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One patient got a $3,600 bill for a 4-mile ride. Another was charged $8,460 for a trip from one California hospital that could not handle his case to a facility that could. Still another found herself marooned at an out-of-network hospital, where she’d been taken by ambulance without her consent.

These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting California and 20 other states to pass laws protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.

Patients choose to go to the doctor or a hospital, but they are vulnerable when they call 911 — or get into an ambulance. The dispatcher picks the ambulance crew, which, in turn, often picks the hospital. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911.

Betsy Imholz, special projects director at the Consumers Union, which has collected over 700 patient stories about surprise medical bills, said at least a quarter concern ambulances.

“It’s a huge problem,” she said.

Forty years ago, most ambulances were free for patients, provided by volunteers or town fire departments using taxpayer money, said Jay Fitch, president of Fitch & Associates, an emergency services consulting firm. Today, ambulances are increasingly run by private companies and venture capital firms. Ambulance providers now often charge by the mile and sometimes for each “service,” like providing oxygen. If the ambulance is staffed by paramedics rather than emergency medical technicians, that will result in a higher charge — even if the patient didn’t need paramedic-level services. Charges range widely from zero to thousands of dollars, depending on billing practices.

The core of the problem is that ambulance and private insurance companies often can’t agree on a fair price, so the ambulance service doesn’t join the insurance network. That leaves patients stuck in the middle with out-of-network charges that are not negotiated, Imholz said.

This happens to patients frequently, according to one recent study of over half a million ambulance trips taken by patients with private insurance in 2014. The study found that 26 percent of these trips were billed on an out-of-network basis.

That figure is “quite jarring,” said Loren Adler, associate director for the USC-Brookings Schaeffer Initiative and co-author of recent research on surprise billing.

The KHN review of complaints revealed two common scenarios leaving patients in debt: First, patients get in an ambulance after a 911 call. Second, an ambulance transfers them between hospitals. In both scenarios, patients later learn the fee is much higher because the ambulance was out-of-network, and after their insurer pays what it deems fair, they get a surprise bill for the balance, also known as a “balance bill.”

The Better Business Bureau has received nearly 1,200 consumer complaints about ambulances in the past three years; half were related to billing, and 46 mentioned out-of-network charges, spokeswoman Katherine Hutt said.
While the federal government sets reimbursement rates for patients on Medicare and Medicaid, it does not regulate ambulance fees for patients with private insurance. In the absence of federal rules, those patients are left with a fragmented system in which the cost of a similar ambulance ride can vary widely from town to town. There are about 14,000 ambulance services across the country, run by governments, volunteers, hospitals and private companies, according to the American Ambulance Association.

For a glimpse into the unpredictable, fragmented system, consider the case of Roman Barshay. The 46-year-old software engineer, who lives in Brooklyn, N.Y., was visiting friends in the Boston suburb of Chestnut Hill last November when he took a nasty fall.

Barshay felt a sharp pain in his chest and back and had trouble walking. An ambulance crew responded to a 911 call at the house and drove him 4 miles to Brigham and Women’s Hospital, taking his blood pressure as he lay down in the back. Doctors there determined he had sprained tendons and ligaments and a bruised foot, and released him after about four hours, he said.

After Barshay returned to Brooklyn, he got a bill totaling $3,660 — which is $915 for each mile of the ambulance ride. His insurance had paid nearly half, leaving him to pay the remaining $1,890.50.

“I thought it was a mistake,” Barshay said.

But Fallon Ambulance Service, a private company, was out-of-network for his UnitedHealthcare insurance plan.

“The cost is outrageous,” said Barshay, who reluctantly paid his nearly $2,000 of the bill after Fallon sent it to a collection agency. If he had known what the ride would cost, he said, he would at least have been able to refuse and “crawl to the hospital myself.”

“You feel horribly to send a patient a bill like that,” said Peter Racicot, senior vice president of Fallon, a family-owned company based outside Boston.

But ambulance companies are “severely underfunded” by Medicare and Medicaid, Racicot said, so Fallon must balance the books by charging higher rates for patients with private insurance.

Racicot said his company has not contracted with Barshay’s insurer because they couldn’t agree on a fair rate. When insurers and ambulance companies can’t agree, he said, “unfortunately, the subscribers wind up in the middle.”

It’s also unrealistic to expect EMTs and paramedics at the scene of an emergency to determine whether the company takes a patient’s insurance, Racicot added.

Ambulance services have to charge higher rates for patients they transport because the crews must be ready around-the-clock even if no calls come in, said Fitch, the ambulance consultant. When ambulance crews drive out to a call, a third of the time they end up not transporting any patients and typically aren’t reimbursed for the trip, he added.

In part, Barshay had bad luck. If the accident had happened just a mile away inside Boston city limits, he could have ridden a city ambulance, which would have charged $1,490 instead of $3,660, according to Boston EMS. That’s still “a huge bill,” said Imholz of Consumers Union.

There is little protection for consumers: Very few states have laws limiting ambulance charges, and most state laws that protect patients from surprise billing do not apply to ground ambulance rides, according to attorney Brian Werfel, consultant to the American Ambulance Association. And none of the state surprise-billing protections applies to people with self-funded employer-sponsored health insurance plans, which are regulated only by federal law. That’s a huge exception: Sixty-one percent of privately insured employees are covered by self-funded employer-sponsored plans.

Some towns that hire private companies to respond to 911 calls may regulate fees or prohibit balance billing, Werfel said, but each locality is different.

Insurance companies try to protect patients from balance billing by negotiating rates with ambulance companies, said Cathryn Donaldson, spokeswoman for America’s Health Insurance Plans. But “some ambulance companies have been resistant to join plan networks” when insurance companies offer Medicare-based rates, she said.

Medicare rates vary widely by geographic area. On average, ambulance services make a small profit on Medicare payments, according to a report by the U.S. Government Accountability Office. If a patient uses a basic life support ambulance in an emergency, in an urban area, for instance, Medicare payments range from $324 to $453, plus $7.29 per mile. Medicaid rates tend to be significantly lower.

There’s evidence of “waste and fraud” in the ambulance industry, Donaldson added, citing a 2015 study from the Office of Inspector General at the U.S. Department of Health and Human Services. The report concluded Medicare paid over $50 million in improper ambulance bills, including for supposedly emergency-level transport that ended at a nursing home, not a hospital. One in 5 ambulance services had “questionable billing practices,” the report found.

Most cases reviewed by Kaiser Health News did not appear to involve fraudulent charges. Instead, patients got caught in a system in which ambulance services can legally charge thousands of dollars for a single trip — even when the trip starts at an in-network hospital.

That’s what happened to Devin Hall, a 67-year-old retired postal inspector in Northern California. While he faces stage 3 prostate cancer, Hall is also fighting a $7,109.70 out-of-network ambulance bill from American Medical Response, the nation’s largest ambulance provider.

On Dec. 27, 2016, Hall went to a local hospital with rectal bleeding. Since the hospital didn’t have the right specialist to treat his symptoms, it arranged for an ambulance ride to another hospital about 20 miles away. Even though the hospital was in-network, the ambulance was not.

Hall was stunned to see that AMR billed $8,460 for the trip. His federal health plan, the Special Agents Mutual Benefit Association, paid $1,350.30 and held Hall responsible for $727.08, records show. The health plan paid that amount because AMR’s charges exceeded its Medicare-based fee schedule, according to its explanation of benefits. But AMR turned over his case to a debt collector, Credence Resource Management, which sent an Aug. 25 notice seeking the full balance of $7,109.70.

“These charges are exorbitant — I just don’t think what AMR is doing is right,” said Hall, noting that he had intentionally sought treatment at an in-network hospital.

He has spent months on the phone calling the hospital, his insurer and AMR trying to resolve the matter. Given his prognosis, he worries about leaving his wife with a legal fight and a lien on their Brentwood, Calif., house for a debt they shouldn’t owe.

After being contacted by Kaiser Health News, AMR said it has pulled Hall’s case from collections while it reviews the billing. After further review, company spokesman Jason Sorrick said the charges were warranted because it was a “critical care transport, which requires a specialized nurse and equipment on board.”

Sorrick faulted Hall’s health plan for underpaying, and said Hall could receive a discount if he qualifies for AMR’s “compassionate care program” based on his financial and medical situation.

“In this case, it appears the patient’s insurance company simply made up a price they wanted to pay,” Sorrick said.

In July, a California law went into effect that protects consumers from surprise medical bills from out-of-network providers. That means if a patient goes to an in-network hospital, then takes an out-of-network ambulance to transfer facilities, the law could limit the patient’s bill to in-network rates. But Hall’s case occurred before that law took effect, and the state law doesn’t apply to his federal insurance plan.

The consumer complaints reviewed by Kaiser Health News reveal a wide variety of ways that patients are left fighting big bills:
• An older patient in California said debt collectors called incessantly, on Sunday mornings and at night, demanding an extra $500 on top of the $1,000 that his insurance had paid for an ambulance trip.
• Two ambulance services responded to a New Jersey man’s 911 call when he felt burning in his chest. The private ambulance company charged him $2,100 for treating him on the scene for less than 30 minutes — even though he never rode in that company’s ambulance.
• A woman who rolled over in her Jeep in Texas received a bill for a $26,400 “trauma activation fee” — a fee triggered when the ambulance service called ahead to the emergency department to assemble a trauma team. The woman, who did not require trauma care, fought the hospital to get the fee waived.

In other cases, patients face financial hardship when ambulances take them to out-of-network hospitals. Patients don’t always have a choice in where to seek care; that’s up to the ambulance crew and depends on the protocols written by the medical director of each ambulance service, said Werfel, the ambulance association consultant.

Sarah Wilson, a 36-year-old microbiologist, had a seizure at her grandmother’s house in rural Ohio on March 18, 2016, the day after having hip surgery at Akron City Hospital. When her husband called 911, the private ambulance crew that responded refused to take her back to Akron City Hospital, instead driving her to an out-of-network hospital that was 22 miles closer. Wilson refused care because the hospital was out-of-network, she said. Wilson wanted to leave. But “I was literally trapped in my stretcher,” without the crutches she needed to walk, she said. Her husband, who had followed by car, wasn’t allowed to see her right away. She ended up leaving against medical advice at 4 a.m. She landed in collections for a $202 hospital bill for a medical examination, which damaged her credit score, she said.

Ken Joseph, chief paramedic of Emergency Medical Transport Inc., the private ambulance company that transported Wilson, said company protocol is to take patients to the “closest appropriate facility.” Serving a wide rural area with just two ambulances, the company has to get each ambulance back to its station quickly so it can be ready for the next call, he said.

Patients like Wilson are often left to battle these bills alone, because there are no federal protections for patients with private insurance.

Rep. Lloyd Doggett (D-Texas), who has been pushing for federal legislation protecting patients from surprise hospital bills, said in a statement that he supports doing the same for ambulance bills.

Meanwhile, patients do have the right to refuse an ambulance ride, as long as they are over 18 and mentally capable.

“You could just take an Uber,” said Adler, of the Schaeffer Initiative. But if you need an ambulance, there’s little recourse to avoid surprise bills, he said, “other than yelling at the insurance company after the fact, or yelling at the ambulance company.”

California Healthline correspondent Chad Terhune contributed to this report.
This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

A shrinking taxpayer base, swelling beneficiary numbers and growing healthcare costs all threaten Medicare’s long-term viability, according to the HHS, and the agency warned the program would need to increase its revenue or drastically reduce benefits to balance its budget.

In a wide-ranging report issued last week, HHS said the Medicare trust fund “is not projected to be sustainable over the long term with the projected tax rates and expenditure levels.”

The agency estimates that the ratio of workers paying taxes to beneficiaries eligible for Medicare will drop from 3:1 in 2016 to 2:1 by 2091. In addition, healthcare costs continue to rise faster than the taxable wages used to support the program. The shortfall is expected to equal $3.3 trillion over the next 75 years.

The CMS would need to significantly increase its revenue or reduce Medicare benefits to balance its budget, HHS said.

While providers have made an effort to move to value-based care and decrease Medicare spending, the move isn’t happening fast enough, according to the agency.

“It is conceivable that providers could improve their productivity, reduce wasteful expenditures and take other steps to keep their cost growth within the bounds imposed by the Medicare price limitations,” HHS said. “For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains—a very challenging and uncertain prospect.”

But there’s another wrinkle. It’s unclear whether providers will continue to want to see Medicare beneficiaries in the coming years, according to Ernst & Young. The firm conducted an independent audit of HHS’ finances and found some clinicians may find it financially unfeasible to continue to participate in Medicare.

Medicare trustees raised similar concerns in their annual report this summer.

“Absent an unprecedented change in healthcare delivery systems and payment mechanisms, the prices paid by Medicare for most health services will fall increasingly short of the costs of providing these services,” the consulting firm said.

HHS itself echoed the concerns in the report, noting that projected MACRA payments for high-performing Merit-based Incentive Payment System (MIPS) and alternative payment model providers are scheduled to expire in 2025 under current law, resulting in a significant one-time payment reduction for most physicians.

In addition, under MACRA the annual physician payment update for 2017 through 2019 will be 0.5%. For 2020 through 2025, there will be no payment update.

“Absent a change in the delivery system or level of update by subsequent legislation, access to Medicare-participating physicians may become a significant issue in the long term under current law,” HHS said.

Shareholders and company executives finalized the Advisory Board Co.’s $2.58 billion deal with UnitedHealth Group and a private equity firm that will split the consulting group’s healthcare business from its education arm, the companies announced Friday.

UnitedHealth’s Optum health-services segment will take over the Advisory Board’s healthcare business for an estimated $1.3 billion, including its debt. The Advisory Board provides independent research, advisory services and data analytics for more than 4,400 healthcare organizations.

Private equity firm Vista Equity Partners Management will acquire the Advisory Board’s education business known as EAB, which includes the high-performing Royall & Co. division, for $1.55 billion. EAB provides research and technology services for more than 1,200 educational institutions and will operate as a stand-alone business.

Advisory Board shareholders will net estimated cash per share of $53.81, down from the initial valuation of $54.29, which includes a fixed payment of $52.65 per share and the amount in cash equal to $1.16 based on the per-share, after-tax value of its equity stake in Evolent Health.

Optum has relationships across the healthcare spectrum that span more than 300 payers and 115 million consumers, which will expand the combined organization’s research breadth, said Advisory Board CEO Robert Musslewhite, who will continue to lead the healthcare research and technology business.

“They bring a ton of data and analytics that strengthen everything we can do in our research, and they bring some technologies we do not have on the consulting side that will allow us to develop deeper relationships,” he said. “The challenges our members have been wrestling with transcend the acute-care market. This positions us to help tackle the changes happening in the industry and how they interplay with other sectors of the broader system.”

The Advisory Board has had trouble maintaining steady revenue growth on the healthcare side following the presidential election and subsequent uncertainty in the market, as some providers dialed back their purchases. But that political uncertainty has also been a boon for its education arm, similar to other consulting firms that are increasingly relied on by healthcare organizations to help them navigate issues like caring for a rising number of uninsured if the Affordable Care Act is repealed.

The company saw its net income plummet in the third quarter to $685,000 on revenue of $183.1 million, down from $37.5 million in net income on $200.5 million of revenue in the third quarter last year.

Given the financial pressures providers are facing as hospital admissions dip, reimbursement dwindles and more difficult cost-cutting strategies like reducing clinical variation loom, there has been more demand for services that deliver return on investment in the short term. Providers seek Advisory Board’s solutions surrounding revenue cycle, cost reduction and risk-adjusted reimbursement, while demand has waned in areas like new technology where return is more difficult to capture and decision making is heavily affected by the ever-changing regulatory environment, Advisory Board executives said.

The organization slimmed down its workforce by 220 employees and narrowed its services to offset the financial headwinds. It has focused its research on optimizing revenue cycle, health system growth and reducing variation and dropped topics including care management workflow and infection control analytics.

Analysts at Canaccord Genuity said that the transaction price is fair given that the Advisory Board’s healthcare business underperformed over the last several years while the education arm has done relatively well.

Some critics have expressed concern that the merger would skew the Advisory Board’s insights to benefit Optum. But Advisory Board and Optum executives were quick to dismiss that notion.

“Delivering credible, objective and independent insight is a fundamental part of our model and that won’t change,” Musslewhite said.

“You don’t acquire the breadth and depth of a client portfolio (like Optum) unless you are thoughtful and focused on the appropriate security, confidentiality and rigor in service delivery models to ensure you are objective,” said Eric Murphy, CEO of OptumInsight, Optum’s advisory consulting branch.

The company has been exploring “strategic alternatives” including a potential sale since 2016 and officially announced it was shopping the Advisory Board around in February, not long after activist hedge fund Elliott Management Corp. and related entities bought about 8.3% of its shares.

“We felt that those business were on different investment and growth strategies,” Musslewhite said. “Throughout 2016 and early 2017, we restructured our healthcare business that had slower revenue growth and accelerated our timeline in exploring strategic alternatives. We felt at some point we needed to have each business make independent decisions rather than allocate capital between them.”

The company spent $7.8 million in the third quarter and $17.2 million over the first nine months of 2017 on merger expenses, according to the company’s third-quarter report.

Advisory Board shareholders approved the transaction along with the executive compensation packages Wednesday. Since the deal cleared, Musslewhite will receive a $2 million transaction bonus, Advisory Board Chief Legal Officer Evan Farber $1 million, Advisory Board Chief Financial Officer Michael Kirshbaum $750,000 and Advisory Board President David Felsenthal $750,000.

Musslewhite and Cormac Miller, the Advisory Board’s chief product officer, will receive an annual base salary of $700,000 and $360,000, respectively, an annual short-term incentive equal to 100% and 50% of base salary, respectively, and annual long-term incentives equal to $3.85 million and $785,000, respectively.

Should the executives leave the company, their golden parachutes would entail a cash and equity package totaling $12.35 million for Musslewhite, $7.69 million for Felsenthal, $3.51 million for Advisory Board Chief Operating Officer Richard Schwartz, $3.31 million for Kirshbaum and $2.35 million for Miller.

Optum has built a business that focuses on operational efficiency and effectiveness—combining relevant insights on the provider side of the market is a natural fit, Optum’s Murphy said.

“If you take that capability and insight and expand it to health plans and life sciences organizations and bring forth the technology and managed services to capture what those insights mean for them, you start to impact the overall healthcare ecosystem,” he said.

CAMBRIDGE, Mass. — Dedalo Sousa, an 85-year-old with type 2 diabetes, has seen the inside of a hospital more times than he can remember.

He has a regular doctor. But sometimes, “when he gets scary things, we don’t want to wait for his doctor visit,” said Sousa’s wife, Emilia Torres.

Once it was a cyst on his back. Another time, Torres said, he had something like heartburn.

Torres admitted that her husband’s emergency room visits are often for “minor things.” She added, however, “I panic when he gets sick.”

That impulse — combined with the fact that health problems crop up outside of office hours, or that even daytime problems can present a transportation challenge — drive many older patients to turn to 911 for help. And laws in many places, including Massachusetts, are very clear: A 911 call means a trip to the hospital.

But hospitals and insurers have begun trying to change that story by changing how emergency medicine is delivered. The idea is, instead of transporting patients to the hospital, emergency medical technicians respond to their needs in their own home. Many patient needs — for instance, slightly elevated blood pressure, a dip in blood sugar — are simple enough to not need a trip to the hospital. Avoiding hospitals saves insurers money, is easier on patients, and reduces the risk of hospital-acquired infections.

It’s called mobile integrated healthcare; currently, more than 100 such programs exist nationwide. In Massachusetts, a number of pilot programs in mobile integrated health have sprouted up in recent years. The Department of Public Health has waived certain rules governing EMS providers for two Boston-area pilot programs.

One such program was started in 2014 by nonprofit Commonwealth Care Alliance. Its participants are so-called “dual eligible” individuals — residents who qualify for both Medicaid and Medicare. This group tends to have multiple complex health issues, often including behavioral health conditions.

They also make up a disproportionate share of health care spending. According to a 2016 MedPAC report, while dual-eligible beneficiaries account for 18 percent of beneficiaries with traditional Medicare coverage, they accounted for 31 percent of spending in 2012. This is due, at least in part, to frequent ER visits.

But avoiding emergency rooms can be trickier than it seems. In evenings when doctors are gone and clinics are closed, a 911 call is some patients’ best bet for medical attention. And Massachusetts law — and similar ones in many other places — dictates that when a person calls 911, the ambulance that responds must transport them to a hospital, regardless of the seriousness of their health needs.

Pilot mobile health projects take a different tack. In the case of the program run by CCA, participants enroll by signing up online or through their doctors. Instead of 911, those participants are given another number on a refrigerator magnet to call if they have a medical emergency between 6 p.m. and 1 a.m., the state rules for their hours of operation.

A nurse practitioner answers the phone and assesses the patient’s condition, and contacts EasCare Ambulance Service, which contracts with the organization.

A patient calling during the program’s hours of operation will usually have a paramedic at the door within an hour. Calls at other times are queued for that evening’s shift.

Once at a patient’s home, the visit proceeds much like a home health care visit — vitals are taken and symptoms are noted. The EMT then relays this information to a doctor over the phone, before beginning treatment such as running an IV, administering medication, or taking tests.

Because the modified ambulances don’t carry stretchers, if the EMTs determine a patient needs to go to the hospital, they call for a regular ambulance.

But generally, that isn’t needed. According to a survey CCA conducted of 275 patients who received mobile care through July 2017, 84 percent avoided any emergency room visits during that time.

According to a CCA-coauthored 2016 report, those avoided visits amount to about $800 to $3,600 in savings per patient, relative to what it would have cost if the patient received the same treatment in a hospital emergency department.

Still, despite the growing enthusiasm of insurers for mobile integrated health programs, their overall efficacy hasn’t been thoroughly studied.

“We’re able to anecdotally note that there is a benefit, but we need to measure how beneficial these programs really are,” said Dr. Stephen Dorner, an emergency medicine physician at Massachusetts General Hospital who co-authored a 2016 journal article on mobile integrated health programs. Dorner also serves as a consultant to CCA.

He and his co-authors pointed out that while mobile health programs are sprouting up across the country, “their performance has rarely been rigorously evaluated.”

CCA’s program is a good example, he said.

“We know that it saved money when people avoided going to the hospital,” Dorner added. “But we’re talking about avoiding something that it’s hard to predict in the first place. There hasn’t been a full-scale, retrospective analysis.”

Currently, CCA’s mobile integrated health service is only available to participants in the Boston area; it hopes to extend its coverage to 28 southeastern Massachusetts cities and towns in the first half of 2018.

But the state would have to change the program’s waiver to allow, among other things, emergency medical technicians to perform some of the duties of paramedics.

“We’re not allowed to do that yet, but we want to, so we can help people more,” said Ron Quaranto, chief operating officer of Cataldo Ambulance Service. Cataldo operates its own mobile health program, called SmartCare Community Paramedics. The program, also created under a DPH waiver, serves Beth Israel Deaconess Medical Center patients with severe health problems that put them at high risk for repeated hospitalizations.

“At least we can continue the pilot program,” Quaranto added. “But we’d like the state to extend the special project waiver.”

For now, they’ll have to wait, said Ann Scales, spokesperson for Massachusetts Department of Public Health Commissioner Monica Bharel. The current state budget does not provide funding for mobile integrated health pilots to become permanent.

“Until the necessary program startup and operating costs are appropriated, the Department of Public Health cannot promulgate the Mobile Integrated Health regulations and implement the program,” she said.

For his part, Sousa is glad he can be treated in his own home.

“He’s a gentleman who will not go to the hospital,” explained Torres, his wife.

“No, no, no,” laughed Sousa, sitting in his recliner, answering freely, with a smile that said he didn’t entirely disagree.

ROCKVILLE, Md. – A new program that targets frequent 911 callers in Montgomery County will receive $400,000 in additional funding once approved by the county council.

Montgomery County Council Executive Ike Leggett announced the Mobile Integrated Healthcare program Wednesday following what officials call a “successful” pilot period.

The program reduced the 33 participants’ 911 calls from 424 to 233.

This was done by sending officials to common callers’ homes to identify anything potentially hazardous, like areas poorly lit or where people could fall.

“All the things that we have seen cause a person in escalating years to have accidents at home, those things can easily be eliminated,” said Chief Scott Goldstein, Montgomery County Fire and Rescue Department.

The program is a collaborative effort by Montgomery County Fire and Rescue Department and the Department of Health and Human Services.

Additional coverage at http://wjla.com/news/local/new-program-reduces-increase-in-911-calls-in-montgomery-county

A program launched to help unclog excessive 911 callers from the city’s emergency system is no longer operating due to staffing challenges facing the City of San Diego’s ambulance service provider, AMR.

In an email to NBC 7 Investigates, AMR attributed the problem to a “paramedic staffing shortage” across San Diego County.

Last November, NBC 7 Investigates rode along with community paramedics involved in the Resource Access Program (RAP) or Community Paramedic Program.

The program’s goal was to reduce the call load for the 911-system and help frequent callers find services best suited to help them.

“We have about 1,200-1,300 people in San Diego that call 911 a lot,” Anne Jensen, who oversaw the program with the city of San Diego Fire Department told NBC 7 Investigates earlier this year. “Some call six times a year, others call more than 100 times a year.”

At the council hearing last month, San Diego Fire Chief Brian Fennessy told the council the city has seen a 22% increase in 911 calls over the last four years and 30% of those transported to the hospital did not actually need to be transported.

The Community Paramedic Program was designed to address those types of patients. Earlier this year, the Fire Department began tracking who was making the most calls to see if personal intervention on the part of the Community Paramedic team might help resolve any long-running problems by the callers. Data provided to NBC 7 Investigates showed there was a 72.7% drop in usage by the top 25 most frequent callers into the 911 system.

Click here to see NBC 7 Investigates’ original story.

AMR moved employees assigned to the community paramedic program at the end of last year to other areas of the city.
In an email to NBC 7 Investigates, Madeleine Baudoin, Manager of Government and Public Affairs for AMR said, “Last year, we redeployed our resources across the city, including the four RAP medics, due to the ongoing paramedic shortage in San Diego County. This action allows us to best serve the community with the resources we have. We will be working with the fire department to study the long-term feasibility of the RAP program.”

NBC 7 Investigates asked the city’s Fire Department if officials could elaborate on when the program stopped and why ending the program was not addressed when an NBC 7 Investigates report talking about the program’s success aired earlier this year. In an email, Deputy Chief Gina La Mantia said the program ended in “late December 2016.“ She also said, “the [AMR] staffing shortages lasted longer than anticipated.”

The community paramedic program was a pilot program that required an exemption from the state. According to California state law, paramedics are only allowed to treat at the emergency scene and during transport. California Emergency Medical Services Director, Doctor Howard Backer pushed and obtained the exemption in order to allow for the paramedic’s role in non-911 settings to be expanded.

NBC 7 Investigates contacted Backer about the program not operating any longer and are waiting to receive a response.

Last month, AMR asked the San Diego City Council to approve rate increases for how much the ambulance provider can charge patients needing emergency services. AMR representatives told city staff, “on-going recruitment challenges” and “the over-triaging of non-life-threatening calls” were among the reasons why a rate increase was necessary to bring stability to the system.

Matt Lavin had just arrived in Charlottesville, Va., for a business trip when he started feeling sick.

By the time he got to his hotel around 11 p.m., he felt excruciating pain.

‘I didn’t know what was happening, but I knew something wasn’t right,’ said Lavin, a lawyer who lived in Washington, D.C., at the time but is also the medical director for a Florida-based chain of addiction recovery centers. He had good insurance through his employer, but still second guessed calling an ambulance for help.

‘My deductible was like $5,000 or something like that. And it was the beginning of the year. I didn’t know how much the ambulance was going to cost me, and I’m away from home in this hotel,’ Lavin said.

So he requested a ride on Uber.

The driver arrived in just three minutes, helped him into the car and sped to the hospital, with Lavin keeled over from intense pain his abdomen.

Later Lavin, 48, would find out his appendix burst. He ended up having emergency surgery that night. But Lavin says he saved himself thousands of dollars by choosing Uber, the ridesharing company that connects passengers with taxi-like independent drivers through a smartphone app, instead of calling 911.

‘I knew they would be fast,’ Lavin said of Uber. ‘But I think (the driver) was pretty freaked out. I was in a lot of pain and I had to lie down. He was new to Charlottesville and didn’t know where the hospital was.

If I’d taken an ambulance, I would have gotten a bed right away. Instead I had to walk in and wait like anyone else. But I think I paid $20, which is much better than the $5,000 I paid the one time I was in a car accident.’

Lavin isn’t alone. Ridesharing drivers in Tampa Bay and beyond are noticing an uptick in rides to and from the emergency room as consumers try to avoid spending what could be thousands of dollars for an ambulance.

It’s an updated version of a role long played by cabs. What’s new is that the ridesharing experience, with its ability to tell people how soon a car will arrive, is seen by many as more nimble and better suited to a spur-of the-moment decision like rushing to the ER.

Dulce Maurer, who has been an Uber driver in St. Petersburg since July 2016, had no issues taking a bleeding passenger to the emergency room recently.

She said she accepted a ride from a passenger who was bleeding from his forehead when she picked him up at his house.

‘I arrived in the back alley of a residence and a man got in with paper towels on his head,’ said Maurer, 32. ‘I saw his destination was the hospital and asked if he was okay or needed more napkins.’ Maurer said the passenger had been drinking and slipped in the shower, where he cut his forehead open.

‘He did not want to pay for an ambulance,’ she said. ‘(Uber) was really the best option for him. He was stitched up within 15 minutes at 3 a.m. and it was cheaper and faster.’ Maurer said she didn’t mind helping him get to the hospital. It wasn’t that much different from the late-night riders who sometimes have to use the puke bucket she permanently keeps in the back seat. But Maurer says she would draw the line if a woman was in labor or if someone was ‘bleeding profusely.’ ‘I don’t want the liability of someone’s life,’ she said.

The decision to choose an Uber or Lyft ride over one with trained paramedics comes with some clear drawbacks.

‘We’ve heard of this before, but my question is, what is the driver going to do if their passenger needs medical attention right away?’ said Charlene Cobb, a spokeswoman with Sunstar, the company under contract with Pinellas County to provide ambulance and paramedic services. ‘A driver may not know which hospital to take you to, as some in the area specialize in certain things. Paramedics are trained to know that, and provide assistance on the way. In an emergency, seconds count.’ Rideshare companies like Uber and Lyft don’t openly condone this kind of service in the case of an emergency, even though their websites share positive stories of drivers helping women in labor get to the hospital on time.

‘We’re grateful our service has helped people get to where they’re going when they need it the most,’ said Javi Correoso, a spokesman with Uber. ‘However, it’s important to note that Uber is not a substitute for law enforcement or medical professionals. In the event of any medical emergency, we encourage riders and driver-partners to call 911.’ Both Uber and Lyft partner with hospital chains to offer discounted rides for routine appointments or medical services, but not emergency rides. Those services aren’t available in Tampa Bay yet. During Hurricane Irma, Lyft and Uber offered relief rides to get people in need to shelter.

Most hospitals in the Tampa Bay area don’t track how often ridesharing drivers drop off or pick up patients, but at Tampa General, they are ‘here quite a bit over the course of a day,’ said spokesman John Dunn.

Cobb, the Sunstar spokeswoman, doesn’t deny that an ambulance ride can be expensive.

In Pinellas, she said, consumers can buy a supplemental insurance policy through the county that covers ambulance fees and complements the insurance they already have.

She said she hopes that costs can come down in the future by training emergency dispatchers to help decide when an ambulance ride is really needed.

‘There’s a program in Texas where a nurse is on the line and helps people make an informed decision on whether or not they need an ambulance ride to the hospital if it’s a non-emergency,’ Cobb said.

‘People call for ambulances and often times they don’t need them,’ she said. ‘But when you need medical care right away, there is no substitute.’ Jeff Abbaticchio didn’t need an ambulance ride when he was headed to Palms of Pasadena Hospital for a hernia surgery, which is why he chose Uber.

‘I knew I couldn’t drive myself and the last thing I wanted to do was to ask a friend or family member to get up so early to drop me off,’ said Abbaticchio, the director of marketing for the Sirata Beach Resort on St. Pete Beach.

He said he’d do it again in a heartbeat.

‘Both times, the rides were incredibly nice. It was so early in the morning and the driver was on time and it wasn’t expensive,’ he said.

But for Lavin, the threat of exorbitant medical bills will always make him second guess calling for ambulance.

‘Getting stuck with a bill like that, it can change your life. It will ruin your credit,’ he said. ‘And that’s for someone who has insurance. Imagine if you’re uninsured or on state-funded insurance. That’s not going to cover much of anything.’

The question of what the healthcare of tomorrow will look like prompts a broad, compelling thought experiment. As healthcare professionals of all stripes gathered in downtown Washington, D.C., last week to discuss that very question, a few key ideas emerged.

Here are the most interesting ideas Healthcare Dive found at U.S. News & World Report’s Healthcare of Tomorrow conference.

Care is moving back into the patient’s home
Health systems that embrace the patient movement toward consumerism are on the right track, according to several speakers at the conference. Locating services in a patient’s home or somewhere close by and easily accessible is more convenient for patients, but also produces more comprehensive and effective care.

Aetna CEO Mark Bertolini (who, despite some clever questioning from the moderator, declined to comment on “market speculation or rumor” that the payer could be acquired by CVS) said the home is the least expensive and most convenient setting for care. If it can’t be in the home, it should be at a retail clinic only a few miles away, he said.

“If you have to go to the hospital, we have failed you. What if that were the way the system was designed?” he said.

One key way the home can become a primary setting for healthcare is through telemedicine. This is particularly true in rural areas, where a patient may have to drive hours to get to their doctor’s office. And it will become more and more common as telemedicine becomes more widely adopted and stops being perceived as a separate category from “regular” care.

“The novelty of telehealth has fallen by the wayside,” said Christopher Northam, vice president for telehealth at HCA.
“There used to be a lot more focus on the technology. Now the focus is on clinical measurement.”

Younger people are a big part of the drive toward consumerism in healthcare, and they want to receive care at their homes, Northam said. “That will shut down hospitals,” he added.

Dr. David Tsay, associate CIO at the New York-Presbyterian Innovation Center, agreed and said a lot of changes will take place in the next 10 years. “I think hospitals will look very, very different,” he said. “Hospitals will primarily be ICUs and ORs, and the rest of care will be done in the convenience of the home.”

Bertolini said ultimately it will come down to what patients demand as consumers, so creating a compelling and enjoyable experience will be key. “Us as customers — as consumers — disrupt the industry. Because we say we no longer want that, we want this.”

Conversion to value-based care continues — but at a glacial pace
HHS under President Donald Trump has walked back some of the previous administration’s payment reform efforts. Although CMS is vocal that it wants to continue the shift from volume to value, the recently finalized Quality Payment Program rule for 2018 indicates otherwise considering the large amount of physicians the administration is exempting from the regulation. Still, albeit slowly, the industry continues to embrace this shift toward value-based care.

The openness to change has resulted in olive branches being extended across the industry as incumbents look to figure out business in the shifting environment. The result is a mix of strategic partnerships and alliances as the lines between traditional healthcare companies begin to blur.

Biotech company Amgen partnered with Humana for an outcomes-based research project that will identify high-risk patients using technology and real-world data, Dr. Jason Spangler, executive director of value, quality and medical policy at Amgen, shared at a keynote panel. “We believe these types of partnerships are where we need to be moving to provide value to patients.”

Providers may be slower to adapt to value-based care. Lori Evans Bernstein, co-founder and COO at HealthReveal, said potential customers are discussing value but also want the ability “to find the good stuff” like reimbursable procedures under a fee-for-service model.

Tom X. Lee, executive chairman at One Medical, said innovating from within the system is challenging. “We operate as if we’re in a value-based world today though the vast majority of our income is still fee-for-service,” Lee said. One Medical, a group of primary care offices that offers 24/7 connectivity with patients through video and chat services, engages with the industry at the primary care layer. This allows it to operate a little outside the system somewhat. He said organizations operating further downstream have a harder time finding such opportunities.

Julie Bietsch, VP of population health management at Dignity Health, told Healthcare Dive the industry is at a tipping point for value-based efforts. About 10% of Dignity’s revenue is accrued from population health or value-based arrangements. “I think that those not investing in population health are going to be the ones left behind,” she said, adding providers need to take the first step toward population health. “If you don’t, you won’t know what happens when it’s mandated.”

Lee believes more changes are coming in the next five to 10 years in care delivery. While the market has spent a lot of time building platforms, apps and services, he sees more changes over improving the virtualized and service experiences coming into healthcare. In addition, he sees more remote care delivery models as an oncoming disruptive force.

“Those are going to be care systems of the future … I don’t think anyone denies that vision,” Lee told Healthcare Dive.
“The question is, who’s going to execute it best? Easier said than done.”

Spangler said he believes the industry could benefit from more care delivery and payment innovations. “One area I think we need to move toward is value-based insurance design,” he said during a keynote panel. “We should pay and incentivize patients toward high value care and disincentivize them against low value care.”

In healthcare, there are no shortage of opinions, and discussions around value-base care will continue. Expect them to get more vocal.

Social determinants of health — a trend that needs direction
“Everyone’s talking about social determinants but no one’s talking about how to do it,” Bietsch told Healthcare Dive.
Social determinants have been a popular topic as evidence mounts that food security and affordable housing help create good health outcomes. However, there isn’t a centralized assessment of the issue, Bietsch said. For example, if an individual tells seven people that they need a home but no one helps, then the process is inefficient.

Social determinants of health and “understanding about how they drive our health” are currently buzzword concepts in the industry, she said. “But the success of it is not there.”

Bertolini is a proponent of thinking about social determinants at every level of healthcare. He noted that a person’s ZIP code is often a bigger indication of life expectancy than their genetic code, and ignoring that reality results in an incomplete approach.

He said it makes sense for payers to be thinking about social determinants of health because that’s how diseases can be prevented and savings can be realized. “Paying for a ramp, an Uber ride, food, fuel assistance is cheaper than one ER visit,” he said.

Progress requires bipartisanship
Calling for bipartisan agreement in D.C. is nothing new and hardly controversial, but at Healthcare of Tomorrow, it was an urgent demand. Budget deals are far from clear, the Children’s Health Insurance Program has still not been reauthorized and rumblings of “repeal and replace” continue despite the unlikeliness that any such legislation could gain traction. This environment breeds more and more uncertainty, which is toxic to the healthcare environment.
Bertolini said major social programs need broad support to be successful, and Congress should shift from the idea of abandoning the ACA and work together to improve upon it. “We can fix it. The list is short,” he said. “We just need a group of people with level heads in the room to fix it.”

Legislation of the magnitude and scope of the ACA isn’t going to be perfect right out of the gate, and the problem even proponents recognize will only get worse with inattention, he said. “If you were to leave Medicare alone for six years, seven years, it would fall apart just like this is,” he said.

Virginia Gov. Terry McAuliffe had a similar message. “We’ve just got to shake up the system and we’ve got to do it together,” he said. McAuliffe said CHIP reauthorization is the most pressing issue today, and lamented that “moms and dads are going to bed tonight scared to death” their children won’t have healthcare coverage.

He also criticized the White House’s decision to stop CSR payments, and said he personally talked to the Anthem CEO to convince the payer to cover nearly 60 counties in Virginia that would have otherwise not had any plan options.

“The middle is gone,” he said, “and I come from a business background, and the middle is where you get stuff done.”

Tom Daschle, former senator and the founder and CEO of The Daschle Group, said healthcare professionals need to make their voices heard in Congress by calling their legislators. “If you don’t know the name of … their health legislation assistant, you’re not engaged,” he said.

Blair Childs, senior vice president for public affairs at Premier, said providers in particular need to lead change and tell lawmakers what is happening now in the market and where it needs to go. “Anyone thinks the healthcare system is going to be fixed by the government or by payers is crazy,” he said. “It’s only the providers who will innovate the system.”

A new pilot program by the Las Vegas Fire and Rescue Department aims to reduce the number of ambulance trips for nonemergency 911 calls.

As one part of providing the right care in the right setting, the city’s 911 operators are being trained to identify health-related complaints that might not require a full-blown emergency response. Those calls are transferred to a nurse who, with the help of computer protocol software, guides the caller to the right kind of care.

An operator may still rush an ambulance to a 911 caller or reassure the caller that this health issue can be dealt with by seeing a primary care doctor through a normal appointment process.

Or the operator may offer to send the patient to an emergency department or urgent care facility in an unexpected way: the ride-hailing service Lyft.

The Emergency Communication Nurse System and the nonprofit Southern Nevada Community Health Improvement Program have teamed up to fund a ride-hailing option via Lyft for callers who are using 911 because they simply have no other way to get to a hospital, urgent care center or doctor.

“EMS is probably one of the most reliable, time-sensitive services anyone can access,” says Las Vegas Assistant Fire Chief Sarah McCrea. “This program looks at people’s normal navigation through the system and then redirects it” when a call to 911 isn’t really an emergency. It is one component of dealing with access to nonemergency primary care, McCrea says.

The chief medical officer of one of the Las Vegas Valley metro area’s busiest emergency departments agrees that access to primary care is lacking.

“Many of the 170,000 ED visits we see annually are due to a lack of access to primary care physicians in our community.
So, clearly a great many of these visits are a result of few alternatives, which also extends to the scarcity of urgent care facilities in our immediate service area,” says Jeff Murawsky, chief medical officer of Sunrise Hospital and Medical Center.

The pilot program employs experienced nurses who have worked in high-acuity settings for at least three years, McCrea says. Before the nurses use the structured computer protocol on a phone call, they say, “Tell me exactly what is happening,” she says.

“The nurse is free to do what they do best — ask probing questions to get the best idea possible, especially because they cannot see the patient,” McCrea says. “The software has a couple [of] hundred protocols to choose from, so we need to ask a lot of questions outside of the protocol first.”

The program went live on July 17, with Melissa Giammarino, R.N., on the phones for the first shift. Giammarino, who is also a surgical recovery nurse at University Medical Center in Las Vegas, believes the program will free up emergency personnel and equipment for more urgent cases and lead to improvements in the hospital ED.

From an ED nurse’s perspective, eliminating unnecessary ambulance calls helps providers focus on real emergencies, she says.

“I was a charge nurse in an emergency room who had to triage every single ambulance lining up at the door,” Giammarino says. “Each ambulance carrying someone who didn’t truly need emergency care took me away from other emergencies, from helping other nurses and from dealing with other problems in the [ED].”

As with any emergency services, certain safeguards are in place, McCrea says. First, 911 operators take the initial call, only sending certain calls to the emergency communications nurse. Second, nurses may only downgrade the computer-generated course of action to a less urgent response by one level, but may upgrade it as much as necessary. The nurse may always choose to immediately dispatch an ambulance. Third, ride-hailing is only used if the patient agrees to it. And fourth, there is follow-up. If an ambulance is not sent for a call, the nurse on duty the next day will call the patient to check on his or her welfare.

Although 911 callers may have believed an ambulance ride was their only choice, “when they find out there are other options than an ambulance ride to the [ED], they’re excited and glad to use ride sharing or go to urgent care or whatever makes the most sense,” Giammarino says.

Because the pilot program has only been active for just over two months, the department is not yet looking at hard data, but if it proves successful in safely eliminating some unnecessary ambulance trips McCrea hopes it will be expanded from its current 9 a.m. to 6 p.m. availability and cover a larger geographic area.

“The partnership that exists between Las Vegas Fire, as well as all EMS providers and Sunrise Hospital, is an extremely important component of our community service,” Murawsky says. “We will work with our first responders to share feedback or recommendations as the pilot moves ahead.”

It’s something we all hope never happens, but now, local school staff are being equipped to respond if the worst were to ever occur.
8News got a look inside Richmond Public Schools as the new ‘bleed kits’ were delivered.

Richmond Ambulance Authority and VCU Medical Center delivered the so-called “bleed kits,” or hemorrhage control kits, to Richmond Public Schools. The kits have essential tools to respond to an emergency.

“We see a fair number of gunshot wounds,” said Karen Shipman, a trauma outreach coordinator at VCU Medical Center. “It’s not the majority of our trauma, but it’s very traumatic for patients and families.”

That’s why she said VCU Medical Center wanted to team up with Richmond Ambulance Authority to give the schools these kits.

“What it does is it teaches the community how to respond to these events,” Shipman said. “With our increase, I would say, in school shootings and mass shootings that are of course making the news more than we would like, this is what we thought we could bring to our community.”

If a mass casualty situation were to occur in the schools, now some RPS employees are trained to take action.

“Our student safety is very very important,” said RPS Assistant Superintendent of Exceptional Education and Student Services Michelle Boyd. “We focus on academics but we need our students to be safe first and foremost and while it’s a slim chance that students would need this information and these resources we always want to be proactive instead of reactive.”

Preparing for a traumatic event like a mass casualty situation is becoming more of a focus for schools.

“We do talk a lot about what can we do in the case of an emergency,” Boyd said. “We want to make sure that folks are knowledgeable and educated as to how to respond in cases where students may be injured on the athletic field or a science classroom, those types of things, so we offer education classes, we partnership for the CPR training and we want to make sure that we can continue to partnership for the bleed safety kits.”

For now, many schools will keep the bleed kits in the nurse’s office until they can get more throughout the school.

So what’s inside the backpack? First there’s a tourniquet. It’s used to apply pressure to a limb if you have a limb injury. Next, there’s what’s called “combat gauze.”

“You put it inside a wound,” Richmond Ambulance Authority Chief Operating Officer Rob Lawrence explained. “The blood then absorbs into the gauze and it helps coagulate and therefore stop the bleeding.”

There are also a variety of dressings, and even some common items that you might need in case of an emergency like gloves and scissors.

It’s all to make sure school staff can treat someone who’s hurt before help arrives…

“These folks that have this equipment are our very very first responders and therefore they arrive on scene and can stop the bleed, and control the patient until we arrive on scene,” said Lawrence, who added that it’s important for schools to have this type of equipment. “It’s a bit like the days of teaching everybody CPR, it’s a basic skill that we all need to have, we need to know how to do CPR, and we also need to know how to control a hemorrhage if a hemorrhage occurs.”

Having the bleed kits could make all the difference if the worst were to occur.

“The worst case scenario is with a gunshot wound, but that said, any penetrating type of trauma or any injury that penetrates the body you can apply these principals to control the bleeding…. and if we can control the bleeding we can save a life,” said Lawrence.

So far, 70 school security officers and 40 nurse staff have been trained on how to use the equipment inside the Bleed Kits. The schools are organizing groups of other staff who want to do the training.

If you work in a school and you’re interested in doing the training, contact your school administrators.