. She had announced her resignation and impending departure a month earlier.

The district believed Rivera’s agreement amounted to a binding revision of the contract.

But in an interview last week, county officials relayed a different version of that discussion.

County lawyers said changing the table would potentially be a substantive change to the contract, Kaplan said. Such a change would risk the county having to start the competitive contracting process over again at the direction of the state’s Emergency Medical Services Authority.

Sorrick, AMR’s spokesperson, agreed.

“This could be in violation of the State EMS Act and the State EMS Authority’s approval of the RFP,” he said.

The county has only recently dragged itself out of a painful yearslong bidding process that began after the county’s contract with its previous provider, American Medical Response, expired in 2019.

The county repeatedly extended AMR’s contract as it struggled to launch a new competitive process and attributed the delay to complications from the wildfires and pandemic.

The bidding delays sparked lawsuits and eventually drew the attention of the state authority throwing the core operating area’s exclusivity into question.

“We're providing a franchise monopoly on a provider to operate in the exclusive operating area and in order to do that, you need state blessing, because otherwise it’s an antitrust violation,” Kaplan said. “And counties don't have the legal authority to be exempt from antitrust violations, but states do.”

The county was under a lot of pressure from the state agency to execute the competitive bid for the exclusive contract, Kaplan said.

Questioning the data

Under the new contract, which went into effect mid-January 2024, the fire district and county officials must review monthly compliance data and produce a public report. By mid-December, nearly a year into the contract, data still had not been publicly released.

On Dec. 17, 2024, The Press Democrat submitted a public records request for data covering the first year of the district’s performance. The county did not provide any records related to that request until March 4 and so far has only provided data covering last October, November and December.

The report shows the district scored 98% overall, exceeding compliance requirements. Though locked in a debate about how to measure response times, both county and district officials said the district has been successful.

But for some in the local emergency response industry, the delay has raised questions about whether the behind-the-scenes dispute will weaken the standards applied to the district.

A former emergency medical services agency official with detailed knowledge of county ambulance contracts said the district’s high score is unusual. The official, who requested anonymity in order to speak freely, said scores in the low to mid-90s are more common in the industry.

Traditionally, the official said, the clock starts ticking on ambulance response times when ambulances are dispatched and ends when the crew arrives at the scene of the emergency. Beginning the clock after the dispatcher has finished interviewing the caller to determine a priority level, can leave anywhere from 30 seconds to minutes off the clock, the official said.

“If they’re getting two or three extra minutes, you would expect them to be on time more,” the official said.

Data for the bulk of 2024 remains pending as county and district officials debate how to evaluate the compliance data. Those officials were due to present a proposed contract amendment to the Board of

Supervisors on March 25, but that discussion was delayed because the related documents could not be completed in time to comply with the state’s open meeting law requirements.

Further news that may indicate significant changes to the GEMT programs in the very near future. Ambulance GEMT programs, including the Managed Care and IGT programs, are part of these referenced State-Directed Medicaid Supplemental Payment Programs.

States and agencies that currently participate in GEMT programs of any kind may want to closely monitor developments that may dramatically change how these programs are structured.

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Conservatives push to cut extra Medicaid payments to hospitals  By Maya Goldman 3/26/25   https://www.axios.com/2025/03/26/congress-medicaid-payments-hospitals-states   A think tank with close ties to the Trump administration is making the case for wonky changes to state Medicaid payments that could solve a big problem for Republican lawmakers: They could cut federal spending in the name of simply cracking down on waste and abuse within the program.   The big picture: State-directed Medicaid payments have grown rapidly, and there's been bipartisan support for reining them in. But slashing or getting rid of the payments would be a big financial hit for providers, and especially hospitals, who vehemently disagree that the payments are wasteful.  Driving the news: Paragon Health Institute released a report Wednesday characterizing state-directed payments as "legalized Medicaid money laundering." States can tax providers or use other means to increase their state share of Medicaid funding, which allows the state to draw down additional federal Medicaid dollars. States can then use that extra money to increase payments to providers. "Not only do these programs sidestep the truly needy on Medicaid and favor special interests instead, but all this is financed by growing the federal debt, leading to inflation and higher interest rates," the report says.  Zoom in: State-directed payment arrangements approved as of last August are projected to cost more than $110 billion per year, a nearly 60% increase over cost projections from early 2023. A small portion of these arrangements are driving most of the increase, according to independent Medicaid advisers to Congress.  What they're saying: "All of this is fits within waste and abuse in the program," Paragon President Brian Blase, who co-authored the report, told Axios. "Congress, looking at $2 trillion budget deficits, needs to make significant reform to the federal-state partnership" in Medicaid. The report advocates for Congress to cap the amount of federal Medicaid funding states can receive, though it acknowledges that such a change is unlikely. The report also recommends other policy changes, like prohibiting states from using provider and insurer taxes to finance Medicaid payments, ending or capping state-directed payments and stopping policy consultants from being paid with Medicaid funds.  Between the lines: The Government Accountability Office and independent Medicaid advisers have both said in recent years that state-directed payment arrangements need more oversight. Democratic lawmakers have also advocated changes to provider taxes. The Biden administration last year finalized a rule to increase transparency into state-directed payments. The Paragon report says the rule helped, but that it should still be repealed over fiscal concerns.  The other side: Hospitals say patients' access to care could suffer without the supplemental payments. "Let's be clear: provider taxes and state directed payments provide the means to offset the crippling underpayment by Medicaid for critical care that meets the medical needs of so many kids, mothers, disabled, and seniors," Chip Kahn, president and CEO of the Federation of American Hospitals, said in a statement to Axios. Taking federal money out of the Medicaid system may ultimately force hospitals to cut back services or staff, affecting beneficiaries' access to care, said Megan Cundari, senior director of federal relations for the American Hospital Association.  What we're watching: Blase said his team is having discussions with congressional offices. Still, lawmakers tend to be very protective over their districts' hospitals, which could make changes an uphill battle. "Everybody knows this is a scam, but it benefits hospitals," Blase said of his team's conversations on Capitol Hill.  Excerpts from the Paragon Report: “These financing schemes have been around since the mid-1980s. They started with provider taxes or donation programs, primarily through hospitals and nursing homes. States collect funds from providers, then return those funds in the form of additional Medicaid spending. These expenditures garner federal matching funds, which are subsequently paid to providers through state directed payments (SDPs) and supplemental payments, with states often keeping a portion of this additional money for other purposes. SDPs are payments that states direct insurers to make to providers.”   “When Congress made those schemes somewhat more difficult in the early 1990s, states turned to intergovernmental transfers (IGTs) to finance the state share of Medicaid. Through an IGT, a local government or government-owned provider transfers money to the state that the state then uses to make much higher Medicaid payments on providers, which are often the very same providers that make the IGT. IGTs raise significant conflict of interest concerns and result in government-owned providers receiving favorable treatment over private providers.”   “States have expanded their use of provider taxes and IGTs in recent years. The newest money laundering tactic are taxes on insurance companies that participate in Medicaid managed care.”   “The providers, with schemes often developed by consultants, lobby the states to engage in this legalized money laundering apparatus. Historically, states made additional supplemental payments to providers, and they are still a significant component of Medicaid, particularly through the IGT mechanism. As states have largely transitioned Medicaid from fee-for-service to managed care, states are requiring insurers to make extra payments to providers through SDPs.”   “States’ reduced financial share means that states are now setting very high Medicaid payment rates for certain providers. In some states, these rates are approaching average commercial rates—rates that are more than 2.5 times above Medicare rates.”   “SDPs exceeded $110 billion in 2024—more than double the amount from just two years earlier. These are on top of supplemental payments that exceeded $57 billion in 2023. Both provider taxes and SDPs soared in 2024, as provider taxes fuel the legalized money laundering that permits states to substantially increase SDPs.”    “What We Recommend Considering a new Congress and the Trump administration’s intent on cutting waste, fraud, and abuse throughout government, there is a real opportunity for federal policymakers to address and limit Medicaid money laundering. Addressing this issue has been bipartisan in the past. Presidents Bush, Obama, and Trump all pushed to rein in Medicaid financing gimmicks.”   The Paragon Report highlights a 2016 report by George Mason University, that states: “The specified 19 classes of providers [eligible for SDPs] are those that provide inpatient hospital services, outpatient hospital services, nursing facility services, services of intermediate care facilities for the mentally retarded, physicians’ services, home health care services, outpatient prescription drugs, services of Medicaid managed care organizations, ambulatory surgical centers, dental services, podiatric services, chiropractic services, optometric/optician services, psychological services, therapist services, nursing services, laboratory and x-ray services, emergency ambulance services, and other health care items or services for which the state has enacted a licensing or certification fee.

DispatchHealth offers in-home urgent care and is a key partner in some EMS-Based MIH programs, including Treatment in Place initiatives.
 
Medically Home has agreements with several EMS agencies across the country to provide Hospital at Home support using Mobile Healthcare Paramedics, specifically allowed under the currently extended CMS waiver referenced in the news report.

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DispatchHealth and Medically Home merge, creating one of nation's largest hospital-at-home providers
By Emma Beavins 
Mar 18, 2025
 
https://www.fiercehealthcare.com/hospitals/dispatchhealth-and-medically-home-merge-creating-one-nations-largest-hospital-home
 
DispatchHealth and Medically Home, two leaders in the hospital at home industry, are merging, the companies announced Tuesday.
 
The companies leverage telehealth, virtual call centers and devices in patients' homes to provide high-complexity care, including for oncology patients and organ transplant patients. Dispatch Health and Medically Home tout that their merger creates the nation’s most comprehensive high-acuity care platform delivering care to patients at home.
 
Medically Home’s technology powers a large swath of hospital at home programs across the country and gives them frameworks to provide hospital at home care with additional support from Medically Home’s technology and staff. Its range of services includes a Medical Command Center that oversees patients’ care 24/7, technology to use at the bedside and a team of clinicians. The company was founded in 2016.
 
Dispatch Health, founded in 2013, provides full-service hospital at home care to patients across the country. DispatchHealth clinicians attend patients at the bedside and coordinate work and requirements for hospitals. The company also provides in-home urgent care services to patients and post-facility recovery at home.
 
Once the merger closes, expected midyear, the combined entity will continue under the name DispatchHealth. It will care for patients in 50 major metropolitan areas with 40 health systems and connections to most major health plans and value-based care entities. The terms of the deal were not disclosed.
 
Together, the companies will save up to 62,000 inpatient hospital stays per year and reduce the cost per patient by up to 30% per month by providing acute hospital-level care in patients’ homes.
 
"Healthcare demands innovative solutions that align clinical excellence with financial sustainability," Jennifer Webster, CEO for DispatchHealth, said in a statement. "We've proven the home can be an extension of the hospital while improving the quality of care. This merger brings together two complementary pioneers in hospital-level care at home, accelerating our ability to expand access, lower costs, drive value, and improve capacity for health systems across the country."
 
This comes as the federal government recently extended the waiver for hospitals to get Medicare dollars by participating in its Acute Hospital Care At Home program. Starting during the pandemic, the Centers for Medicare & Medicaid Services (CMS) began offering incentives for hospitals to shift qualifying patients out of facilities and to care for them at home due to hospital overcrowding.
 
The program has been repeatedly extended since the end of the COVID-19 public health emergency, albeit for short periods of time. Most recently, Congress extended the CMS’ hospital at home program through Sept. 30, 2025, though there is bipartisan support for a five-year extension.
 
"Hospital-at-home has consistently demonstrated better outcomes, and we believe every patient—regardless of where they live—deserves access to that level of care. This merger allows us to break down barriers, reaching more families in underserved communities with high-quality, advanced medical care in their homes," Pippa Shulman, chief medical officer and chief strategy officer of Medically Home, said in a statement.

March 12, 2025

The Honorable Brett Guthrie Chair Committee on Energy and Commerce United States House of Representatives 2161 Rayburn House Office Building Washington, DC 20515	The Honorable Buddy Carter Chair Energy and Commerce Subcommittee on Health United States House of Representatives 2432 Rayburn House Office Building Washington, DC 20515
The Honorable Frank Pallone, Jr. Ranking Member Committee on Energy and Commerce United States House of Representatives 2107 Rayburn House Office Building Washington, DC 20515	The Honorable Dianna DeGette Ranking Member Energy and Commerce Subcommittee on Health United States House of Representatives 2111 Rayburn House Office Building Washington, DC 20515

Re: Medicaid Reimbursement for Ground Ambulance Services

Dear Chair Guthrie, Ranking Member Pallone, Chair Carter, and Ranking Member DeGette,

On behalf of our members, and the more than 16 million citizens served by our members, the Academy of International Mobile Healthcare Integration asks for your continued support for Medicaid supplemental payment programs that provide critical support to Emergency Medical Service (EMS) systems and providers.

Ambulance service providers face financial pressures and risk closure at an alarming rate in every state. A new tracking system we help support has documented over 2,700 local and national news reports about EMS, with 79% of the reports highlighting the economic and staffing crisis in EMS. In rural communities in particular, EMS providers are often the only healthcare providers delivering care for hundreds of miles. Medicaid supplemental payment programs offer transparent and sustainable ways to support first responders, allowing them to continue providing life-saving services, train paramedics, and ensure our rural communities are not left without care.

The most at-risk ambulance service providers—those serving rural communities—face unique challenges including large coverage areas, increased travel distances, and higher costs per transport. Adequate support for staffing, training, and equipment is already a major challenge. Medicaid and Medicaid supplemental payment programs help improve rural access to care by helping to fund the dedicated resources serving those communities.

We are deeply concerned by recent reports of proposals that may severely reduce critical Medicaid reimbursement by reducing federal matching funds, altering provider assessments and mandating the use of artificial caps on supplemental payments, any of which would likely have a significant impact on EMS delivery, especially in rural communities or communities with large proportions of Medicaid beneficiaries. 

EMS and ambulance service providers, rural hospitals, and safety-net health clinics would be at risk of closure without continued funding that Medicaid supplemental payment funds provide. The previously mentioned news tracking system has already identified 219 news reports of ambulance service closures since January 2021.

We, and other ambulance associations, are eager to collaborate with Congress and the Administration on solutions that sustain Medicaid financing to help ensure ambulance service providers can continue to meet the needs of their communities.

We appreciate the opportunity to engage in further discussion and provide data on how these programs directly affect each of our states.

Sincerely,

Robert Lawrence, President

Academy of International Mobile Healthcare Integration

Member Agencies:

• ·         Alberta Health EMS; Alberta, Ontario, CA
• ·         Emergency Medical Services Authority; Tulsa and Oklahoma City, OK
• ·         Mecklenburg EMS Agency; Charlotte, NC
• ·         Medic Ambulance; Vallejo, CA
• ·         Medic Ambulance of Scott County; Davenport, IA
• ·         Metropolitan Area EMS Authority; Fort Worth, TX
• ·         Metropolitan EMS, Little Rock; AR
• ·         Northwell Health Center for EMS; Syosset, NY
• ·         Novant Health; Wilmington, NC
• ·         Pinellas County Ambulance Authority; Largo, FL
• ·         Pro EMS; Cambridge, MA
• ·         REMSA Health; Reno, NV
• ·         Richmond Ambulance Authority; Richmond, VA
• ·         Three Rivers Ambulance Authority; Fort Wayne, IN

There has been much discussion about the future of Ground Emergency Medical Transport (GEMT) programs since the Centers for Medicare and Medicaid (CMS), Office of the Inspector General (OIG) announced audits of GEMT program in 2023, following a memo from CMS to state Medicaid Directors in 2022 (see the link below to see the memo).

The most recent GEMT reimbursement allocations in Texas may provide insight into the future direction of GEMT programs across states that currently have these programs, and those who have pending applications for Medicaid State Plan Amendments with CMS.

PWW Advisory Group has done a deep dive into the changes in the Texas GEMT program, including what the changes were, and how the Federal Settlement Amounts and distribution of GEMT funds based on revised cost and revenue reporting methodology, and the impact on GEMT reimbursements to participating agencies.

Could this new model be an example of changes coming to all GEMT programs? 

Read the full analysis here: 

PWWAG Assessment - Texas GEMT Program 2023 vs 2022.pdf

Informational summary data tables:

2022 CMS memo to State Medicaid Directors on GEMT cost allocation:

Highlighted - CMS Memo on Cost Allocation for GEMT - 8-17-22.pdf

Another excellent example of how Mobile Integrated Healthcare/Community Paramedic (MIH/CP) programs can partner with hospitals for a H@H program.
 
H@H programs can be an effective alternative to typical inpatient admissions, not only in rural areas, but also for other hospitals struggling with ED boarding due to limited inpatient resources at ‘brick and mortar’ facilities. Excessive ED boarding leads to delays in assessing ED patients which could negatively impact 2 key CMS hospital “Timely and Effective Care” quality metrics:

• ‘Percentage of patients who left the emergency department before being seen’
• ‘Average (median) time patients spent in the emergency department before leaving from the visit’

Source: https://data.cms.gov/provider-data/topics/hospitals/timely-effective-care#emergency-department-care
 
ED delays also impact hospital patient experience scores and may be a contributing factor to lengthy Ambulance Patient Offloading Times (APOT).
 
CMS specifically allows MIH paramedics to be part of the H@H team through an ongoing H@H waiver for this care model. There are several requirements that a hospital must meet in order to participate in the program. These include:

• Having appropriate screening protocols in place before care at home begins to assess both medical and non-medical factors
• Having a physician or advanced practice provider evaluate each patient daily either in-person or remotely
• Having a registered nurse evaluate each patient once daily either in-person or remotely
• Having two in-person visits daily by either registered nurses or mobile integrated health paramedics based on the patient’s nursing plan and hospital policies

Source: https://files.asprtracie.hhs.gov/documents/aspr-tracie-acute-care-delivery-at-home-tip-sheet-.pdf

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Sanford Fargo (ND) offers Hospital at Home
Feb. 24, 2025
 
https://news.sanfordhealth.org/news-release/sanford-fargo-offers-hospital-at-home/
 
FARGO, N.D. – Sanford Health Fargo is the first hospital in North Dakota to participate in the Hospital at Home program.
 
Hospital at Home gives patients the ability to transfer from the hospital to their home while continuing to receive care. Patients who are admitted to the emergency room or an inpatient unit and qualify for Hospital at Home can receive IVs, antibiotics, medications, treatments and ongoing care and observation from home until they are eligible for discharge.
 
The program includes two in-person caregiver visits a day from a nurse or community paramedic, as well as dailyvirtual visitswith a provider using a TytoCare device. Transportation is provided if patients need diagnostic tests at the hospital.
 
“Hospital at Home has a chance to be a real game changer for our patients. We are dedicated to ensuring high-quality care is accessible to all patients, regardless of their location or health challenges,” said Susan Jarvis, Sanford Fargo chief operating officer. “Hospital at home provides many benefits, such as more comfort, better sleep and greater independence with clothing, food and environment. This program also leads to less hospital-acquired infections, shorter hospitalizations and lower readmission rates. Sanford Health is committed to addressing rural health care challenges and providing high-quality, affordable care to everyone in our communities.”
 
The admitting provider and care team will assess each patient for eligibility in the Hospital at Home program. To qualify, patients must:
• Live within 25 miles of Sanford Medical Center Fargo
• Be at least 18-years-old
• Complete initial assessments at the medical center
• Have a diagnosis and care plan that can be safely provided at home
• Be comfortable using a TytoCare device
• Be able to move safely within their home
• Be able to follow home care instructions
 
It is recommended that patients have a caregiver in the home when joining the program.
 
About Sanford Health
Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization serves 2.4 million patients and more than 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan. The integrated nonprofit health system includes 56 hospitals, more than 270 clinic locations, 144 senior care communities, 4,500 physicians and advanced practice providers, nearly 1,000 active clinical trials and studies, and nine world clinic locations around the globe.

A great example of EMS agencies filling local healthcare gaps through innovative Mobile Integrated Healthcare (MIH) programming.

The key is to sustainability is to identify the gap, create a program that will likely fill that gap, find payers willing to fund the initiative, then track and report data that proves the value of the program to the payer.

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Acadian Health launches pilot program to divert ‘super-utilizer’ patients from ERs

February 20, 2025

by Alena Maschke

https://thecurrentla.com/2025/acadian-health-launches-pilot-program-to-divert-super-utilizer-patients-from-ers/

Acadian Health, a division of Acadian Companies that provides home-based health services, is launching a pilot program designed to keep patients out of hospital emergency departments if their condition can be treated in a home environment.

Approximately 20% of the state’s Medicaid patients visit local emergency rooms on average 17 times per year, making them “super-utilizers” in the Louisiana Department of Health’s lingo, often for non-life-threatening situations or due to social factors, such as a lack of transportation, according to recent data gathered by LDH’s Bureau of Health Services Financing.

“We took a close look at emergency room use by ‘super-utilizers’ over a one-year period and found opportunities to meet patient needs more effectively,” LDH Secretary Michael Harrington said in a press release announcing the program. “Through this project, we will increase access and simplify care delivery while helping hospital emergency rooms to remain highly flexible and accessible.”

Many patients are “excessively using the ER, almost as a primary care clinic,” said Acadian Health Director of Business Development Rob Burnell. “Which kind of lets us know that they probably don’t have a primary care physician.” Or if they do, they don’t have a way of getting to their office. “Oftentimes, they have a lack of transportation. They have limited mobility. A lot of these patients simply don’t have a ride,” he pointed out.

That’s why Acadian is hoping to bring care directly to them.

The pilot will focus on a cohort of 7,000 Medicaid beneficiaries in Southwest Louisiana, a majority of whom will be referred to Acadian by their managed care organization — the insurance company that administers their Medicaid benefits.

Those patients will then be scheduled for a visit with an Acadian Health community paramedic, with follow-up visits as needed to prevent unnecessary trips to the emergency room.

“If they don’t have a primary care physician, a lot of them have chronic conditions — diabetes, high blood pressure, congestive heart failure — that are left untreated,” Burnell said of the target demographic. “So what happens is those chronic conditions exacerbate.”

Almost all of Louisiana is considered a Health Professional Shortage Area, a designation that includes a lack of primary care doctors. The Cicero Institute, a conservative Austin think tank, projects that by 2030, the state will be short almost 5,000 doctors, nearly 400 of them primary care physicians, to meet the medical needs of its residents.

For those who have a primary care physician, the program offers an acute care alternative that can provide urgent care services to patients at home within an hour, after being referred by their doctor or an Acadian physician outside of regular business hours.

Whether the program will have a noticeable impact on emergency departments’ workloads, which can lead to long wait times during peak hours, remains to be seen, said Zach Barnhill, director of emergency services at Our Lady of Lourdes. “I’m excited to see where this program is going to go and what it’s going to do for our area,” Barnhill said. “I think it’s going to have a positive impact on the patients it’s going to serve.”

According to Barnhill, one of the most common non-emergent conditions patients visit the emergency room for is pain, such as back pain or pain caused by a variety of chronic conditions. Patients in pain will likely be a large portion of those served by the Acadian pilot, Burnell anticipates.

“The patient doesn’t really know what’s going on until we get there,” he said. Should the source of the pain require treatment in a hospital, paramedics can still call an ambulance, but, according to Burnell, that is rare — only roughly 5% of patients, he estimates, actually need to be transported to an emergency room.

This is a relatively long read, but an excellent summary of potential actions the feds may take to reduce Medicaid spending by $880 billion over the next decade.

Of interest to EMS folks is the target on Medicaid Directed Payment programs, which is the general framework for many of the Ground Emergency Medical Transport (GEMT) Medicaid supplemental payment programs.

The report references that these programs will likely be targeted for ‘reform’, even those ‘supported’ by a “provider tax” (i.e.: IGT).

The CMS OIG has been auditing GEMT programs and cost reports by public providers since 2024. Public ambulance provider cost reports from California, Texas and Florida have been most heavily targeted.

The OIG report is due out this year: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000786.asp

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1 big thing: The Medicaid money bag

Caitlyn Owens - Axios

February 14, 2025

https://www.axios.com/newsletters/axios-future-of-health-care-71bdf630-e98d-11ef-b85f-dda25f81fbf4.html

House Republicans finally previewed what level of spending cuts they'll be looking for to pay for tax cuts later this year, and there's a big target on Medicaid.

The big picture: Republicans may be looking for Medicaid spending reductions to the tune of nearly $900 billion over the next decade. While some options have come up more than others, there are actually quite a few different levers they could pull to get there.

The question is which — if any — end up being politically palatable enough to eventually make it through both the House and the Senate.

This is ultimately a fight with providers

Most — if not all — roads to big Medicaid savings for the federal government lead to hospitals' and other providers' wallets.

Why it matters: Some hospitals are making a lot of money (and running Super Bowl ads), while others are struggling and on the brink of failure. Regardless, the hospital industry is a formidable presence in Washington, which could create big headaches for lawmakers seeking to enact reforms that hospitals don't like.

Where it stands: Industry statements started hitting my inbox yesterday shortly after House Republicans released their budget resolution, which called for $880 billion in spending reductions within the jurisdiction of the committee that covers Medicaid.

"While some have suggested dramatic reductions in the Medicaid program as part of a reconciliation vehicle, we would urge Congress to reject that approach," the American Hospital Association warned.

"America's Essential Hospitals stoutly opposes and categorically condemns any cuts to Medicaid and Medicare that would result from this blueprint," the group wrote. "We cannot afford the resulting loss of life-saving safety net services that millions of Americans need to stay healthy."

Between the lines: Yes, if people lose Medicaid and become uninsured, hospitals will face higher uncompensated care costs. But it's more than that.

Many cost-saving proposals simply reduce the amount of federal dollars that states get for the program, in one way or another. States would then have to decide whether to make up the costs themselves, cut enrollment, reduce benefits or reduce what they pay providers.

Cutting enrollment and reducing benefits in a way that meaningfully curbs costs is hard, said Matt Salo, the former executive director of the National Association of Medicaid Directors. That leaves provider cuts.

"I think what's different this time around is the hospitals have gotten much more sophisticated about articulating what happens if you crack down," Salo said.

"If you squeeze the money to the states, the states are going to squeeze the money to providers. And if you squeeze the money to providers, they're going to squeeze access to beneficiaries. It's a vicious cycle."

Zoom in: Capping federal Medicaid spending — one of the two most-talked-about reforms on the menu so far, along with work requirements — could reduce federal spending by hundreds of billions of dollars, or even more than a trillion dollars, depending on how it's structured, per the Committee for a Responsible Federal Budget.

Getting moderates to support per capita caps in 2017 was really hard, and ultimately a lot of them wouldn't do it. That ended up being OK given the House GOP's vote margin at the time, but that margin is now much, much smaller.

Yes, but: There are other ways to get to $880 billion in cuts, should Republicans end up needing to hit somewhere in that ballpark and choose to do it primarily via the Medicaid program.

For example ...

They could simply reduce the level of federal reimbursement for Medicaid expansion enrollees, which is currently at 90% — much higher than the reimbursement rate for other populations.

They could reduce the minimum federal match rate generally, which would result in wealthier and generally bluer states getting less funding. (The problem: There are still plenty of House Republicans from New York and California.)

Or they could target providers directly through provider taxes and what are called state-directed payments, which have ballooned in recent years. Keep reading for more on that.

And, of course, the Trump administration has been big on cutting waste, fraud and abuse writ large.

The bottom line: "It all comes back to the providers eventually in different ways," said Chip Kahn, CEO of the Federation of American Hospitals.

"All the ways you have to get to 880 [billion dollars] are not in the interest of the Medicaid recipients who depend on hospitals, doctors and nursing homes and other settings for their care," he added.

Here's a little-known fact, outside of the health nerds circle: Some providers actually get pretty high payment rates now for seeing Medicaid enrollees.

Between the lines: What's been a brewing think-tank fight over Medicaid payments to hospitals and doctors could soon spill onto the main political stage should Republicans decide this is the most politically palatable route of attack.

Context: State-directed Medicaid payments have ballooned in size and allow some providers to now get paid similarly for seeing Medicaid and commercially insured patients.

That's been great for states, hospitals and arguably Medicaid patients, but not so great for the federal budget.

It's also a relatively new phenomenon; CMS first allowed states to begin directing managed care organizations to pay providers under certain circumstances in 2016.

"We've seen sort of the initial explosion of these, so the growth trend is going to be astronomical as more and more states figure out how to game the system," said the Paragon Health Institute's Ryan Long, who until recently was a top GOP health aide on the Hill.

The intrigue: Some reform advocates argue that this is indeed an easier political lift, namely because it's had bipartisan support in the past and most members simply don't know how much providers are being paid to see Medicaid patients these days.

"We've now constructed a welfare program to be a financial windfall for nonprofit hospitals, and Congress should address that," said Paragon President Brian Blase, who has been on the Hill discussing the think tank's policy views with members.

Spoiler: Providers won't like it if Republicans go this route.

"If you go after it, either you're going to have hospitals and other settings having to cut back on services, because you're not getting paid sufficiently for them, or you're going to have to go to other payers and there will be more cost shift," Kahn said.

By the numbers: MACPAC has estimated that directed payments approved as of August totaled more than $110 billion in 2024 — a 60% increase over the projections they made based on arrangements approved as of early 2023.

MACPAC identified 29 payment arrangements that would each increase provider payments by more than $1 billion a year. Most of these raise provider reimbursement rates above the Medicare rate, and 11 bumped up rates to at least 90% of the average commercial rate.

Commercial payments are often multiples of what Medicare pays, and are frequently criticized as exorbitant.

Health systems were the beneficiaries in 24 of the 29 large payment arrangements.

HCA received nearly $4 billion from 18 different states in 2023 related to supplemental payment programs, according to a Raymond James investor note from last year. Tenet received nearly $1 billion in 2023, and Universal Health Services expected to receive around $1.3 billion from supplemental programs in 2024.

These payments are often financed through provider taxes, which have been targeted by both parties in the past.

These taxes, levied by states on providers, ultimately allow the state to get reimbursed more from the federal government.

Reforms to the policy, depending on how they're structured, could save the federal government hundreds of billions of dollars, per CBO — a solid chunk of the Medicaid money Republicans may need.

What they're saying: Whether this rise in Medicaid payment rates is a good or bad thing depends who you ask.

Proponents say they help promote access and equity, as Medicaid payments have historically been lower than both commercial and Medicare rates.

"Higher payments are expected to grow the pool of providers who serve Medicaid patients and improve access to providers that limit the number of Medicaid patients they serve. Additionally, as Medicaid becomes a more competitive payer, the policy can provide critical support to safety-net providers," the Commonwealth Fund argued in a blog post last year.

But critics say the federal government is getting ripped off. Paragon is referring to such measures as "money laundering."