News & Updates

An international challenge – Fundamental changes are need to how EMS is delivered….

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Data shows ambulance unavailability getting worse in Winnipeg

In January, there were 28 hours where zero ambulances were available, according to City of Winnipeg figures

Sarah Petz · CBC News

Apr 20, 2022

https://www.cbc.ca/news/canada/manitoba/winnipeg-ambulance-unavailability-1.6425663

There were 28 hours in January when there were zero ambulances available in the City of Winnipeg to respond to emergencies, according to data obtained by the Manitoba NDP. 

That's four times longer than it was two years before in December 2019, which at the time was the longest monthly total in four years. 

It also wasn't even the worst month for ambulance unavailability in Winnipeg in the last year.

Figures from the City of Winnipeg show that in August 2021, there were nearly 31 hours where there were no ambulances available to respond to calls. 

That works out to about 59.69 non-consecutive minutes per day, a City of Winnipeg spokesperson confirmed. 

The data, obtained through a freedom of information request, was tabled in question period Wednesday by NDP Health Critic Uzoma Asagwara. 

It also shows that in the same month, there were 588 instances where there were no EMS units available to respond to calls for service. 

"The problems were known long before the pandemic, and the government did absolutely nothing to resolve it," Asagwara said. 

Paramedics exhausted

The figures for January also show that nearly two-thirds of the time that month the ambulances were in degraded mode — meaning there were six or fewer ambulances available for service.

Six is the base number the Winnipeg Fire Paramedic Service uses to determine whether they can meet target response times.

After working through the pandemic, paramedics are burned out, and numbers reflect that, said Ryan Woiden, a longtime paramedic who is the president of the paramedic union, Manitoba Government and General Employees' Union Local 911.

"The days of trying to pick up the over time when the staffing levels are low, they're becoming fewer and far between because of the exhaustion," he said.

Back in December 2019, Woiden told CBC News he had never seen it so busy for paramedics. 

The fact that it's gotten even worse reflects that the entire system needs to be revamped, he said. 

"Truly I think that you end up seeing those numbers increase because there hasn't been any major changes to the way we do business," he said. 

"I'm not sitting here saying that we need ten more ambulances and 100 more paramedics. What I'm saying is, what if we were to think outside the box and do things a little bit differently?"

Population growth, increased call volumes and call complexity, longer wait times for transferring patients, and the ongoing impact of the COVID-19 pandemic have put additional pressures on the city's transport ambulance availability, a spokesperson for the City of Winnipeg said via email.

However, the Winnipeg Fire Paramedic Service and Shared Health are implementing measures to reduce strain on the system, such as serving lower acuity patients through the community paramedic when safe to do so, and establishing transfer of care procedures to minimize the time ambulances remain at a hospital, said Michelle Lancaster, communications officer for the Winnipeg Fire Paramedic Service.

Health Minister Audrey Gordon said she hadn't seen the data yet, but will review it. 

She added that her government's most recent budget includes money to hire 35 more paramedics across the province.

In addition, the City of Winnipeg and Shared Health are currently working on a new deal over funding for ambulances and paramedics, she said. 

"And it's my job to listen to Manitobans and ensure that, as part of the discussions around development of that agreement, we're looking at these concerns," she said.

A timely blog post, as some agencies are still facing this challenge – perhaps some kernels that folks can use?

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Improving Flow: Addressing the Complexities of Emergency Department Overcrowding

By Patricia Rutherford | Monday, April 11, 2022

http://www.ihi.org/communities/blogs/improving-flow-addressing-the-complexities-of-emergency-department-overcrowding

When patients have to wait for long periods in overcrowded emergency departments (EDs), it’s not just an inconvenience. Evidence shows that ED crowding leads to significant patient harm, resulting from delays in treatment and increases in preventable harm. A systematic review in 2022 concluded that ED crowding was associated with higher mortality in 45 percent of the studies, worse quality of care in 75 percent, and a worse perception of care in 100 percent.

ED Crowding Has Multiple Sources

The problem of ED crowding is widely recognized. Too often, however, ED crowding is seen in isolation — as a matter of simply making ED operations more efficient. To be sure, there are ways that ED staff can improve their operations to ease crowding, but there are limits to how much those efforts can accomplish. Efficient, high-quality ED care is also dependent on factors outside the control of the ED — such as lack of sufficient and timely primary care and mental health services as well as timely availability of post-acute care services. To solve the problem of ED crowding and delays in admitting patients to the hospital, improvements in community-wide and hospital-wide patient flow are needed.

Indeed, the situation is reminiscent of the metaphor about the people who are all looking at a different part of an elephant. The one who sees a tusk thinks it’s a spear, the one who sees the tail thinks it’s a rope, and so on. Something analogous occurs when clinicians and staff only see flow problems from their perspective in the ED and within other units or departments throughout the hospital. While the ED staff see long delays in admitting patients, the clinical staff on medical and surgical units see unnecessary bed days and long delays in discharging patients to homes and community-based care settings. To improve patient flow in the ED, we need to look at the whole “elephant” — the whole system that impacts hospital-wide patient flow.

Efficiency Improvements in the ED

There is certainly some potential for improvement in the ED itself. For example:

• Separate flows in the ED (based on acuity) with dedicated clinical teams for each flow. Many EDs that have implemented these lean principles have significantly improved efficiencies and decreased the length of stay for patients discharged from the ED and for patients being admitted to the hospital.
• Create a separate protocol-driven unit for short-stay patients with relatively straightforward diagnoses. These units are intended for patients who may not be sick enough to warrant a hospital admission but are not well enough to be discharged immediately. A 2013 article found that, compared to patients under observation elsewhere in the hospital, patients in dedicated observation units with defined protocols had 23 to 38 percent shorter length-of-stay, and their likelihood of subsequent inpatient admission was 17 to 44 percent lower.

In addition, clinical teams in the ED can partner with community providers of care to shape demand for ED visits.

• Provide end-of-life care in accordance with patients’ wishes. This step often prevents admissions to intensive care units.  
• Utilize case managers. These team members can facilitate discharges to home and arrange home care and timely follow-up care after discharge from the ED.
• Support patients with low-acuity needs in community-based care settings. Extend the hours of primary care offices and offer more virtual office visits for primary care, specialists, and mental health care.

Addressing Common Bottlenecks in the Hospital

Often, beds are not available in the hospital, leaving patients to wait for inexcusably long periods in the ED. A commentary in NEJM Catalyst suggests the problem is, in fact, getting worse.

Common bottlenecks and system constraints include:

• Discharge delays — Difficulty finding the right settings and needed services for patients who are otherwise ready to be discharged from the hospital causes delays. Address this bottleneck by focusing on efficient discharge planning and collaborations with family caregivers and community providers of care. In other words, focus on the “back door” in addition to the “front door” of the hospital.
• Unnecessary bed days — Unnecessary bed days occur when patients remain in the hospital for extra days or weeks after they are medically ready for discharge. Comprehensive assessments for post-acute care needs, interdisciplinary planning with a patient and their family, and decision-making can all take time and extend a patient’s stay. In addition, the lack of availability of post-acute facility beds and home care services often leads to long-term hospital occupancy. Inpatient units lose functional capacity as patients await placement in post-discharge health care settings (rehabilitation centers, skilled nursing facilities, or nursing homes).
• Uneven elective surgical scheduling — It is common for surgeons to schedule elective surgery in an uneven manner throughout the week, which can contribute significantly to hospital-wide flow problems. Efforts to “smooth” the flow of elective surgical patients throughout the week can have multiple benefits: more predictable flows of patients from the operating room to intensive care units and other inpatient units, less competition between ED and elective admissions, and more predictable and appropriate nurse staffing on units.

A NEJM Catalyst article identified essential steps to mitigate crowding in the ED, including acknowledging it as a serious problem and threat to patient safety, and urging visible, committed leadership buy-in as an essential part of the solution.

It is crucial to address hospital-wide patient flow, not just to pursue isolated improvement projects that may not have an impact on timely patient progression throughout the hospital. In addition, community-wide efforts to create timely access to care can prevent overutilization of ED services and lengthy hospital admissions. We need to see the “whole elephant” to address both system-wide hospital flow issues and the availability of community-based health care services which impact overutilization in hospitals.

The Pandemic Exacerbates the 'Paramedic Paradox' in Rural America

Katheryn Houghton Kaiser Health News

April 07, 2022

https://khn.org/news/article/rural-paramedic-pandemic-shortage-montana/

Even after she's clocked out, Sarah Lewin keeps a Ford Explorer outfitted with medical gear parked outside her house. As one of just four paramedics covering five counties across vast, sprawling eastern Montana, she knows a call that someone had a heart attack, was in a serious car crash, or needs life support and is 100-plus miles away from the nearest hospital can come at any time.

"I've had as much as 100 hours of overtime in a two-week period," said Lewin, the battalion chief for the Miles City Fire and Rescue department. "Other people have had more."

Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don't have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn't have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn't balance the intense program with their day jobs. Others didn't want the added workload that comes with being a paramedic.

"If you're the only paramedic on, you end up taking more calls," Lewin said.

What's happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

"The patients who need the paramedics the most are in the more rural areas," said Dia Gainor, executive director of the National Association of State EMS Officials. But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

"Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education," Gainor said. "The list goes on."

The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage "a full-blown emergency" and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

At the beginning of this year, Colorado reactivated its crisis standard of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in covid cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school to pique students' interest.

In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state's five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state's 147,000 square miles. Meanwhile, 21 of Montana's 56 counties don't have a single licensed EMS paramedic.

The Pandemic Exacerbates the "Paramedic Paradox" in Rural America

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

If those rural groups do find or train paramedics in-house, they're often poached by larger stations. "Paramedics get siphoned off because as soon as they have those skills, they're marketable," Gienapp said.

Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

But action at the state level doesn't always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a "minimum level" of ambulance services. But legislators didn't appropriate any money to go with the law, leaving the added cost — estimated to be up to $41 per resident each year — for local governments to figure out.

Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn't contribute to the department's costs. The team's territory includes 6,000 miles of roads and trails, and Smith said it's a constant struggle to find and retain the staffers to cover that ground.

Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven't attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can't match.

"The public has this expectation that if something happens, we always have an ambulance available, we're there in a couple of minutes, and we have the highest-trained people," Smith said. "The reality is that's not always the case when the money is rare and it's hard to find and retain people."

Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic health care in rural areas. Montana is among the states trying to expand EMS work to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

A private ambulance provider in Montana's Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic health care is on the back burner. The top priority is hiring a paramedic.

Advancing the care that EMT crews can do without paramedics is possible. Montana's EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

"Realistically, you're just not going to have paramedics in those rural areas where there's no income available," Graham said.

Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she's not sure she'll be able to fill the spots. She has a few new EMT hires, but they won't be ready for paramedic certification by then.

"I don't have any people interested," Lewin said. For now, she'll keep that emergency care rig in her driveway, ready to go.

Interesting case…  The amounts billed do seem odd….

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The Case of the $489,000 Air Ambulance Ride

By Julie Appleby

MARCH 25, 2022

https://khn.org/news/article/the-case-of-the-489000-air-ambulance-ride/

Sean Deines and his wife, Rebekah, were road-tripping after he lost his job as a bartender when the pandemic hit. But while visiting his grandfather in a remote part of Wyoming, Sean started to feel very ill.

Rebekah insisted he go to an urgent care center in Laramie.

“‘Your white blood count is through the roof. You need to get to an ER right now,’” Deines, 32, recalls a staffer saying. The North Carolina couple initially drove to a hospital in Casper but were quickly airlifted to the University of Colorado Hospital near Denver, where he was admitted on Nov. 28, 2020.

There, specialists confirmed his diagnosis: acute lymphoblastic leukemia, a fast-growing blood cancer.

“Literally within 12 hours, I needed to figure out what to do with the next step of my life,” said Deines.

So, after he was started on intravenous treatments, including steroids and antibiotics, in Colorado to stabilize him, the couple decided it was prudent to return to North Carolina, where they could get help from his mother and mother-in-law. They selected Duke University Medical Center in Durham, which was in his insurance network.

His family called Angel MedFlight, part of Aviation West Charters of Scottsdale, Arizona, which told Rebekah Deines that it would accept whatever the couple’s insurer would pay and that they would not be held responsible for any remaining balance.

Sean Deines was flown to North Carolina on Dec. 1, 2020, and taken by ground ambulance to Duke, where he spent the next 28 days as an inpatient.

By his discharge, he felt better and things were looking up.

Then the bills came.

The Patient: Sean Deines, 32, who purchased coverage through the Affordable Care Act marketplace with Blue Cross Blue Shield of North Carolina.

Medical Service: A 1,468-mile air ambulance flight from Colorado to North Carolina, along with ground transportation between the hospitals and airports.

Service Provider: Aviation West Charters, doing business as Angel MedFlight, a medical transport company.

Total Bill: $489,000, most of which was for the flight from Denver, with approximately $70,000 for the ground ambulance service to and from the Denver and Raleigh-Durham airports.

What Gives: Insurers generally get to decide what care is “medically necessary” and therefore covered. And that is often in the eye of the beholder. In this case, the debate revolved first around whether Deines was stable enough to safely take a three-plus-hour commercial flight to North Carolina during a pandemic or required the intensive care the air ambulance provided. Second, there was the question of whether Deines should have stayed in Denver for his 28-day treatment to get him into remission. Insurers tend not to consider patient stress or family convenience in their decisions.

Also, both air and ground ambulance services have been center stage in the national fight over huge surprise bills, since the for-profit companies that run them frequently do not participate in insurance networks.

Angel MedFlight, which was not in Deines’ insurance network, sought prior authorization from Blue Cross Blue Shield of North Carolina. The request was dated Nov. 30, but the insurer said the fax arrived in the predawn hours the same day as the flight, Dec. 1, 2020.

On that day, Angel MedFlight flew Deines to North Carolina in an airplane, along with a nurse to oversee his IV medications and oxygen levels.

Angel MedFlight spokesperson Kimberly Halloran did not answer a specific written question from KHN about why the flight went ahead without prior approval; often medical interventions are postponed until it has been obtained. But in an emailed statement, she said the company “satisfied each step in the health insurance process and transported Sean to his long-term health care providers in good faith.”

According to the review of the case done months later by an independent evaluator, Blue Cross on Dec. 3 denied coverage for the air ambulance services because medical records did not support that it was an emergency and Deines was already in an appropriate medical facility.

At the end of December, an appeal was filed against that decision on behalf of Deines by Angel MedFlight.

Then, in March 2021, Blue Cross sent Deines a check for $72,000 to cover part of the $489,000 bill, which he forwarded to the air ambulance company. The explanation of benefits showed the majority of the charges were ruled “not medically necessary.”

Angel MedFlight, through a revenue management firm it hires called MedHealth Partners, continued to appeal to Blue Cross to overturn the denial of the flight portion of the bill.

Then, three months after Blue Cross sent the check that Deines then sent on to Angel MedFlight, the insurer demanded Deines pay back the $72,000.

“The initial thought was ‘I can’t believe this is happening,’” said Deines.

Medical necessity criteria are set by insurers, with North Carolina Blue Cross covering air ambulances in “exceptional circumstances,” such as when needed treatment isn’t available locally.

When Deines, who was still unemployed and undergoing treatment, couldn’t pay, the debt was sent to collections.

In late June, Deines’ representatives at Angel MedFlight took the next step allowed under the Affordable Care Act, appealing the insurer’s internal determination that the flight wasn’t medically necessary to an independent third party through the state.

On July 29, the evaluator ruled in favor of Blue Cross.

Normally, such a flight would be appropriate because the patient was “medically unfit to travel via commercial airflight,” the review noted. But, it went on to say, there was actually no need to travel, as the University of Colorado Hospital — a member of the National Comprehensive Cancer Network — could have managed Deines’ treatment.

His health plan “clearly stipulates their indications for medical flight coverage and, unfortunately, this case does not meet that criteria,” the review concluded.

Resolution: The bill disappeared only after the press got involved. Shortly after a KHN reporter contacted the communications representatives for both the insurer and Angel MedFlight, Deines heard from both of them.

The $72,000 payment was made in error, said Blue Cross spokesperson Jami Sowers.

“We apologize for putting the member in the middle of this complicated situation,” she said in an email that also noted “the air ambulance company billed more than $70,000 just for ground transportation to and from the airport — more than 30 times the average cost of medical ground transport.”

Such a situation would “typically” be flagged by internal systems but for some reason was not, Sowers said.

“I have never heard of a ground transport that costs that much. That’s shocking,” said Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University College of Law, who studies patient billing and air ambulance costs.

Still, there’s good news for Deines: Both the insurer and the air ambulance company told KHN he will not be held responsible for any of the charges. (None of the charges stemmed from his first air ambulance flight from Casper to Denver, which was covered by the insurer.)

“Once North Carolina Blue engages in our formal inquiries about its refund request, the status of the funds will be resolved,” the ambulance spokesperson wrote in her email. “One thing is certain, Sean will not have to pay for North Carolina’s wavering coverage decision.”

In an email, Sowers said Blue Cross had “ceased all recoupment efforts” related to Sean’s case.

The Takeaway: If the flight had happened this year, the couple might have received more price information before they took the flight.

A law called the No Surprises Act took effect Jan. 1. Its main thrust is to protect insured patients from “balance bills” for the difference between what their insurance pays and what an out-of-network provider charges in emergencies.

It also covers nonemergency situations in which an insured patient is treated in an in-network facility by an out-of-network provider. In those cases, the patient would pay only what they would owe had the service been fully in-network.

Another part of the law, called a good faith estimate, might have provided Deines with more transparency into the costs.

That portion says medical providers, including air ambulances, must give upfront cost estimates in nonemergency situations to patients. Had the law been in effect, Deines might have learned before the flight that it could be billed at $489,000.

Insured patients in similar situations today should always check first with their insurer, if they are able, to see if an air transport would be covered, experts said.

Even if the law had been in effect, it likely would not have helped with the big hang-up in Deines’ case: the disagreement over “medical necessity.” Insurers still have leeway to define it.

For his part, Deines said he’s glad he took the flight to be closer to home and family, despite the later financial shock.

“I would not change it, because it provided support for myself and my wife, who needed to take care of me; she was keeping my sanity,” he said.

'It’s been a nightmare': EMS leaders warn industry on verge of collapse

They say underfunding, staffing shortages to blame

By Clay LePard

Mar 14, 2022

https://www.news5cleveland.com/news/local-news/oh-ashtabula/its-been-a-nightmare-ems-leaders-warn-industry-on-verge-of-collapse

GENEVA, Ohio — During a recent Ohio EMS Chiefs Association meeting, board members pointed to the mix of staffing and supply shortages, as well as funding issues, as the driving forces behind major issues eroding their industry.

“The state of the EMS industry is on the verge of collapse,” Eric Burns, vice president of Tri-Village Joint Ambulance District in Darke County said. “If we don’t do something quickly, I think EMS as we know it is going to fall apart.”

When a 911 call is made, you expect an ambulance to show up. But what happens when it doesn’t?

It's a question Cody Buskirk knows well. His mother passed away last month, after he says she waited for two hours for an ambulance to arrive at her rehabilitation center.

"I was furious," he said. "Two hours of her waiting there for someone to get her, that was a death penalty right there."

Buskirk told News 5 his mother passed away as crews were loading her into an ambulance when it finally showed up. The ambulance was supposed to transport her to a hospital a mile and a half away.

"I don’t want people to brush this under the rug," Buskirk added. "We should be confident that we can call an ambulance and they’ll be there for us when we need them."

On top of Buskirk's situation, Vince Gildone also wonders more often nowadays about the idea of ambulances not being able to show up when called.

When the pandemic began, Gildone’s staff at Northwest Ambulance in Geneva consisted of 10 full-time EMTs and around 30 on call. Today, that on-call auxiliary staff is about half and Gildone told News 5 there’s no new names at his doorstep waiting to join.

“I think EMS is in trouble,” Gildone said. “It’s been a nightmare. It was a career path before and now it’s not being looked at as a career path by most people.”

It’s an industry that nowadays pays about the same as some fast-food restaurants, and on top of people not liking the pay, Gildone said the earlier days of uncertainty surrounding COVID-19 scared away quite a few staffers.

To make matters worse, Gildone said supply chain issues have made it harder to repair or replace aging equipment.

“To get a new truck used to take three months, now it’s 18 months,” he added. “[This industry has] been ignored and it's been shoestring-funded for many years, and I think COVID-19 was the thing that pushed us over the edge.”

The board members told News 5 the issue starts first and foremost with funding, with much of theirs coming from reimbursements from programs such as Medicaid.

“When I'm only getting $98 per call, it’s hard to maintain a budget and maintain good equipment and staffing relying on those types of reimbursements,” Burns added. “I worry about who is taking the place of us older ones getting ready to retire.”

And keep in mind, those reimbursements, they say, only come through if someone is transported to a hospital; meaning if care is declined when an ambulance shows up, the ambulance company doesn’t get paid.

“We’re almost treated as a trucking company,” Todd Shroyer, Coshocton County EMS, said. “If a trucking company isn’t hauling freight, they’re not making money. As EMS, if we’re not hauling patients, we’re not making money. Everything we do that doesn’t involve transport, there’s no reimbursement.”

Right now, all 50 states classify police and fire departments as essential services, which means they are required by the government and as a result, those departments can gain access to additional funding.

However, when it comes to EMS, only 11 states classify EMS as an essential service, with Ohio as one of the 39 states that does not.

States that classify EMS as an essential service include Oregon, Washington, Utah, Iowa, Pennsylvania, Indiana, Tennessee, North Carolina, Delaware, Connecticut, and West Virginia according to the National Association of State EMS Officials.

“To think EMS is not considered essential, I can't even imagine how that slipped through the cracks at some point,” Eric Burgess, president of the Ohio EMS Chiefs Association, said.

Burgess, who oversees Delaware County EMS, estimates local EMS budgets only amount to about one-fourth of the budgets of fire and police departments.

This coalition plans to lobby in Columbus later this year in hopes that lawmakers will put them closer to a level playing field with other first responders when it comes to attracting new talent.

“We are having people retire, we have people who say, ‘it’s enough, I'm getting out of the business and I'm doing something else,’ and we’re not bringing new people in fast enough to replace the people as they’re leaving,” Burgess said.

A cycle of problems with the power to pummel a profession.

“Until we fix the reimbursement issue, we can't really get our wages where they need to be,” Shroyer explained. “And until we can get our wages where they need to be, I'm not sure how we’re going to attract people into the business.”

“We frequently talk about when you call an ambulance and there isn't one to send,” Gildone said. “That's clearly something we need to think about and could happen. I think COVID-19 has forever changed how we do business and we don’t know what the outcome is going to be.”

The telehealth extension includes coverage for telehealth services provided in the patient’s residence.  This may help many EMS agencies.

‘‘(iii) EXPANDING ACCESS TO TELEHEALTH SERVICES.—With respect to telehealth services identified in subparagraph (F)(i) as of the date of the enactment of this clause that are furnished during the 151-day period beginning on the first day after the end of the emergency period described in section 1135(g)(1)(B), the term ‘originating site’ means any site in the United States at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system, including the home of an individual.’’

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Congress to temporarily extend Medicare telehealth coverage in funding package

March 08, 2022

JESSIE HELLMANN

https://www.modernhealthcare.com/politics-policy/congress-temporarily-extend-medicare-telehealth-coverage

Congress will include a months-long extension of telehealth flexibilities in a package to fund the government, fulfilling a key ask made by providers and advocates.

Under a draft of the provisions obtained by Modern Healthcare, Medicare will cover an array of telehealth services for at least 151 days after the end of the public health emergency, allowing beneficiaries to continue accessing care from their homes, at least temporarily.

That will allow Congress more time to study the impacts of expanding telehealth access under Medicare and to decide whether lawmakers want to make those changes permanent.

Before the pandemic, Medicare coverage of telehealth was fairly limited. But with the pandemic came an explosion of telehealth usage as people became afraid to seek care. It forced Medicare to update its coverage policies, and stakeholders have argued those changes should be made permanent.

Under the public health emergency, Medicare has temporarily waived several restrictions on coverage, including a requirement that beneficiaries be at a rural healthcare facility to receive telehealth services. Many of those waivers expire at the end of the public health emergency, which could end as soon as July 15.

Congress has been pushed by providers and telehealth advocates to permanently repeal those restrictions, but due to concerns about fraud and abuse, lawmakers decided to extend the flexibilities temporarily to allow for more time to collect data on costs and utilization.

The package directs the Medicare Payment Advisory Commission to release a report by June 15, 2023 detailing telehealth utilization in Medicare and costs. Congress will also direct the Office of the Inspector General to submit a report by the same date on program integrity risks associated with Medicare coverage of telehealth.

Under the temporary extension, federally qualified health centers and rural health clinics will be allowed to offer telehealth for 151 days after the public health emergency.

Medicare will continue to cover occupational and physical therapy as well as speech-language pathology delivered through telehealth during the 151-day period.

The package will also delay requirements that Medicare beneficiaries using telehealth for mental health services be examined in person by the provider within six months of starting treatment, and every year after.

The requirement, which was included in the government funding bill passed in 2020, was criticized by healthcare providers as a barrier to mental healthcare, especially for people in rural areas.

The package would also temporarily extend Medicare coverage of audio-only telehealth services.

Axios Source Article | Comments Courtesy of Matt Zavadsky

Lots to unpack here…

Interesting findings from a reputable and widely respected non-profit, which is often cited by governmental leaders as a basis for fee and payment analysis.  The hyperlinks to related commentary are also interesting reads.

It may be a good idea for a coalition of EMS experts from the AAA, NAEMT, IAFC, AIMHI, etc., form a task force to digest this report, compare ambulance fee changes compared to other emergency/safety-net medical care services, and do some localized research (i.e.: ground truth) on things like cost of service delivery trends, trends in payer mix and payment practices, impact of performance expectations that have little correlation to patient outcomes (response times, staffing), etc., to prepare and publish an analysis of this report, with recommendations for things like alternate deployment models, clinically relevant performance standards, alternate dispositions, etc.

Some of the most interesting findings and charts from the report included below.

Strongly recommend that interested folks download the full report here.

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Ambulance rides are getting a lot more expensive

Tina Reed, 2/22/22

https://www.axios.com/ambulance-rides-are-getting-a-lot-more-expensive-cee897fe-63b7-4412-aa67-718109773e79.html

The cost of an ambulance ride has soared over the past five years, according to a report from FAIR Health, shared first with Axios.

Why it matters: Patients typically have little ability to choose their ambulance provider, and often find themselves on the hook for hundreds, if not thousands of dollars.

The details: Most ambulance trips billed insurers for "advanced life support," according to FAIR Health's analysis.

• Private insurers' average payment for those rides jumped by 56% between 2017 and 2020 — from $486 to $758.
• Ambulance operators' sticker prices, before accounting for discounts negotiated with insurers, have risen 22% over the same period, and are now over $1,200.

Medicare, however, kept its payments in check: Its average reimbursement for advanced life support ambulance rides increased by just 5%, from $441 to $463.

Between the lines: Ambulances aren't covered by the new law that bans most surprise medical bills, meaning patients are still on the hook in payment disputes between insurers and ambulance operators.

State of play: Ground ambulances are operated by local fire departments, private companies, hospitals and other providers and paid for in a variety of ways, which makes this a tricky issue to address, according to the Commonwealth Fund.

• Some states — such as Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia — have protections against surprise ground ambulance billing, a columnist in the Deseret News pointed out earlier this year.
• But in California, Florida, Colorado, Texas, Illinois, Washington state and Wisconsin, more than two-thirds of emergency ambulance rides included an out-of-network charge for ambulance-related services that posed a surprise bill risk in 2018, according to a Peterson-KFF Health System Tracker brief.
• The Biden administration has said it's working on the problem.

The bottom line: Costs for ground ambulance care are on the rise and, with few balance billing protections, that means patients could still be hit with some big surprises if they wind up needing a ride in an ambulance.

Telehealth in Transit: How Cleveland Clinic Achieves ED Avoidance & Reduced Readmissions through its ET3 Model and Other Virtual Care Programs

Thursday, February 24th, 2022 | 12:00 PM - 1:00 PM CT

Receiving quality care from an emergency medicine physician following a 9-1-1 call is critical, but how can you bring the expertise of the physician directly to the patient without transport to the ED to reduce delays in care and unnecessary admissions? From initial emergency dispatch and treatment in place to in-transit care, telehealth has a place in the EMS care. At least that’s what Cleveland Clinic found with its ET3 Model.

In the webinar, Dr. Bryan Graham, Medical Director of the Virtual Emergency Medicine Program at Cleveland Clinic, and Chris O’Rourke, Institute Administrator for the Emergency Services Institute at Cleveland Clinic, will discuss how the health system has scaled and grown its ET3 Model to divert unnecessary emergency department admissions and reduce readmission, all while replicating emergency care in the field.

Register for the webinar to learn how Cleveland Clinic

• Avoided ED transports for 70% of ET3 patients by virtually triaging them in the field
• Secured EMS buy-in for the ET3 Model workflow
• Partnered with a major wireless network operator to improve connectivity in the field
• Staffed its ET3 program with dedicated emergency medicine physicians
• Replicated the ET3 Model to reduce transports in other settings like nursing homes

REGISTER NOW►

In an outstanding demonstration of collaboration and focus on provider, patient, and community safety, 14 national and international associations have partnered on the release of a Joint Statement on Lights & Siren Vehicle Operations on Emergency Medical Services (EMS) Responses.

This level of agreement on any topic in EMS delivery is exceptionally rare, and we are grateful to the leaders of these associations for coming together to recognize the importance of balancing provider, patient, and community safety, with patient outcomes and community expectations!

The link to the full statement is below, and the key provisions of the statement are here.  

The sponsoring organizations of this statement believe that the following principles should guide L&S use during emergency vehicle response to medical calls and initiatives to safely decrease the use of L&S when appropriate:

• The primary mission of the EMS system is to provide out-of-hospital health care, saving lives and improving patient outcomes, when possible, while promoting safety and health in communities. In selected time-sensitive medical conditions, the difference in response time with L&S may improve the patient’s outcome.
• EMS vehicle operations using L&S pose a significant risk to both EMS practitioners and the public. Therefore, during response to emergencies or transport of patients by EMS, L&S should only be used for situations where the time saved by L&S operations is anticipated to be clinically important to a patient’s outcome. They should not be used when returning to station or posting on stand-by assignments.
• Communication centers should use EMD programs developed, maintained, and approved by national standard-setting organizations with structured call triage and call categorization to identify subsets of calls based upon response resources needed and medical urgency of the call. Active physician medical oversight is critical in developing response configurations and modes for these EMD protocols. These programs should be closely monitored by a formal quality assurance (QA) program for accurate use and response outcomes, with such QA programs being in collaboration with the EMS agency physician medical director.
• Responding emergency agencies should use response based EMD categories and other local policies to further identify and operationalize the situations where L&S response or transport are clinically justified. Response agencies should use these dispatch categories to prioritize expected L&S response modes. The EMS agency physician medical director and QA programs must be engaged in developing these agency operational policies/guidelines.
• Emergency response agency leaderships, including physician medical oversight and QA personnel should monitor the rates of use, appropriateness, EMD protocol compliance, and medical outcomes related to L&S use during response and patient transport.
• Emergency response assignments based upon approved protocols should be developed at the local/department/agency level. A thorough community risk assessment, including risk reduction analysis, should be conducted, and used in conjunction with local physician medical oversight to develop and establish safe response policies.
• All emergency vehicle operators should successfully complete a robust initial emergency vehicle driver training program, and all operators should have required regular continuing education on emergency vehicle driving and appropriate L&S use.
• Municipal government leaders should be aware of the increased risk of crashes associated with L&S response to the public, emergency responders, and patients. Service agreements with emergency medical response agencies can mitigate this risk by using tiered response time expectations based upon EMD categorization of calls. Quality care metrics, rather than time metrics, should drive these contract agreements.
• Emergency vehicle crashes and near misses should trigger clinical and operational QA reviews. States and provinces should monitor and report on emergency medical vehicle crashes for better understanding of the use and risks of these warning devices.
• EMS and fire agency leaders should work to understand public perceptions and expectations regarding L&S use. These leaders should work toward improving public education about the risks of L&S use to create safer expectations of the public and government officials.

Joint Statement on Red Light and Siren Operations with Logos - FINAL.pdf

MedPage Source Article | Comments Courtesy of Matt Zavadsky

Many patients who call 911 don’t need ambulance transport to an ER.  But, if that is the only way EMS providers are reimbursed for an emergency response, you generally get what you pay for…

One of the ways we can help preserve Medicare is to transform the reimbursement model for EMS away from the model that only pays if we use the highest cost mode of transportation (an ambulance), to the highest cost setting for care (an ER). 

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Senators Mull Ways to Cut Costs in Medicare

— "The Medicare system is hemorrhaging money on scams and fraud," says Sen. Warren

by Joyce Frieden, Washington Editor

February 3, 2022 

WASHINGTON -- The Medicare program could easily become solvent if regulators cracked down harder on fraudsters and profiteers, Sen. Elizabeth Warren (D-Mass.), chair of the Senate Finance Subcommittee on Fiscal Responsibility and Economic Growth, said Wednesday.

 

"The Medicare system is hemorrhaging money on scams and fraud," Warren said at a hearing on Medicare financing. "It is critical that we stop the flow and if we do, the system will have more than enough money to operate at its current level and increase coverage."

 

Concerns About Drug Prices

Pharmaceutical companies were one target of Warren's ire. "In 2019, total Medicare spending on prescription drugs was $220 billion," she said. "Because Medicare cannot negotiate prices, drug companies are able to rake in billions in profits. Now that's bad enough, but the drug companies have more ways to juice their profits: they use anti-competitive tactics like 'pay for delay,' product hopping, and patent thickening, all while anti-trust regulators turn a blind eye. It's enough to gag a maggot."

 

She also pointed to the private insurers who participate in Medicare Advantage. "Medicare Advantage was ... built on vague promises of cost savings, but instead, it has cost Medicare almost $150 billion extra over the past 12 years," Warren said. "Because greedy private insurers are gaining the program's rules, including its risk adjustment process, its benchmark policy, and its quality bonus program, all to squeeze more money out of Medicare and to drive up the costs for taxpayers."

 

Making changes to both those programs could save more than $900 billion over 10 years, while the estimated shortfall in Medicare's hospital insurance trust fund is $517 billion between 2026 and 2031, and the cost of extending Medicare coverage to include dental, vision, and hearing benefits is just under $360 billion. "In other words, we don't need to cut Medicare benefits. We need to cut out the scams that are bringing Medicare down," she said.

 

Arguments Against Expanding Medicare Benefits

Sen. Bill Cassidy, MD (R-La.), the subcommittee's ranking member, had different ideas. Expanding Medicare benefits "doesn't make sense to me," he said. "We have an obligation to the people currently being covered, and yet we will expand the benefit and maybe have insolvency come even quicker." Cassidy noted that if Medicare were to become insolvent, "under current law, it would be an immediate cut to providers of roughly 20% to 30%," something that providers would not be able to afford, leading to less provider access for beneficiaries.

 

Although some people have suggested doing away with beneficiary cost-sharing, "there's a lot of data showing that one thing that puts the brakes on it is if you have just a little bit of cost-sharing, Cassidy said. "Not too much so the diabetic does not get her needed care, but at least a little bit so people think twice."

 

"It's time to take a modern approach to the way we deliver healthcare," using an approach "that rewards providers for keeping patients out of hospital beds and one that recognizes the patient, and the doctor, and that relationship as the ultimate arbiter of value, health, and well-being," he continued. "We can get there without disrupting the quality and access our constituents need, but the discussion has to begin today."

 

Hearing witness James Capretta, senior fellow at the American Enterprise Institute, a right-leaning think tank here, suggested five ways to modernize the program: putting the Medicare benefit together into one understandable, coordinated benefit with rational cost-sharing; making the choices between various Medicare plans more understandable for patients; strengthening premium competition among the available options; improving price competition among providers; and consolidating the various Medicare trust funds, so the financing of the entire program would be more clear.

 

Amy Kapczynski, JD, faculty co-director of the Law and Political Economy Project at Yale Law School in New Haven, Connecticut, noted that current drug pricing doesn't accurately reflect companies' research and development costs. She had several suggestions for improving Medicare drug coverage. In addition to allowing Medicare to negotiate drug prices, "we should also have legislation that penalizes price spikes to prevent price gouging on existing drugs," she said. "We should explore legislation to curb anti-competitive patent-thickening, and [legislation] that would strengthen rules against 'pay for delay' settlement deals. And we should also critically provide the [Federal Trade Commission] with more resources and authority to address anti-competitive conduct in the sector."

 

Direct Contracting in the Spotlight

A Medicare demonstration program known as Direct Contracting came under some criticism at the hearing. Under the program, accountable care organizations (ACOs), insurance companies, and health systems, would agree to provide care for a certain number of traditional Medicare beneficiaries in a geographic area for a set amount of money.

 

"CMS has invited the same insurers that are already scamming Medicare and dozens of new investor-owned organizations to cover traditional Medicare beneficiaries through a new privatized Direct Contracting model that lets them pocket -- get this -- as much as 40% in profits," Warren said. "This invites fiscal disaster, and I hope this administration will reverse this decision."

 

Susan Rogers, MD, president of Physicians for a National Health Program, a lobbying group for single-payer healthcare that has protested against Direct Contracting, agreed. "We cannot let Medicare become a playground for Wall Street investors," Rogers said. "We need to get back to what we know works, and that's traditional Medicare."

 

On the other hand, Katherine Baicker, PhD, professor of public policy at the University of Chicago, spoke in favor of more use of alternative payment models in Medicare, including ACOs. "Right now, Medicare's fee-for-service traditional structure gets the prices wrong, despite all best efforts," she said. "It's very difficult to write down prices that align with value on a line-by-line basis. And we see overuse of some services at the same time that we see underuse of other services. And that's not the best way to ensure we get the most health for beneficiaries for every dollar that we spend."

 

Instead, "reforms that align payments to providers with the value of healthcare that the service provides could help our dollars go further in promoting health and well-being for beneficiaries," Baicker said. "That would include some alternative payment models, each of which has challenges but has potential. We've seen experiments in the Medicare program with alternative payment models like bundled payments or capitated payments or ACOs ... Some of the experiments in bundled payments, particularly those looking at joint replacement, have seen reduction in costs while maintaining the quality of outcome for beneficiaries."