News & Updates

For those known as the “familiar faces” most likely to dial 911, this island city across the bay from San Francisco is trying a new approach – getting in touch with them before they call.

“It changes the role we’ve traditionally had with folks,” said Patrick Corder, part of the local fire department’s Community Paramedic Program who used to spend his shifts racing to fires and accidents. “911 is purely reactive. This position is proactive.”

The program is part of the state’s two-year pilot study to look at whether local agencies can save money and improve lives by using firefighters and paramedics to check on the highest users of their services. A study of the program’s first year, 2016, showed a 37 percent decrease in visits by frequent users to the local hospital’s emergency department.

The program, administered by the state Emergency Medical Services Authority, involves 13 departments around the state that are using paramedics to check on people recently released from hospitals, admitted to sober centers, and are most likely to use emergency services. Only two agencies, in Alameda and San Diego, are enrolling the most frequent users of 911. While the program’s initial funding ends this year, there is pending state legislation that may extend it.

These days Corder and another paramedic in the program can be found, as he describes it, “trying to put out figurative fires” – checking on about a half dozen regulars who might be homeless, recently released from the hospital or in precarious health.

One recent day began with a few calls to patients getting ready to leave the hospital and one to another who’d moved to Auburn but was still unsettled. A meeting was set up with a woman who had “graduated” from the program after 30 days but wanted to talk to Corder about her concerns over moving to an assisted living home.

“I promised her I’d follow up,” said Corder, sitting in his office in one of the buildings dotting a former military base on the island. “Her family wants her to move, and she has a lot of questions. She’s anxious.”

If his visit keeps the woman “happy and healthy,” and prevents her from needing to rely on 911 – as she’d frequently done in the past – he was glad to visit, he said. He will check her vital signs and whether she’s taking medications correctly, as he does on all home visits, but mostly what he does is “less medical and more social welfare,” he says.

Later in the day he will head to his fire-red car, which holds emergency medical supplies and equipment, make a hospital visit and then look for another man enrolled in the program who is homeless.

“I know where he’s likely to be,” said Corder. “Any one of three places.”

So far Corder has helped the man find a primary care doctor and get his prescriptions refilled. He’s also written a letter of support, requested by the public defender seeking to get a criminal charge reduced. With a cleaner record, Corder said, the man would have a better chance of getting housed.

“The thing that surprised me was the eagerness and willingness of paramedics to work on social needs and to be very patient and caring with folks who had mental illness and substance abuse,” said Janet Coffman, an associate professor at UC San Francisco School of Medicine and coauthor of a report on the pilot program.

Alameda, with a population of just under 80,000, enrolled 40 people in the first year and saved $8,114 a month in emergency department transports and visits, according to the report. Similar programs outside California have been successful in reducing hospital admissions, Coffman said, and there’s evidence a small program like the one in Alameda can work in larger cities.

She credited some of the programs’ success to “robust training” where paramedics learn how to recognize and handle needs of the high-risk population. Corder said it had given him a closer look at the complicated, inter-related health system. He now talks regularly with social workers at the hospital to enroll people who have little or no help when they’re released.

The program offers services to hospitalized people with chronic heart or lung disease, diabetes, pneumonia or sepsis. Once released, Corder and his partner might refer them to prevention services, meal programs or senior centers where they won’t be isolated. Not all interventions work. Some people in the program disappear or reject help.

“It’s not what I initially signed up for,” said Corder, who’d been in the department seven years when he volunteered for the program. But he found the assignment a good fit, both because he studied psychology in school and is from Alameda.

He and his partner have helped people get identification cards at the DMV and helped clean an unusually cluttered apartment. And they’ve attended funerals.

“It’s been a blessing in the way that I can really communicate with people and follow them at what is often the end of their lives,” Corder said. “A lot of people had their whole lives here. Sometimes I’m just there to be a witness.”

In an elaborate scheme for scammers to get cash, some people are being led to believe their loved ones are in danger. Maria Mejia said she was working at a North Texas hospital when her phone began ringing repeatedly one afternoon.

When she answered, the person on the other end of the line claimed to a paramedic and had a man hurt, who listed her as an emergency contact. “I said, ‘What’s his name?’ They said, ‘Ma’am, he’s unidentified, unconscious,'” Mejia said.

The caller asked Mejia for the name of her father, husband or brother and what type of car they drove. When she told him, she said he screamed to someone to check to see if the crashed car was a black Suburban and then came back to the phone.

“He says, ‘That’s your dad in the accident.’ I started crying, I was shaking, I was scared,” Mejia said. Her co-workers saw she was shaken and rushed to her side as the call went on.

“He said, ‘Your dad was exiting Exxon, and he hit a 17-year old on a motorcycle, and the 17-year old was my son, and now your dad is going to pay for the damages,'” Mejia said.

The story had changed. Now, she’s got an angry family member, wanting money.

Before she could wrap her head around that, it changed again.

“He said he was kidnapped, they took him to apartments, and that he had my dad’s phone, and if he received call or texts from you or anybody, ‘We’re going to put a bullet in your dad’s head,'” Mejia said. The caller wanted $3,000 in ransom. She didn’t know any longer if this was an angry father, kidnapper or a paramedic.

“My coworker told me ask him for a picture of your dad. So, I said I want a picture of my dad. He said, ‘Lady are you listening? We have your dad kidnapped and we’re going to put a bullet in his head.’ He said, ‘You can save the money for the funeral.’ He said, ‘Maria are you there?’ I started to respond but he hung up,” Mejia said.

Mejia said she was too panicked to doubt the story. She didn’t want to call him back either.

“I was scared, because he said if he gets a call they’re going to blow his brains out,” Mejia said. Instead, she called 911, and reached a dispatcher who called her dad, conferenced him in, and her dad said he was home, safe and doing chores.

The 911 dispatcher told her they’ve gotten calls like this before, but the Dallas Police Department said it wasn’t familiar with them. Other departments were saying the scheme almost always starts with a loved one who is hurt and a paramedic needing cash.

Macara Trusty is a paramedic with MedStar. She says anytime you get a call from someone claiming to be an emergency responder with a critical patient, that’s a red flag. “If the patient is so critical that they can’t talk on the phone, we don’t have time to make those phone calls,” Trusty said.

Police are investigating these calls but want you to know just because the number pops up as local doesn’t mean the caller is in town or even in the country.

If you do get a call like this, police ask you to file a report.

From what BlueCross BlueShield of New Mexico has found, establishing a partnership with community paramedics is not only good medicine, it’s good for business.

The insurer’s Community Paramedicine program, which started out as a pilot project in the fall of 2015, is targeted at Medicaid members who have either been identified as emergency room super-users or are at high risk for readmission within 30 days of being discharged from the hospital.

BCBSNM chose those two populations because “we thought we could track those well and see if this is working,” Duane Ross, M.D., the insurer’s medical director, told FierceHealthcare.

Now, the insurer has produced promising preliminary results.

Since the program’s full launch in 2016, BCBSNM estimates that it saved $1.7 million—after taking into account the cost of the program itself. Among the 1,100 participating members, there was a 62% reduction in ER utilization and a 63% reduction in ambulance usage.

In addition, the 30-day readmission rate among BCBSNM’s members has dropped from 15% to 11.2% since it began the paramedicine program. While the insurer has undertaken multiple initiatives to lower that percentage, “we’re confident that this program was a big part of that reduction,” Ross said.

Just as important, Ross added, is the fact that “the paramedics indicate they’re actually very happy to be able to see people proactively rather than in a reactive fashion.”

The anatomy of a house call

Most BCBSNM members involved in the Community Paramedicine program receive only one house call, Ross said—though there occasionally might be a follow-up visit.

First, though, they always call the member to ensure they’re OK with the visit taking place. As Ross puts it: “You don’t want to have a person in uniform knocking on your door unexpectedly.”

Paramedics who conduct house calls are tasked with ensuring that patients know all the information related to their diagnosis; who their primary care physician is and how to use primary care services; and how to reach a care coordinator with BCBSNM.

The primary-care discussion is particularly important for ER super-users who did not previously have insurance before signing up for Medicaid, Ross noted, because they tend to have a long-established habit of getting all their care through the emergency room.

“Sometimes it takes a visit to get them to make that switch,” he said. “Surprisingly, it actually sticks fairly well once they’re shown how to do that.”

Paramedics also conduct a home assessment to check, for instance, whether the residence has any hygiene issues, whether there are fall hazards and whether there’s food in the refrigerator. While paramedics can check patients’ vital signs, Ross noted, they don’t typically administer any other type of care.

For patients at risk of readmission, paramedics take the extra step of making sure they understand—and can follow—the hospital’s post-discharge care plan. That can involve ensuring they have a way to pick up any needed medications and know how to take them, and ensuring that they’re aware of and can find transportation to follow-up doctor visits.

Crucially, Ross, said, “we’re trying to get to them within 48 hours of the discharge, because if they lack transportation to pick up prescriptions, supplies or anything like that, the clock is ticking before they find themselves back in the hospital.”

Paramedics as partners

BCBSNM’s program is hardly the only instance of paramedics rethinking their traditional role as emergency responders.

For example, the North Memorial Health system in Minneapolis started a program in 2012 that used community paramedics to conduct home visits with patients who visited the ER nine or more times in a year. Similarly, the Valley Hospital in Ridgewood, New Jersey, launched a program 2014 to provide proactive, post-discharge home check-ups to certain patients with cardiopulmonary disease who are at high risk for readmission.

“This is actually a big movement,” Ross said. In fact, in Albuquerque, “the paramedics in the community had been looking at something like this for a while, but had not been able to get some of the logistics worked out.”

Therefore, BCBSNM figured out a “claims-based approach” to pay for home visits, which helped get the program off the ground. The result is the insurer has control over how many home visits are going to occur and who will receive them.

Besides working out a payment model, another secret to the Community Paramedicine program’s success is that the person running it is a paramedic himself, Ross noted. That helps establish trust and communication with the paramedic companies involved.

While BCBSNM is happy with the current scope of the program, in the future it’s interested in looking at the possibility of having paramedics conduct multiple visits with patients who have chronic conditions to help stabilize them, Ross said.

The insurer is also hoping to expand the program to cover more geographic areas than those in which it currently operates: Albuquerque, Belen, Rio Rancho, Las Cruces and Alamogordo. Because the paramedicine project has produced positive results and been well-received by paramedics, Ross said, “it’s easier to go out to more far-flung ambulance companies and even fire departments.”

Dr. Patrick Conway, the CMS’ chief medical officer, is headed to work for Blue Cross and Blue Shield of North Carolina as its president and CEO, starting Oct. 1.

The insurer’s current president and CEO Brad Wilson, who is retiring, will remain in his role “for an appropriate period to ensure an effective transition,” the company said Tuesday.

“Blue Cross NC’s role in transforming the healthcare system in North Carolina is a model that other plans aspire to and that I want to work with the Blue Cross NC team to further improve,” Conway said in a statement.

Conway, a pediatrician, joined the CMS in 2011. He also currently serves as the agency’s deputy administrator for innovation and quality and its director of the Center for Medicare and Medicaid Innovation.

At the CMS, he is responsible for overseeing quality of care and innovation for the Medicare, Medicaid, and Children’s Health Insurance Program programs, and the federal insurance marketplace. He is also charged with testing new value-based payment and service delivery models, such as accountable care organizations, bundled payments and primary care medical homes.

“Dr. Conway is a national and international leader in health system transformation, quality and innovation,” Frank Holding Jr., Blue Cross NC’s board chair, said in a statement. “His unique experiences as a healthcare provider and as a leader of the world’s largest healthcare payor will help Blue Cross NC fulfill its mission to improve the health and well-being of our customers and communities.”

Wilson announced in February that he would retire this year. Wilson, who began working for the health plan in 1996, has served as president and CEO since 2010.

“At this important time in healthcare and health insurance transformation, Dr. Conway brings a unique background and perspective to our company and state,” Wilson said in a statement.

While the United States ranks dead last in quality among 11 wealthy nations, a new report reveals that Louisiana is the worst state for healthcare overall.

The Pelican State has one of the highest rates of heart disease in the country, the third highest cancer rate and a significantly low number of dentists per capita, according to WalletHub’s annual list of the best and worst states for healthcare.

The personal finance website compared the 50 states and the District of Columbia for healthcare cost, access and outcomes. Among the 35 measures they considered within those categories were: costs of medical and dental visits, average emergency room wait times, physicians per capita, average monthly insurance premiums, heart disease and cancer rates, and life expectancy rates.

Louisiana was also ranked one of the worst states for nurses in a recent WalletHub report. And New Orleans held the distinction earlier this year of being one of the worst cities in the nation in which to practice medicine, according to a Medscape report.

WalletHub determined that the best state overall for healthcare was Hawaii, which has one of the highest percentages of insured children and adults and the lowest heart disease rate in the country. However, the report notes that the Aloha State also has the lowest rate of physician acceptance of Medicare.

The 10 best states in the nation overall for healthcare:
1. Hawaii
2. Iowa
3. Minnesota
4. New Hampshire
5. District of Columbia
6. Connecticut
7. South Dakota
8. Vermont
9. Massachusetts
10. Rhode Island

The 10 worst states for healthcare:
51. Louisiana
50. Mississippi
49. Alaska
48. Arkansas
47. North Carolina
46. Georgia
45. South Carolina
44. Alabama
43. Florida
42. Nevada

Anthem is rolling out restrictions on what it will cover for emergency room visits, but providers worry that the policy could cause patients with potentially life-threatening conditions to avoid care—and that the hard-line approach could violate federal law.

Anthem has deployed a reduced ER coverage policy in several of its state subsidiaries in regions that include Indiana and Missouri. The insurer said it will deny claims for minor injuries or conditions, like cuts and bruises, swimmer’s ear or athlete’s foot, that bring people to the emergency department, reports the Indianapolis Business Journal.

But physicians in those states worry that patients with potential dangerous symptoms, such as chest pain, may avoid care because they fear higher bills. Missouri provider groups, including the Missouri Hospital Association, the Missouri College of Emergency Physicians and the Missouri State Medical Association filed a letter (PDF) urging the state’s insurance commissioner to take a look at the policy.

“We see the Anthem policy as a cost-shifting tactic that will have a dangerous chilling effect on patients,” they wrote. “When policyholders learn that they might be held financially responsible for emergency department care, we worry some will delay or altogether forgo seeking vitally important and life-saving care at a time when they are most critically ill and vulnerable.”

Anthem maintains that the policy is designed to curb unnecessary ED use, which is a significant financial drain on the healthcare system.

Joseph Fox, M.D., the insurer’s medical director for its Indiana operations, told the IBJ that nearly three-quarters of ER visits are for nonemergencies, and despite prevention and outreach efforts, the number of visits for emergency care continues to climb between 4% and 8% each year. He said the payer has cut down the number of codes it will reject to a list of about 300 so that patients don’t fear visiting the ER if they really think it’s needed.

In Indiana, where Anthem dominates the market, he estimated that about 8% of visits would be flagged for review under the policy, and about 4% of claims would likely be rejected.

“It’s not a draconian program that we’re rolling out here,” Fox said. “We don’t want that to be misunderstood or misconstrued.”

State and federal laws abide by the “prudent layperson” standard, in which payers are required to cover emergency care for patients who feel their symptoms warrant immediate attention. In the letter, the groups argue that Anthem’s policy violates this standard, and “creates an untenable situation that is at best unfairly punitive, and at worst unacceptably harmful to patients.”

The American College of Physicians expressed similar concerns earlier this year when the policy was rolled out in Missouri. The group notes that a number of the some-2,000 conditions that Anthem would deem “non-urgent” could significantly harm patients.

Anthem’s ER policy is yet another example of payers trying to avoid paying for emergency care, Rebecca Parker, M.D., president of ACEP said in a statement.

“For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law,” Parker said. “Now, as healthcare reforms are being debated again, insurance companies are trying to reintroduce this practice.”

CMS has issued its Inpatient Prospective Payment System final rule for fiscal year 2018, which increases payments to acute care hospitals next year.

The 2,456-page rule also includes proposed rates for long-term care hospitals. Overall, the final rule applies to about 3,330 acute care hospitals and 420 long-term care hospitals.

Here are 10 key points from CMS’ final IPPS rule.

Payment update
1. Under the final rule, acute care hospitals that report quality data and are also meaningful users of EHRs will receive a 1.2 percent increase in Medicare operating rates in fiscal year 2018.

2. CMS arrived at its rate of 1.2 percent through the following updates: a positive 2.7 percent market basket update, a negative 0.6 percentage point update for a productivity adjustment, a positive 0.45 percentage point adjustment required by the 21st Century Cures Act, a negative 0.75 percentage point update for cuts under the ACA and a negative 0.6 percent updated to remove the adjustment to offset the estimated costs of the two-midnight rule.

3. CMS projects the rate increase, together with other changes to IPPS payment policies, will cause total Medicare spending on inpatient hospital services to increase by approximately $2.4 billion in fiscal 2018.

Medicare disproportionate share hospital payments
4. CMS will use data from its National Health Expenditure Accounts instead of data from the Congressional Budget Office to estimate the percent change in the rate of uninsurance, which is used in calculating the total amount of uncompensated care payments available to Medicare Disproportionate Share Hospitals. CMS said this change will result in Medicare DSH payments increasing by $800 million in fiscal year 2018.

5. CMS will use worksheet S-10 data to determine uncompensated care payments and distribution beginning in fiscal year 2018.

Hospital Inpatient Quality Reporting Program
6. Under the final rule, CMS will replace the pain management questions in the HCAHPS Survey to focus on the hospital’s communications with patients about the patients’ pain during the hospital stay. This change will take effect with surveys administered in January 2018.

7. CMS finalized several changes to the electronic clinical quality measures and updated the extraordinary circumstances exception policy.

Hospital Readmissions Reduction Program
8. CMS will implement the socioeconomic adjustment approach mandated by the 21st Century Cures Act for the fiscal year 2019 Hospital Readmissions Reduction Program. CMS will assess penalties based on a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and Medicaid.

EHR Incentive Program
9. For 2018, CMS modified the EHR reporting periods for hospitals attesting to meaningful use from a full year to a minimum of any continuous 90-day period during the calendar year.

Hospital Value-Based Purchasing Program
10. CMS will remove one measure in fiscal year 2019 and adopt one new measure in FY 2022 and another in FY 2023. CMS will remove the PSI 90 measure from the safety domain beginning in FY 2019, and adopt the patient safety and adverse events composite PSI 90 measure beginning in FY 2023. CMS will also adopt the hospital-level, risk-standardized payment associated with a 30-day episode of care for pneumonia measure for the efficiency and cost reduction domain in FY 2022.

For those who want more info on the PSI 90 measures, here’s more info:
https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf

Kohlberg Kravis Roberts & Co., the private equity giant that sold most of its stock in HCA a year ago, agreed Monday to acquire WebMD for about $2.8 billion, KKR announced Monday.

KKR is paying $66.50 per share for publicly traded WebMD, a 20% premium over WebMD’s closing price Friday of $55.26.

WebMD’s shares jumped to $65.98 by 11 a.m. ET Monday.

WebMD is the nation’s largest online health information portal, serving consumers and clinicians with public and private sites and publications.

The company’s board and management put the business up for sale in February when its stock was trading about 30% below KKR’s offer Monday.

KKR’s Internet Brands is the umbrella company buying WebMD. KKR will begin a tender offer of the shares within 10 days, it said in a release Monday.

The private equity firm, which has about $100 billion under management, is no stranger to healthcare. It was one of the main investment groups that took hospital chain HCA private in 2006, then public again in a 2011 initial public offering.

A year ago, KKR sold back to HCA about 9.4 million of HCA’s common shares for $750 million.

Despite the divestiture of shares, KKR remains one of HCA’s largest institutional shareholders with 5.2 million shares outstanding or 1.5% of its stock as of Dec. 31, according to Morningstar.

The CMS is interested in launching a new pay model that will target behavioral health services and is seeking public comment on what the new effort should look like.

On Thursday, the CMS announced that its Innovation Center would like to design a payment or service delivery model to improve healthcare quality and access for Medicare, Medicaid or Children’s Health Insurance Program beneficiaries with behavioral health conditions.

The model may address the needs of beneficiaries battling substance use or mental disorders. It could also target Alzheimer’s disease and related dementias.

The Innovation Center will be soliciting ideas at a public meeting on Sept. 8 at CMS headquarters in Baltimore.

The announcement comes at a time when agency officials say they are still committed to value-based care. For months, there have been concerns the CMS would abandon its move toward value-based pay models after Dr. Tom Price became HHS secretary. Price had been critical of the Innovation Center and bundled-pay efforts when he was a member of Congress.

These concerns intensified when the CMS delayed the effective dates for four Obama-era bundled-payment initiatives covering cardiac and orthopedic care and announced it was seeking public comment on the overall future of the models. The agency also announced plans to allow up to 800,000 small and rural providers to be exempt from the new quality reporting system outlined in the Medicare Access and CHIP Reauthorization Act.

Since then, CMS officials have reiterated that clinicians who have invested millions in implementing pay models or the quality reporting system under MACRA don’t need to worry about the CMS changing course.

“The horse is out of the barn on this,” Dr. Kate Goodrich, chief medical officer at the CMS said at a bundled-pay summit in late June. “We will be continuing this progress towards value-based care under this new administration.”

However, the Trump administration’s value-based efforts may differ from the prior administration’s in terms of how much Medicare spending will be tied to new models of care.

The Obama administration wanted 30% of payments for traditional Medicare benefits to be tied to alternative payment models such as accountable care organizations or bundled-pay models by the end of 2016 and had set a goal of hitting 50% by the end of 2018.

The Obama administration hit the first goal last March, but it’s unclear if the Trump administration will shoot for the second one, according to Goodrich.

“We are currently thinking about what we want the next set of goals and targets to be,” Goodrich said.

Freezing implementation of various models was merely new leadership’s attempt to better understand them and their potential benefits, according to Christina Ritter, director of the patient care models group at the CMS.

“These kinds of delays a very typical for a new administration,” Ritter said at last month’s summit. “I want to make sure people understand that before there is a whole ton of reading tea leaves.”

Patients in rural areas face long waits for paramedics to arrive, according to a new study.

Researchers reviewed data on more than 1.7 million emergency medical services runs from 485 agencies in 2015 and found that 1 in 10 rural patients waited half an hour for emergency personnel to arrive. The average wait in urban and suburban areas was 6 minutes, while the average was 13 minutes in rural areas. The findings were published Wednesday in JAMA Surgery.

The average wait time overall was 7 minutes, according to the study. The findings underscore the importance of training more people in CPR and other potentially life-saving techniques. The American College of Emergency Physicians (ACEP) has launched a campaign called “Until Help Arrives” that aims to empower people to provide care to the ill or injured while they wait for emergency responders to arrive.

“Those 7 minutes—or even longer in rural areas—are ripe for bystander intervention, especially for bystanders trained in first aid and/or CPR,” Howard Mell, M.D., a spokesperson for ACEP and one of the study’s authors, said in an announcement.

Patients in rural areas face a number of healthcare challenges outside of trauma and emergency care, but a 2016 study found that just 29% of rural patients treated by EMS personnel are taken directly to a major trauma center, whereas 79% of patients in urban areas are taken to Level 1 or Level 2 facilities.

In addition to patients in more remote locations having limited access to care options, many rural providers are cash-strapped and at risk of closing, which could leave some people in “medical deserts” where they have no care options nearby at all.

Emergency crews in these regions are also being asked to do more with less, and a number perform procedures in patient homes, like starting intravenous antibiotics or intubating patients, based on the distances they have to travel.