News & Updates

Herein lies a fundamental challenge with our healthcare system….

While providers and patients suffer with underpayments and balance billing issues….

This could be the banner article for payment reform as providers struggle to survive.

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Health systems suffer while payer profits soar

Laura Dyrda

11/3/22

https://www.beckershospitalreview.com/finance/health-systems-suffer-while-payer-profits-soar.html

Large health systems are reporting big losses this year while insurers continue to turn billion-dollar profits.

Humana reported $1.2 billion in third quarter profits, a slight drop from the same period last year. The company has focused on regaining Medicare Advantage market share and increased quarterly revenues 10.2 percent year over year.

Cigna's third quarter profits jumped 70 percent year over year, hitting $2.8 billion. The company reported $45.3 billion in third quarter revenues and raised its annual earnings outlook based on the results. The company now projects $179 billion for full year 2022 adjusted revenue.

CVS Health also beat investor expectations in the third quarter and raised its earnings outlook. The company's third quarter revenue jumped almost 10 percent year over year to $81.2 billion, although it reported $3.4 billion in losses after agreeing to pay into a $5 billion global opioid lawsuit settlement over 10 years.

At the same time, health systems are reporting multimillion and even billion-dollar losses. Chicago-based CommonSpirit Health reported $1.3 billion operating loss for the 12-months end on June 30. Ascension, based in St. Louis, also reported a $1.8 billion loss for the fiscal year's end in June.

Community Health System reported a $42 million net loss for the third quarter in October and both Dallas-based Tenet Healthcare and Nashville, Tenn.-based HCA Healthcare reported more than 50 percent drops in quarterly net income from 2021 to 2022.

The profitability mismatch between the nation's largest payers and health systems of all sizes will be front and center during contract negotiations in the coming year. There have already been high profile contract impasses between insurers and large systems, with some leading to contract termination.

Aspirational for the U.S. Healthcare System?  Imagine, using evidence-based, accredited, emergency medical dispatch processes to send the right resource, to the right patient, at the right time!

Interestingly, single payer systems seem more willing to make investments in systems like this to reduce potentially avoidable acute care utilization…. 

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$42m to improve ambulance availability and ease pressure on hospitals

October 25, 2022

https://australianseniorsnews.com.au/health/42m-to-improve-ambulance-availability-and-ease-pressure-on-hospitals/

The Queensland Government has today announced it will invest $42.35 million over four years to expand the Clinical Hub, an initiative aimed at improving ambulance availability, reducing pressures on hospital emergency departments and increasing health system capacity.

Minister for Health and Ambulance Services, Yvette D’Ath said the funds would go to growing the team significantly, which first started as five paramedics and two Emergency Medical Dispatchers (EMDs) back in 2020.

“The Clinical Hub first started in the early days of the pandemic as a small team making big in-roads,” Ms D’Ath said.

“By the end of the year we expect the hub to be operating 24 hours a day, 7 days a week with over 64 specialist staff, including senior paramedics, doctors, EMDS, Emergency Medical Specialists and mental health clinicians.

“This means we have more of the right people making the right calls to provide the right care for Queenslanders and freeing up capacity for the state’s most critical and urgent cases.”

Queensland Ambulance Service Commissioner Craig Emery said the Clinical Hub initiative was already making a difference.

“Currently, around 250 calls per day are directed to the Clinical Hub and over 60 of these are offered care which does not require an ambulance attendance,” he said.

Cases can also be upgraded after a reassessment from the Clinical Hub, once the needs and status of the patient are better understood with a longer, more detailed triage, he said.

“This system means we can ensure everyone is getting exactly the right treatment pathway.

“It also means we can free up resources for more urgent emergency cases, whether that’s ambulances on the road or potentially reducing some pressure on emergency departments,” said Commissioner Emery.

Kudos to the team at TRAA for this accomplishment!

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TRAA improves top-priority response times in first month managing operations in-house

Devan Filchak

Oct 14, 2022

https://www.journalgazette.net/local/traa-improves-top-priority-response-times-in-first-month-managing-operations-in-house/article_f7e6346c-4be1-11ed-a914-87dcd38008a6.html

Three Rivers Ambulance Authority medics reached an 80% response rate to top-priority emergency calls within 8 1/2 minutes in September, the first month after its split with contractor Paramedics Logistics LLC, the organization announced Friday.

September marks the first month that the ambulance authority has handled its own operations. Three Rivers Ambulance Authority, also known as TRAA, has provided emergency medical services to Fort Wayne residents since 1983 through an agreement with the city and county, both of which appoint members to the authority’s board.

The ambulance authority handled billing while it contracted out operations to manage paramedics and emergency medical technicians, ambulances and other equipment.

To be considered compliant, at least 90% of priority one calls – emergencies including strokes, heart attacks, difficulty breathing and major traumas – have to be reached by medics within 8 1/2 minutes.

Paramedics Logistics, which had been the contractor since 2009, was unable to meet that standard for two years. The ambulance authority’s 80% September rate is 7 percentage points higher than the city’s final month of emergency service by Paramedics Logistics, a news release said.

Three Rivers Ambulance Authority also asked county ambulance services to step in and respond to a call the least number of times since June 2021, the release said.

Joel Benz, executive director, commented on the data.

“Some of the changes we are implementing are already having an effect, thanks in large part to the hard-working paramedics and EMTs within our organizations,” he said in a statement. “Statistically, this was our best month in a year and a half. We still have many challenges ahead of us as an organization, but I believe we are taking steps in the right direction.”

TRAA’s board declared a state of emergency about a year and a half ago after several months of what were considered unacceptably slow response times on priority one calls. Gary Booher, who had been the executive director for 32 years, retired about a year ago.

Benz, a local paramedic of more than 20 years and former Allen County Council member, was hired to replace Booher.

The ambulance authority’s board has made several changes aside from taking over operations in-house, including raising medic wages by $5 an hour and providing paid training for prospective paramedics and EMTs.

Interesting paper from Dr. Newberger and Dr. Braithwaite². 

Supports the use of clinically based, collaboratively developed, high quality 911 call taking medical triage to help dispatch the right resources to the right type of 911 call, especially as EMS response volumes tax existing resources.

Also, an interesting description of how the U.K. uses this process to assign resources to call, with 90% reliability standards of 10 minutes for life-threatening calls, 40 minutes for emergent, but not critical calls, two hours for urgent calls, and 3 hours for less urgent calls.

There are examples of innovative EMS agencies taking an evidence-based approach to evaluating their own data based on medical care provided on scene, need for Medical First Response (MFR), and actual patient experience scores based on response times to make changes to their response configurations to balance clinical needs with resource availability and cost.

Something that perhaps more communities should do!?

Tip of the hat to Bill Bullard of Healthcare Strategists for finding and sharing this study!

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EMS Prioritization Of Response

Authors

Ryan Newberger, M.D.¹; Sabina Braithwaite, M.D.².

Affiliations

¹ University of Illinois College of Medicine at Peoria

² Washington University in St Louis

May 15, 2022.

https://www.ncbi.nlm.nih.gov/books/NBK559294/

Introduction

Public safety access points (PSAP) are tasked with the responsibility of taking all emergency calls (911 in the US), triaging and prioritizing each call using the provided information, notifying and dispatching the appropriate responders, and offering pre-arrival first aid instructions to callers.  Standardized dispatch systems that are available for querying callers, categorizing calls, and matching the call type to the appropriate response units and priority have been shown to improve metrics such as time to dispatch.[1] 

In EMS systems with multiple simultaneous requests for service or inadequate response resources to meet the call demand at any given time, decisions must be made which call is believed to be most emergent, and which call is less urgent or can be delayed.[2] Ideally, the call prioritization, as well as the response profile, follows consistent guidelines from the local EMS agency, a regional EMS regulatory body, a national accrediting organization, or even a governmental agency.

Issues of Concern

Trends have shown steady increases in annual EMS calls and subsequent EMS dispatches. As a result, appropriate prioritization of calls is necessary both to use limited resources effectively as well as assure that patients' needs are met in a timely fashion.  Also, prioritization can address public safety concerns by reducing the number of calls responded to emergently (lights and sirens) to those which are predicted to be genuinely urgent or emergent. This approach then reduces the risk of injury to both EMS providers and the general public from lights and sirens-related accidents and multiple responding public safety units.   

Several common frameworks are widely used by PSAPs to categorize and prioritize calls in the United States.[3]  Common elements include having dispatchers ask specific, scripted triage questions to determine the chief complaint and patient's clinical status.[4] Answers to these questions allow dispatchers to link the call type to the anticipated resource needs based on the information provided. 

Some studies have shown significant improvement in the detection of cardiac arrest with standardization of the triage process and avoiding sole reliance on a dispatcher's judgment.[5]  However, dispatcher consistency in following the standardized scripts remains a valid concern.[3]  Another part of this process is determining which emergency resources should respond to each emergency call, rather than asking the dispatcher to make these decisions on a case-by-case basis. These predetermined response profiles or configurations link to specific call types (i.e., MVC vs. sick case) and which type of EMS unit (Basic versus Advanced Life Support unit) and other emergency apparatus (fire, law enforcement) with the urgency of the response (e.g., routine versus emergent).  While these are suggestions, in practice, they represent a "floor" that the dispatcher can add resources too based on information received, rather than subtracting from the response profile. Once the patient's needs are identified, the pre-established units within the response profile correlating to that complaint can be dispatched.  

Widely used models in the US rely on variations on a number-letter-number system, with many categories and subclassifications of anticipated disease processes. Several European countries, and some large American cities, use a simplified model with fewer categories focused on determining the urgency and timeframe in which response should occur. This second type of system is more feasible in more homogeneous systems without different levels of medical response capability, i.e., only ALS units. As such, there is a higher emphasis placed on the response time that is allowed for each call.

In the United Kingdom, for example, the National Health Service Clinical Response Model sorts calls into one of five categories.

• Category 1 calls are the most severe/critically ill calls and categorize as "Life-Threatening Illnesses or Injuries," which warrant an immediate response, with the expectation that in-person response will arrive within 10 minutes.
• The next, less serious, category of calls are the category 2 calls, in which response is deemed emergent but not critical with ninety percent of response times within 40 minutes.
• Urgent calls are considered category 3 and are responded to within two hours ninety percent of the time.
• Category 4 calls are considered less urgent and generally receive a response within 3 hours.
• Category 5 is reserved for what are considered "non-urgent calls," deemed not to warrant any in-person EMS response but which instead are transferred to a telephone triage line or referral service to help resolve their issue.[6]

There is a misperception that the existing dispatch systems and categories have an evidence-based correlation with patient acuity and outcomes, yet the evidence does not support this.[4][7] For example, the lowest acuity levels in two common US systems merely identify that based on the information received from the caller, either no emergent response or a basic life support response is expected to be appropriate. 

Some systems use these categories to determine eligibility for prolonged response times or nonresponse, as noted in the NHS system. Since the categorization is based entirely on the information from the caller, it relies on the quality of the information received, the proximity of the caller to the patient (with the patient, or a third party "drive-by" caller), the caller's ability to communicate (i.e., language barriers, etc.), and the pertinence and clarity of the questions asked by the dispatcher. 

Some EMS systems choose to respond to all categories in the same manner, and with the same types of units, others use the categories stratify their response profiles, as noted above. Thoughtfully created response profiles decide whether the complaint warrants a first responder, requires additional personnel (i.e., engine/pumper for cardiac arrest), a BLS ambulance only, an ALS ambulance only, an EMS supervisor or chief, specialized responders (such as police, SWAT, a rescue truck for extrication, a helicopter). In this way, PSAPs can limit over-triage (too many resources) as well as under-triage (too few or too slow) responses.[6] It also specifies the mode of response for each responding unit, either "quiet" vs. red lights and sirens.

Well-designed response profiles that are created by the collaboration between the leadership of all the relevant responding and dispatching agencies can help assure that the patient's apparent needs are timely met, that EMS and related public safety resources are utilized appropriately, that the general public's safety is considered in the response mode and that inherently more dangerous red lights and sirens responses are limited. 

New Innovations            

In the United States, the National Highway Traffic Safety Administration Office of EMS "EMS Agenda 2050" is a forward-looking guidance document that creates a vision for the advancement of EMS systems.[8] The goal of this document is to use data-driven, evidence-based principles to provide the most sustainable, innovative, socially equitable, and reliable patient care possible. 

One recent innovation in the US is the redirection of low acuity 911 calls to a secondary nurse triage line, as noted in the NHS example. This strategy allows EMS agencies to diverge from the traditional practice that every 911 call gets a response, regardless of how minor the caller's complaint is.  Rather than perpetuating this mismatch of emergency resources with non-emergent calls, the nurse triage line provides additional medical advice and connects the caller to non-emergent resources to meet their needs.[9] If the acuity of the call is deemed too high or otherwise inappropriate for the on-call nurse, the call is then routed back to EMS dispatch for an in-person response.[5] To date, this strategy has yielded mixed results, with one study showing that in a call center with an annual volume of 90,000 calls only averaged of two calls per day appropriate for nurse-triage with an average of less than one patient per day successfully completing this protocol and thus avoiding in-person EMS response.

Of those patients who did complete the protocol for a nurse-triage response only, there was a high rate of satisfaction with their experience, with approximately 92% of patients reporting that the non-transport option met their healthcare needs.[10] While it appears that there is more research needed to investigate how to optimize the nurse-triage system best, logic would suggest that its use could be expanded to allow more patients to meet criteria, and thus reduce EMS response volume.

Another innovation informs EMS call prioritization and response, the use of advanced automatic crash notification (AACN) from car accidents, using sophisticated sensors and crash detection monitors, which automatically provide PSAP with information including the location of the crash, the speed at the time of impact and the forces involved. This data is analyzed automatically by the vehicle to determine the likelihood of serious injury, and the vehicle transmits that data directly to the nearest PSAP. If the AACN indicates that there is a high likelihood of serious injury, the call can be prioritized differently, and a more appropriate response profile than the generic motor vehicle collision response can be dispatched immediately, rather than waiting for responders to arrive on the scene, assess the patient, and request additional resources, including potentially having helicopter EMS on standby.[11]

Another focus both in the United States and abroad is on frequent callers or EMS system users.  Such callers are identified and flagged, and a multidisciplinary approach is applied to determine the root cause of the frequent emergency system activation and address the underlying need, whether that be access to food, healthcare, in-home support, or other needs.[12] However, as yet there is no definitive study demonstrating a statistically significant benefit to these types of programs.[13]

Clinical Significance

PSAP EMS response prioritization systems have been in place for decades and match patient needs to the most appropriate response units and urgency of response. While models vary, the common goal of PSAPs is to provide the most suitable, safe, and timely response to requests for service.  

The expectation is that for a variety of reasons, the demand for EMS will continue to increase, so the ability to better match anticipated patient needs to resources is critical, since the continued expansion of the EMS to keep pace with demand is not expected. 

The EMS Agenda 2050 document highlights opportunities to ease this burden by leveraging technology to meet the patient’s needs while remaining patient-focused. Research on various strategies to show which are most effective at meeting patient needs while appropriately using resources is critical to tailor prioritization of response going forward.

References

1. Grisanti K, Martorano L, Redmond M, Scherzer R, Strothman K, Malthaner L, Davis J, Zhao S, Kline D, Leonard JC. Emergency Call Characteristics and EMS Dispatcher Protocol Adherence for Possible Anaphylaxis. Prehosp Emerg Care. 2019 Sep-Oct;23(5):691-699. [PubMed: 30526221]

2. S, Lane C, Eckstein M. Effect of New 9-1-1 System on Efficiency of Initial Resource Assignment. Prehosp Emerg Care. 2020 Sep-Oct;24(5):634-643. [PubMed: 31664875]

3. Hodell EM, Sporer KA, Brown JF. Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community? Prehosp Emerg Care. 2014 Jan-Mar;18(1):28-34. [PubMed: 24028558]

4. Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc Emerg Med. 2018 Nov 09;26(1):94. [PMC free article: PMC6230269] [PubMed: 30413213]

5. Torlén K, Kurland L, Castrén M, Olanders K, Bohm K. A comparison of two emergency medical dispatch protocols with respect to accuracy. Scand J Trauma Resusc Emerg Med. 2017 Dec 29;25(1):122. [PMC free article: PMC5747276] [PubMed: 29284542]

6. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection? Emerg Med J. 2004 Jan;21(1):115-8. [PMC free article: PMC1756371] [PubMed: 14734398]

7. Hettinger AZ, Cushman JT, Shah MN, Noyes K. Emergency medical dispatch codes association with emergency department outcomes. Prehosp Emerg Care. 2013 Jan-Mar;17(1):29-37. [PubMed: 23140195]

8. Gausche-Hill M, Krug S, Wright J. Emergency Medical Services (EMS) 2050: A Vision for the Future of Pediatric Prehospital Care. Prehosp Emerg Care. 2021 Jan-Feb;25(1):91-94. [PubMed: 32091291]

9. Infinger A, Studnek JR, Hawkins E, Bagwell B, Swanson D. Implementation of prehospital dispatch protocols that triage low-acuity patients to advice-line nurses. Prehosp Emerg Care. 2013 Oct-Dec;17(4):481-5. [PubMed: 23865776]

10. O’Cathain A, Knowles E, Bishop-Edwards L, Coster J, Crum A, Jacques R, James C, Lawson R, Marsh M, O’Hara R, Siriwardena AN, Stone T, Turner J, Williams J. Understanding variation in ambulance service non-conveyance rates: a mixed methods study. NIHR Journals Library; Southampton (UK): May, 2018. [PubMed: 29870196]

11. Panchal AR, Berg KM, Cabañas JG, Kurz MC, Link MS, Del Rios M, Hirsch KG, Chan PS, Hazinski MF, Morley PT, Donnino MW, Kudenchuk PJ. 2019 American Heart Association Focused Update on Systems of Care: Dispatcher-Assisted Cardiopulmonary Resuscitation and Cardiac Arrest Centers: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e895-e903. [PubMed: 31722563]

12. Snooks HA, Khanom A, Cole R, Edwards A, Edwards BM, Evans BA, Foster T, Fothergill RT, Gripper CP, Hampton C, John A, Petterson R, Porter A, Rosser A, Scott J. What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom. BMC Emerg Med. 2019 Dec 28;19(1):82. [PMC free article: PMC6935477] [PubMed: 31883535]

13. Eastwood K, Morgans A, Stoelwinder J, Smith K. The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: A retrospective cohort study. PLoS One. 2019;14(8):e0221158. [PMC free article: PMC6691999] [PubMed: 31408496]

Copyright © 2022, StatPearls Publishing LLC.

Medi-Cal ambulance rides are going to cost taxpayers a lot more

By AUSTILL STUART

September 17, 2022

https://www.ocregister.com/2022/09/17/medi-cal-ambulance-rides-are-going-to-cost-taxpayers-a-lot-more/

A little-noticed amendment recently approved by the Centers for Medicaid Services for California’s Medicaid plan, Medi-Cal, could cost the state’s taxpayers and patients dramatically. The amendment, 22-0015, raises the reimbursement rate that Medi-Cal will pay for ambulance rides by over $800 per trip. A Medi-Cal patient’s ambulance ride will now cost state taxpayers over $1,000 per trip, up from about $120 per trip.

The increased reimbursement rates in the amendment could result in a revenue windfall for local fire departments that are increasingly looking to provide emergency medical services (EMS)—not so they can better serve patients, but so they can use EMS as a revenue generator. Notably, despite handling over 70% of ambulance rides in California, private ambulance companies aren’t going to receive this higher reimbursement rate because it is only available to public EMS providers.

EMS agencies exist to serve all patients with life-saving services as quickly and effectively as possible, not to charge taxpayers high costs and siphon off the most profitable patients to generate money that can be shifted to other projects.

While Medi-Cal patients may have previously provided less reimbursement than rates paid by some insured patients for their ambulance trips, justifying a ninefold increase in per-trip rate needs clear justification. Yet, proponents and state officials have not provided any data justifying the ambulance ride cost increase.

California’s county-based emergency medical services system has existed since 1981. The state Emergency Medical Services Authority (EMSA) was created after the proliferation of city- and county-based EMS agencies led to jurisdictional conflicts, and a more unified approach to EMS transport was needed. Since then, the county-based EMS system has served Californians well for over four decades, with EMSA providing oversight and many local governments partnering with private ambulance companies.

But, today, fire departments view emergency medical services as a way to get more funding. Earlier this year, Senate Bill 443, which died in the state legislature, would have allowed local fire departments to effectively create their own EMS agencies. But fire departments don’t want oversight from the state’s Emergency Medical Services Authority. And they don’t want to conduct competitive bidding for ambulance subcontracts, where private providers would likely provide better services at lower costs.

Recent experience shows how this unaccountable fire department takeover of EMS happens. For example, in 2019-20, Chula Vista entered an EMS contract with the same company that had provided its ambulance services since the late-1970s. Chula Vista raised rates considerably to nearly $3,900 per ambulance trip. But, the ambulance company providing those services only received $1,720 per trip while the fire district siphoned off over $2,000 per trip. Then, after jacking up ambulance prices, the fire department told city leaders that, rather than hold another competitive bidding process to see what private companies would charge per trip, the fire department should provide all emergency services and keep all of the funding.

If municipal fire agencies want to take control of emergency medical services away from cities, counties, and private providers, they should competitively bid for the opportunity to do so alongside other EMS providers. They should also be subject to the same standards and oversight, which they aren’t currently.

Unfortunately, this Medi-Cal amendment raising reimbursement rates to public providers and the previously proposed state legislation, which may return next session, make it look as though fire departments believe they can bully their way into becoming unregulated EMS agencies that charge astronomical prices to taxpayers.

Ambulance services are obviously often a matter of life and death. If lawmakers and regulators believe the state’s system needs improvement, they should publicly and transparently propose EMS changes and judge providers on a level playing field. If fire departments want to displace existing county EMS providers and private ambulance companies, they should be offering taxpayers higher quality services at lower costs. Right now, it appears they’re offering neither.

Austill Stuart is the director of privatization research at Reason Foundation.

An idea whose time has come? EMS and local communities should investigate transformative models to reduce psych holds in local EDs – something hospitals and EMS agencies often say contribute to EMS offload delays.

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Mental Health Crisis Leads Hospitals to Create a New Type of ER

Recliners and games in “Empath units” are helping move patients with psychiatric ailments out of emergency rooms.

ByJohn Tozzi

September 26, 2022

https://www.bloomberg.com/news/articles/2022-09-26/hospitals-empath-units-replace-the-er-for-mental-health-patients

With mental health treatment in short supply, Americans experiencing a psychiatric crisis frequently land in a hospital emergency room—brought in by the police or loved ones—and usually stay there until they can be safely discharged or transferred. That means patients can spend hours or even days stuck on a gurney until a spot opens in a psych ward, the only other setting deemed appropriate.

The approach rarely offers any real treatment for mental health conditions, and it ties up scarce ER beds. That’s spurred some hospitals to try a new idea: mental health crisis units designed to treat people quickly in a more serene setting, so they can stabilize patients and send them home. “There’s no other emergency in the ER where the default treatment is to find them a bed,” says Scott Zeller, assistant clinical professor of psychiatry at the University of California in Riverside. Zeller developed the model, called Empath (emergency psychiatric assessment, treatment, and healing), to improve care while avoiding unnecessary time in the emergency department.

The idea is an open room with recliners, soft lighting, TVs, and card tables. At the two dozen or so Empath centers in the US today—with dozens more on the way—patients who are medically stable are seen by a psychiatric specialist within an hour and quickly start any needed medication. By speeding up treatment and observing the response, doctors can send more patients home with recommendations for follow-up care, rather than automatically placing them in a psychiatric hospital.

Since the 1950s, most US psychiatric beds have vanished under the policy of “deinstitutionalization” that followed budget cuts and exposés of inhumane conditions in mental hospitals. The number of public psychiatric beds per 100,000 people dropped from 340 in 1955 to 12 in 2016, according to the nonprofit Treatment Advocacy Center. After the institutions emptied out, hospitals and jails became the de facto replacements.

Covid-19, which strained hospital capacity while exacerbating Americans’ mental distress, amplified the problem. A study of one pediatric facility found the average length of psychiatric boarding more than doubled, to 4.6 days, during the first year of the pandemic. A survey by the Massachusetts College of Emergency Physicians showed that at the average hospital, almost 30% of ER beds are occupied by people experiencing a behavioral health emergency, with some patients remaining there for weeks.

Zeller developed what became the Empath model when he was medical director of a psychiatric emergency center in Alameda County, Calif., which served as a regional destination for psychiatric transfers from local emergency departments. Most patients were brought in involuntarily by the police, and the county aimed to move those who were medically stable to the center as quickly as possible. The approach, Zeller found in a 2014 study, meant patients spent less than two hours in the ER waiting for treatment, and only 1 in 4 needed to be admitted for inpatient psychiatric care.

Part of the solution was getting people out of a setting that can aggravate mental distress. “That environment itself, within the ED, can be very frightening,” Zeller says. “It’s claustrophobic, there are lights and noises and scary equipment and uniformed personnel running all around, and they’re not allowed to move.”

The setting for the Alameda study was essentially a big waiting room. The hospital bought recliners to make patients more comfortable, organized group activities such as board games, and added stations where patients could get water, snacks, and linens so they wouldn’t have to ask a nurse for basics. “That allows the treatment to work a little better, if people aren’t feeling adversarial, but rather engaged,” Zeller says.

As the Alameda study got more attention, other hospitals sought to replicate the approach. Zeller and his colleagues started talking about redesigning the concept. “If we were going to be able to build something from scratch, what would we do?” he asked. Hospitals envisioning new facilities could make them feel less clinical and more inviting than the waiting room, with more space, higher ceilings, natural light, and fresh air.

M Health Fairview Southdale Hospital in suburban Minneapolis opened an Empath unit in March 2021. Lewis Zeidner, director of clinical triage and transition services, says it’s more like a living room than an ER, though it’s adjacent to the emergency department. The unit has 15 recliners and a staff of psychiatrists, psychiatric nurses, and therapists—one clinician for every two patients—around the clock. Hospital admissions for mental health crises have fallen to 14% from 40%, and there’s been a dramatic drop in repeat visits.

The unit sees 250 patients a month with depression, anxiety, PTSD, and substance use problems. “They’re everyday people who get to a place in their life where things feel more out of control,” Zeidner says. The setting opens a window to evaluate patients and determine whether they should be admitted for inpatient treatment. Before the Empath option, that was usually the only destination if a clinician was worried about a patient’s security. “We want to keep people safe,” he says. “You can’t reverse suicide.”

After University of Iowa Health Care opened an Empath unit in its main hospital building in Iowa City, the number of suicidal patients admitted and the length of time they waited in the ER dropped dramatically, researchers found. “Once we had it, we were like, ‘Oh my gosh, how did we do this without it?’” says Heidi Robinson, director of behavioral health services for the hospital’s nursing department.

A separate Iowa study looked at the economics of the approach and found that revenue in the emergency department increased as fewer patients left before being treated. But the boost wasn’t enough to cover the cost of the Empath unit—$1.4 million to open and $2.6 million in annual operating expenses. Zeidner says hospitals tend to lose money on inpatient mental health beds anyway, and the advantages to patients of avoiding those admissions are clear. With the success of its suburban Southdale Empath unit, M Health Fairview is considering another at its downtown Minneapolis location, with room to treat adolescents as well as adults. “There’s a growing understanding,” Zeidner says, “that this crisis is not going away.”

The latest legal challenge. 

Perhaps one of the reasons that the Congressionally mandated Committee on Ground Ambulance Balance Billing has not been seeded yet is that the feds are waiting for the various legal challenges to play out to help guide the recommendations from that committee?

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Texas Medical Association files another surprise billing lawsuit

MAYA GOLDMAN

September 22, 2022

https://www.modernhealthcare.com/legal/surprise-billing-lawsuit-texas-doctors

The Texas Medical Association filed its second lawsuit against the federal government’s surprise billing arbitration process Thursday.

An August rule on the independent dispute resolution for surprise medical bills still unlawfully favors insurers over providers, the medical association alleges in its complaint to the U.S. District Court for the Eastern District of Texas.

“We are, once again, asking for the law to be followed as Congress intended, and for the challenged provisions to be invalidated. There should be a level playing field for physicians and healthcare providers in payment disputes after they’ve cared for patients,” Texas Medical Association President Dr. Gary Floyd said in a news release.

The lawsuit comes just after the American Medical Association and American Hospital Association dropped their legal challenges to the policy. The AMA and AHA support the Texas lawsuit. “We intend to make our voice heard in this case by filing an amicus brief that explains how the final rule departs from congressional intent just as the September 2021 interim final rule did,” the organizations said in a joint statement Thursday.

The Texas Medical Association first sued regulators over the arbitration policy last year. The interim regulation required arbiters to pick the offer for surprise bill payment that came closest to the insurer's median contracted in-network rate. Judge Jeremy Kernodle of the U.S. District Court for the Eastern District of Texas ruled in favor of the Texas physicians in February.

The federal government appealed the decision in April, but subsequently finalized a rule requiring arbiters to consider both an insurer’s median contracted in-network rate and additional information when deciding the payment for a surprise bill.

The Texas Medical Association contends the final rule does not go far enough to protect provider payments. The methodology for calculating insurers’ median in-network rates is “deflated” compared to insurers’ actual average contracted rates, the group argued in the news release.

“These provisions of the final rule are manifestly unlawful and will unfairly skew [independent dispute resolution] results in insurers’ favor, granting them a windfall they were unable to obtain in the legislative process. At the same time, they will undermine healthcare providers’ ability to obtain adequate reimbursement for their services, to the detriment of both providers and the patients they serve,” the complaint says.

Very, very well-done article in the Des Moines Register.

Special thanks to West Des Moines EMS Deputy Chief and NAEMT Board Member David Edgar for coordinating this important series.

The on-line article is behind a subscription wall, but we’ve placed a PDF version of the 2 part series, and the accompanying editorial here.

De Moines EMS Series.pdf

Notable quotes:

“Many people regard EMS as an essential service, but the system in Iowa and across the U.S. struggles to remain financially viable and to fulfill its mission of quickly delivering care to the sick or injured, local and national emergency officials say.”

“According to U.S. Bureau of Labor Statistics' data from 2021, the median pay for a full-time emergency medical technician was $17.76 an hour, even though the job requires training that, for a full-fledged paramedic, typically costs $10,000 to $20,000.”

"The fix isn’t just money, but the fixes require money,"

This is good news for some systems using the PHE waivers for their EMS delivery…  Some will expire when the PHE ends, some carry on until the end of the calendar year in which the PHE ends.  There is a link and list of these waivers at the end of this note.  

Many of the telehealth waivers will expire 151 days after the PHE ends, unless Congress moves to make them permanent.

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HHS expected to renew COVID-19 PHE for 11th time

Molly Gamble

Sept. 14, 2022

https://www.beckershospitalreview.com/finance/hhs-expected-to-renew-covid-19-phe-for-11th-time.html

HHS is set to extend the COVID-19 public health emergency by its standing deadline of Oct. 13.

HHS last renewed the PHE July 15 for another increment of 90 days with a pledge to provide states with 60 days' notice if it decided to terminate the declaration or allow it to expire. Aug. 14, the date in which states would have 60 days' notice, came and went without updates or notifications from the agency, suggesting the declaration will extend.

If renewed on the deadline of Oct. 13, the next deadline would be Jan. 11, 2023.

This would make for the 11th renewal of the PHE since its declaration in January 2020 by former and current HHS secretaries Alex Azar and Xavier Becerra, respectively. The renewal would occur as HHS plans to shift costs of COVID-19 vaccines and treatments to the commercial market, a process beginning this fall that is expected to take months. 

Hospitals have advocated for the PHE's extension. In July, the Federation of American Hospitals, which represents investor-owned or managed hospitals, urged HHS "in the strongest terms possible" to renew PHE through 2023.

"While we all long for the day when we can declare the emergency over, that day is not yet in sight for America's hospitals," FAH CEO Chip Kahn wrote in his July 27 letter to Mr. Becerra. Mr. Kahn urged HHS to not only renew the PHE for another 90 days by its current deadline of Oct. 13, but to "send a clear signal that an additional 90-day extension may be necessary."

For an overview of the flexibilities tied to the PHE and what occurs when the declaration ends, check out a comprehensive brief from Kaiser Family Foundation here.

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https://www.cms.gov/files/document/ambulances-cms-flexibilities-fight-covid-19.pdf

Payment for Vaccine Administration:

“CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines in outpatient settings for Medicare beneficiaries through the end of the calendar year that the COVID-19 PHE ends.”

Add-On Payment for Vaccines in the Home:

“We’ll continue to pay a total payment of approximately $75 per dose to administer COVID-19 vaccines in the home for certain Medicare patients through the end of the calendar year that the COVID-19 PHE ends.”

Ambulance Treat in Place:

“This waiver will end with the end of the PHE.”

CMS Hospital Without Walls (Transport to Alternate Destinations):

During the Public Health Emergency (PHE) for the COVID-19 pandemic, we have temporarily expanded the list of allowable destinations. {Editor’s Note: Although not expressly stated in the waiver, this waiver will likely end with the PHE.}

Another example of how existing services models are not sustainable with skyrocketing costs of service delivery and historically low reimbursement rates, regardless of who the provider is, public, private, hospital-based, etc.

Community leaders need to be educated on the true cost of EMS service delivery, the cost differences based on service levels and provider types (public, private, 3^rd service governmental, hospital-based, etc.), decide what service level the community really wants based on the levels of investment needed for each level, and begin to fund EMS delivery the way other essential public services are funded.

Click here to view a recent webinar hosted by the Academy of International Mobile Healthcare Integration discussing costs and funding models based on service delivery levels.

This may be the latest, but it WILL NOT be the last!

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AMR to discontinue service in Youngstown

by: Jennifer Rodriguez, Megan Lee

Sep 14, 2022

https://www.wkbn.com/news/local-news/amr-to-discontinue-service-in-youngstown/

YOUNGSTOWN, Ohio (WKBN) – American Medical Response (AMR) sent a letter to the City of Youngstown Wednesday notifying the city that it will be discontinuing service in Youngstown.

According to the letter sent to the city, AMR will not renew its agreement with the city, and the current agreement will end on December 31, at 11:59 p.m.

The letter states AMR has been serving the city for over 30 years without any cost to the city or taxpayers. It also states that the company is not being reimbursed for medical calls.

“We have discussed throughout the last three years, the subsidy is needed to overcome inadequate Medicaid reimbursement which makes up a significant portion of our services and which is below our costs,” it stated.

It goes on to state, “The current Ohio Medicaid base rate for a basic life support emergency transport is $120 and has not been re-based by the state in years. When we treat and transport Medicaid patients, we are reimbursed far below the cost of providing service — approximately 42% of our cost. More than half our transports, or 54%, are Medicaid recipients.”

In April, Youngstown City Council voted down a $625,000 subsidy to “ensure continued EMS and ambulance services” for the city. All council members voted no except Third Ward Councilwoman Samantha Turner.

At that time, Fourth Ward Councilman Mike Ray said the door was not completely shut, but there were some details that needed to be worked out first.

We don’t know if that’s still the amount to keep AMR in place. When asked if the city should reconsider the vote, Turner said, “We should. If they’ll take it.”

Today, we asked several council members their thoughts on the notice and AMR stating they need more money.

“We asked admin months and months ago to go out for an RFP to see who else may be interested with that much money on the line, it’s only responsible of us to do that but the admin hasn’t done it, surprise, surprise,” said Fifth Ward Councilwoman Lauren McNally. “They are the largest EMS service in the country and I feel they are bullying us into a money grab since we have ARP money right now.”

“They are the largest ambulance company in the country, I feel like they are extorting us because we have some extra money now. I’m not sure what’s going to happen. My ultimate feeling is, have their services improved, what are they willing to give in return? Are they adding trucks, are we going to get better response terms, are the citizens of Youngstown going to be served any better because of the extra money? If not, what’s the point of payment? We can’t get or continue to get mediocre or bad service,” Oliver said.

“What we see in front of us doesn’t make sense to pass at this point, so we definitely wanna continue the conversation,” Ray said.

In January, AMR Regional Director Ed Powers used a computer presentation to explain the problems, saying while an average ambulance run costs about $300, Medicaid only reimburses the company $130 – a gap of 48%.

“Medicaid currently covers about 48% of our expense. We need another 52% just to break even,” Powers said.

“During that three years, we’ve explored all kinds of different models, trying to create a sustainable model. I mean, we knew five years ago that the model wasn’t sustainable,” he said.

Youngstown Law Director Jeff Limbian said the letter from AMR was not unexpected.

“The City of Youngstown, under Mayor Brown’s direction, has been to negotiate with AMR for many months now. Some members of City Council would like a more expansive analysis to see if there are other ambulance companies available to come into the city,” he said. “There is currently a request for proposals to determine if there are other interested ambulance entities. If that process does not produce an additional option, we anticipate that discussions will continue with AMR.”

According to Powers, AMR gave the city a 115-day notice to find new services. And if services aren’t found…

“Oh, it would mean a holy disaster to be perfectly blunt. We don’t anticipate that’ll happen. Mayor Brown is going to move heaven and earth to make sure that the citizens are protected. There will be ambulance service one way or another,” Limbian said.

Powers says the company hopes that the administration in Youngstown sits down with AMR to discuss any future plans or negotiations because he says AMR has invested a lot in the City of Youngstown.

“We actually hire residents off the street that are non-medical providers. We train them to be a medical provider and then give them jobs to work on our ambulances, and then they’re paying taxes to the City of Youngstown. So they’re… everybody here is invested in the City of Youngstown and nobody wants to leave,” Powers said.

Limbian hopes AMR will want to go back to the drawing board if the administration is unsuccessful in finding an alternative company.

“You know, it was a hard lesson for us to learn, to come to that realization, but now that we do understand that there just isn’t the money for them to make in the town the size of Youngstown with the volume that we have. So their requests are reasonable,” Limbian said.

The Youngstown Fire Department recently stopped using its fire trucks for emergency medical calls after it was determined what they were doing was illegal. The fire department needs what is known as “standing orders” from a hospital and is working to get them.

The Youngstown Professional Fire Fighters IAFF Local 312 responded to AMR’s announcement calling on city leaders to talk about the future of pre-hospital care for the city:

“Now is the time to address the inequalities that have plagued Youngstown for years. We are witnessing firsthand the ramifications of putting profits over patients. The citizens of Youngstown deserve access to basic infrastructure like public safety, which includes a sustainable, professional EMS system. The Youngstown Professional Fire Fighters urge the city leaders to finally recognize our abilities to help our citizens and negotiate the implementation of a first-class pre-hospital system.”