News & Updates

Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

This is encouraging news for those who have quietly questioned whether the arrangements where hospitals, physician groups, hospice and home health agencies are paying EMS to provide care coordination for their patients could be construed as running afoul of the Stark Law.

Although these proposed rules apply to non-EMS agencies, it may signal the intent of the OIG.

Recall that JEMS published an article Steve Wirth penned on this issue in March 2019 - https://www.jems.com/articles/2019/03/recent-federal-advisory-opinion-favors-community-paramedic-programs.html

Stark Law, anti-kickback updates may boost value-based payments

October 09, 2019

ALEX KACIK

HHS on Wednesday unveiled its long-awaited proposal to change its anti-kickback and self-referral laws, a move that was largely well-received by industry observers who expect the proposals to facilitate more value-based payments and coordinated care.

In two proposed rules from the CMS and HHS Office of Inspector General, the agencies said the current regulations limit data sharing and care coordination in their attempts to root out fraud.

Under the proposed rules, specialty physician practices could share patient information with primary care physicians to manage care or work with hospitals on discharges using data analytics. It also would allow local hospitals to work together on cybersecurity issues without running afoul of data sharing concerns.

The safe harbors include allowing hospitals to pay physicians incentives as part of CMS-sponsored care models.

Continue reading►

Reasons to Be Cheerful Source Article | Comments Courtesy of Matt Zavadsky

Very nice article about the Eagle County and MedStar MIH-CP programs!

No highlights, because it’s ALL good!  J

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Free the Paramedics!

They’re the medical system’s eyes and ears, yet they’re treated as crisis managers. Now some cities are letting their paramedics get to know their patients, with remarkable results.

October 4, 2019

By: Allison McNearney

Twice a week, Amy Yang drives her white Chevy Malibu to Mollie Wagar’s apartment in a senior living community in Fort Worth, Texas. Wagar, 78, lives alone and is a bit of a night owl, so Yang always calls her a few minutes before her scheduled 9 a.m. arrival to warn her she’s on the way. 

Once situated in Wagar’s living room, an array of devices appear from Yang’s black cargo pants and medical bag—a stethoscope, a blood pressure cuff, a blood sugar meter. While the paramedic gets to work, she chats with Wagar about her recent road trip to Mississippi and new developments in her health since they last saw each other four days earlier.

These casual visits and friendly chats are a gratifying change for Yang, who, until about a year ago, spent 11 years speeding patients to emergency rooms in an ambulance. Now, she is able to develop a slow-paced relationship with patients like Wagar, witnessing and monitoring their health improvements first-hand. Wagar’s situation isn’t an emergency, but in another city it might be treated as one, not because she requires urgent care, but because most cities don’t have a system like Fort Worth’s. 

In most cities, a call placed to 911 triggers an automatic series of responses involving an ambulance, a crew of paramedics and a rush to the ER, sirens blaring. But this response is often excessive—one in three 911 calls don’t require an ER visit. Yet few cities have a system in place to deal with cases like Wagar’s—non-emergencies that nonetheless necessitate a medical professional to be dispatched to the person’s home.

Continue reading and see pictures►

Kaiser Health News Source Articles | Comments Courtesy of Matt Zavadsky

Hospital and EMS-based Mobile Integrated Healthcare (MIH) partnerships to reduce readmissions continues to be one of the most popular programs. 

Effective partnerships have shown excellent reductions in preventable readmissions.

NOTE: At the end of this article, KHN provides links to download all the readmission penalties since 2015 for all hospitals, and a look up tool where you can look up hospital’s readmission penalties.  

An exceptional resource!

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New Round of Medicare Readmission Penalties Hits 2,583 Hospitals

Jordan Rau

October 1, 2019

 

 

Medicare cut payments to 2,583 hospitals Tuesday, continuing the Affordable Care Act’s eight-year campaign to financially pressure hospitals into reducing the number of patients who return for a second stay within a month.

The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today.

CONTINUE READING>

JEMS Source Article | Comments Courtesy of Matt Zavadsky

Interesting commentary from Dr. Bledsoe…

Many of us, when asked if there is a paramedic ‘shortage’ have difficulty answering the question.  The reason? By definition, to express a shortage of anything, we first need to know the answer to the question “How many do we need?”  Once we have the answer to that question, then we might be able to determine if there is a shortage.

Some systems have an overabundance of paramedics, while others struggle to recruit and retain paramedics.  So, you could say we have a paramedic mal-distribution?

Dr. Bledsoe asks the tough questions…

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The Paramedic Shortage — Opportunity or Crisis?

By Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P | 9.24.19

There has been a great deal discussion, of late, related to a shortage of paramedics in the United States. It is often debated, and there are deniers, as well as believers. However, the data are clear in that fewer people are entering EMS when compared to a decade or two ago. The reasons are debatable but include such things as poor pay, working conditions, schedules, work type, and cultural changes in younger individuals and their belief systems. Many lament this but it may actually be the opportunity needed to drive EMS to the next level.

At a most fundamental level, the term “shortage” refers to a state or condition where something needed cannot be attained in sufficient amounts. From a business standpoint, it is the difference between supply and demand. A shortage can be rectified by increasing the supply of the necessary product. It can also be rectified by decreasing demand for that product. This is the basis of this discussion.

Keep reading►

ModernHealthcare Source Article | Comments Courtesy of Matt Zavadsky

This is a little long, but very much worth perusal. For our EMS stakeholders, what things have you changed in your organization to make your care more ‘person’ centered, as contemplated in the EMS Agenda 2050?

Also, what role can transformed EMS agencies play in collaboration with other healthcare system stakeholders (hospitals, payers, physicians, home health agencies, etc.) in the march to ‘person centered care’? Supporting hospital in the home programs? Navigating 9-1-1 callers to dispositions other than a de facto transport to an ED (much like CMS’ ET3 model contemplates)?

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Patient-centered care becoming 'person-centered care'

JESSICA KIM COHEN

September 14, 2019

Health systems are broadening their definition of patient-centered care, sometimes extending the concept beyond clinical care by replacing the term “patient” with a seemingly more holistic “consumer” or “person.”

Patient-centered care, a term popularized by the Institute of Medicine in 2001, initially described an approach to care that allows patients to guide their own clinical decisions. Now its definition has expanded—health systems see it as encompassing not just clinical care, but also patient experience, including how encounters stack up to patients’ expectations from other consumer-facing industries and, subsequently, whether patients view their care as worth the expensive price tag.

But even as the term’s definition changes, health systems are in general agreement about the concept’s continued importance, according to Modern Healthcare’s most recent Power Panel survey of top healthcare CEOs. Nearly 70% of CEOs said they’ve made changes to the structure of their organization to be more patient-centered, and more than half have someone formally in charge of leading those efforts.

CONTINUE READING►

Axios source article | Comments courtesy of Matt Zavadsky

How air ambulances got so expensive

 

 

Air ambulances have become a lucrative business over the last few decades, at patients' expense, fueled by private equity and aided by the industry's relationships with providers, John Hopkins' Marty Makary writes in a new book out today.

 

Why it matters: The rise of the air ambulance industry has resulted in massive surprise medical bills and a spike in unnecessary use.

• Congress has included air ambulances in its effort to crack down on surprise medical bills, and the industry is fighting to avoid this regulation.

 

Background: Air ambulances used to be owned and operated by hospitals, which sometimes took financial losses on their helicopter programs.

• But that changed when investors saw a profit opportunity and began buying the ambulance services from hospitals. They then billed patients directly for rides.

 

By the numbers: Between 2007 and 2016, the average price charged by one air ambulance company for a transport rose from $13,000 to $50,000.

• With this kind of money on the table, the number of air ambulance companies rose by 1,000% between the 1980s and 2017.

 

People in rural areas are hit the hardest. While some of these transports are necessary and life-saving, many others could be avoided, Makary writes.

• Of the more than half a million ambulance flights a year, 80% aren't emergencies, but rather more like routine transfers.
• To grow their business, companies began paying paramedics, nurses and doctors to become advisers with "informal agreements" to promote the company to emergency personnel and other providers.

 

The other side: Air ambulances say that they have to charge higher rates to commercially insured patients to make up for lower government rates.

 

The bottom line: "The air ambulance industry has become big business in America," Makary writes.

 

• Go deeper: Air ambulances are expensive and most likely out of network

Order the book.

FierceHealthcare Source Article | Comments from Matt Zavadsky

The findings in the referenced study could be due to a myriad of reasons – Many EMS agencies have protocols that determine patient destinations – including patient preference.

Two seemingly most important quotes:

Although proximity is important, previous studies reveal that the capabilities of an ED are also significant when EMS or patients make decisions about which ED to visit. For example, patients with a history of using inpatient care at a specific hospital may prefer to be transported to their so-called "home ED."

The study also supports the idea that family or patient choice of ED may have a big impact on transport. Although data were not given specifically for ED destination by patient preferability, there was considerable overlap in the ED destination patterns of EMS transports and walk-ins (61.3% versus 52.9%), supporting this notion that patients have a choice in their destination hospital.

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White Medicare patients transported to closest ED more often than blacks, Hispanics

by Jacqueline Renfrow 

Sep 6, 2019

White Medicare patients are more likely to be transported to the closest emergency department (ED) than their black or Hispanic counterparts, according to a new study out of Boston University’s School of Medicine.

Researchers recently set out to discover whether black and Hispanic Medicare patients are likely to be transported by emergency medical services (EMS) to the same emergency departments as white Medicare patients living in the same area—and to the closest available ED, according to proper protocol.

KEEP READING>

New York Times Source Article | Comments by Matt Zavadsky

Nice article about North Carolina’s efforts.  Raleigh was one of the 1^st EMS systems in the country to deploy EMS-based Mobile Integrated Healthcare with outstanding results!

And, prior to joining BCBS of North Carolina, Dr. Conway was the CMO at CMMI – in meetings with Dr. Conway in that role, we was acutely aware of the impact EMS-based MIH programs were having in their communities – CMMI funded several MIH initiatives with Health Care Innovation Award grants.

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Inside North Carolina’s Big Effort to Transform Health Care

By Steve Lohr

Aug. 26, 2019

 

RALEIGH, N.C. — North Carolina seems like an unlikely laboratory for health care reform. It refused to expand Medicaid coverage under the Affordable Care Act, and ranks in the bottom third among states in measures of overall health.

But the state has embarked on one of the country’s most ambitious efforts to transform how health care is defined and paid for.

North Carolina is in the early stages of turning away from the traditional fee-for-service model, in which doctors and hospitals are paid for each office visit, test or operation. Instead, providers will often be paid based on health outcomes like controlling diabetes patients’ blood sugar or heart patients’ cholesterol. The better the providers do, the more they can earn. If they perform poorly, money could eventually come out of their pocket.

The goal is to keep people healthy and out of the hospital and to save money on health care spending.

Continue Reading>

A very innovative proposal by Wyoming!  There are several Public Utility Model (PUM) EMS systems that have stood the test of time by continually proving value.  These systems provide exceptional clinical outcomes, excellent operational effectiveness and unparalleled economic efficiency. 

PUM systems are set up under the premise that the fixed cost of providing EMS (capital, readiness, etc.) are best managed by empowering a governmental authority with the responsibility to provide all services – thus assuring consistency of clinical oversight and QA, maximizing operational synergy and distributing the infrastructure cost over all ambulance calls in the service area.

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Wyoming's air ambulance coverage pitch

Wyoming has come up with a unique way to make air ambulances — a common source of huge surprise medical bills — more affordable, according to the Georgetown University Health Policy Institute's blog.

The big picture: The state is essentially proposing to turn air ambulances into a public utility.

• Wyoming's health department has put together a Medicaid waiver that would make all residents, regardless of their income, eligible for Medicaid coverage of air ambulance services.
• Providers would submit bids to serve as the only air ambulance operator within a particular geographic region.
• The state would make flat payments to the operator that wins the bid, rather than paying them for each ambulance ride.
• Patients' cost-sharing would vary based on their income, and insurers would pay into the program rather than covering air ambulances themselves.

What we're watching: To go into effect, the proposal first has to be approved by CMS. State lawmakers would then have to make the necessary policy changes.

Yes, but: The blog's author, Sabrina Corlette, correctly warns that "both federal officials and state lawmakers will likely be lobbied extensively by the air ambulance industry, which has a vested interest in maintaining the status quo."

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Will it Fly? Wyoming Attempts End Run Around High Air Ambulance Prices

August 21, 2019 

by Sabrina Corlette

http://chirblog.org/will-it-fly-wy-end-run-air-ambulance/

As we’ve written before in this space, air ambulance charges are a growing source of surprise medical bills for consumers, and the charges can be eye-popping – five figures or more. Unfortunately, state-level efforts to limit balance billing by air ambulance companies have thus far been stymied by the Airline Deregulation Act (ADA) of 1978, which prevents states from enacting laws regulating the prices of any air carrier, including air ambulance. In 2018, the U.S. Congress considered legislation that would have given state officials the ability to regulate the more egregious billing practices of air ambulance providers, but congressional leaders ultimately bowed to pressure from the industry. The enacted bill authorized a Department of Transportation advisory committee to study the issue, the ultimate “kick the can” solution to the problem.

This year, although Congress is debating several bills to protect patients from surprise medical charges, only one – sponsored by Senators Lamar Alexander and Patty Murray – would extend those protections to patients needing emergency air transport. Meanwhile, air ambulance bills are only getting higher (for example, air ambulance charges in New Mexico have risen 300 percent since 2006) and more air ambulance providers are choosing not to participate in health plan networks, making it easier for them to sock patients directly with their high charges.

Some states have tried to protect consumers, but the scope of these efforts are curtailed by federal law. For example, Texas and North Dakota laws to limit air ambulance balance billing were ruled as preempted by the ADA in two federal district courts. Another federal law – the Employee Income Security Act (ERISA) – preempts states from regulating self-funded employer plans, including any imposition of a requirement that these plans include air ambulances in their networks or hold enrollees harmless for out-of-network charges.

Wyoming may have hit on a unique solution. The state is proposing to turn air ambulances effectively into a public utility.

Wyoming’s Plan

The Wyoming Department of Health has developed an 1115 Medicaid waiver application that would make all Wyoming residents, regardless of income, eligible for Medicaid for air ambulance services only. Under the plan, the state would:

• Set the basic parameters of air ambulance coverage under the Medicaid program.
• Solicit competitive bids from air ambulance providers to serve as the sole provider within a prescribed geographic area within the state.
• Create a centralized call center that would direct all calls for air ambulance services to the approved providers.
• Make regular flat payments to these providers (instead of reimbursing on a fee-for-service basis).
• Set patient cost-sharing on a sliding scale, based on income.
• Recoup costs for operating the program from private insurers, employer plans, and individuals already paying for transports.

In its pitch to state lawmakers and stakeholders, the Department of Health argues that the air ambulance industry is an example of market failure, noting that most patients cannot “shop around” for air ambulance services. Even in situations when the patient is conscious or in serious medical distress, the cost is not transparent because of differences in network arrangements and cost-sharing among plans. Officials further note that the supply of air ambulances has risen dramatically in the past five years, and these providers have very high fixed costs that they must recoup, largely from private payers and patients. Indeed, in 2018, Wyoming employers paid an average of $36,000 per flight. The Department argues that, as with other critical commodities with high fixed costs such as water and electricity, a regulated monopoly is a more efficient way to deliver the needed services.

Questions and Next Steps

There remain a number of hurdles before Wyoming’s unique plan can take effect. First, the federal government would have to approve the waiver proposal. The Wyoming legislature would then have to enact state-level legislative changes to authorize the program. Both federal officials and state lawmakers will likely be lobbied extensively by the air ambulance industry, which has a vested interest in maintaining the status quo. Also, although the state argues that the Medicaid program should not be preempted under the Airline Deregulation Act, that premise has not yet been tested in court. Other questions include whether self-funded employer plans, which are not subject to state regulation, will opt-in to the state program, enabling it to be budget neutral.

Wyoming has posted its waiver application and invited public comment. It expects to submit the proposal to federal authorities by September 1, 2019, with another public comment period expected later in the year.

The latest report from the Healthforce Center and Philip R. Lee Institute for Health Policy Studies at UC San Francisco. 

The full report can be downloaded at the link below, but we’ve included some outcome highlights, specifically because many of you are evaluating the initiation of similar programs, and one, the Alternate Destination – Urgent Care project seems to be similar to one of the interventions included in the CMMI ET3 model.  The experience and findings in the CA model may help potential ET3 participants refine their programs.

https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/UpdateEvaluationCACommunityParamedicine.pdf

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Evaluation of California’s Community Paramedicine Pilot Program

Author(s): Janet M. Coffman, Cynthia Wides, Lisel Blash,Ginachukwu Amah, Igor Geyn and Matthew Niedzwiecki

Date: August 6, 2019

Community paramedicine, also known as mobile integrated health, is an innovative model of care that is being implemented throughout the United States. The California Emergency Medical Services Authority has sponsored a pilot project under which specially trained paramedics perform duties beyond their traditional roles of responding to 911 calls, transporting patients to emergency departments and performing inter-facility transfers. Healthforce Center at UCSF is conducting an evaluation of the pilot project that was funded by the California Health Care Foundation.

The evaluation found that community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals and social workers to fill gaps in the health and social services safety net. The evaluation has yielded consistent findings for six of the seven community paramedicine concepts tested. All of the post-discharge, frequent 911 users, tuberculosis, hospice, and alternate destination – mental health projects have been in operation for at least two and one half years and have improved patients’ well-being. In most cases, they have yielded savings for payers and other parts of the health care system. Findings regarding outcomes of a project testing the sixth concept, alternate destination – sobering center, suggest that this project is also benefitting patients and the health care system over the course of its first 14 months. The seventh concept, alternate destination – urgent care, shows potential but further research involving a larger volume of patients is needed to draw definitive conclusions.

Conclusion

The community paramedicine pilot projects have demonstrated that specially trained paramedics can provide services beyond their traditional and current statutory scope of practice in California. No adverse outcome is attributable to any of these pilot projects. The projects are enhancing patients’ well-being by improving the coordination of medical, behavioral health, and social services, and reducing ambulance transports, ED visits, and hospital readmissions. The majority of potential savings associated with these pilot projects accrued to Medicare and Medi-Cal and hospitals that care for Medicare and Medi-Cal beneficiaries because Medicare and Medi-Cal beneficiaries accounted for the largest share of persons enrolled in the pilot projects.

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Alternate Destination – Mental Health

·       The three Alternate Destination – Mental Health projects enrolled 2,045 persons between September 2015 and March 2019.

·       The City of Los Angeles launched an Alternate Destination – Mental Health project in late June 2019 and will be included in subsequent updates to this report.

·       Across the three Alternate Destination – Mental Health projects, 28% to 45% of patients screened were transported to the mental health crisis center rather than an ED. In Stanislaus County, an additional 27% could have been transported to the crisis center if the county had more inpatient psychiatric beds or if the crisis center accepted people with private insurance or Medicare.

·       Transport of these patients directly to a mental health crisis center has reduced the number of persons in EDs who need only mental health services, which can help reduce ED overcrowding.

·       Only 2% of patients enrolled in the three Alternate Destination – Mental Health projects (n = 47) were transferred from the mental health crisis center to an ED within six hours of admission. None of the transfers involved a life-threatening condition, and only four of the patients transferred to an ED were admitted for inpatient medical care.

·       In addition to responding to 911 calls regarding mental health emergencies, the community paramedics in Stanislaus County screen “walk-in” clients, who come to the mental health crisis center on their own or who are brought by friends or family, to determine whether they have any medical conditions that might necessitate transport to an ED instead of direct admission to the crisis center.

·       Law enforcement officers in Stanislaus County report that having community paramedics available enhances their ability to respond effectively to persons with mental illness.

·       The three Alternate Destination – Mental Health projects avoided potential costs of $2.2 million by reducing the number of 911 calls that resulted in an ED visit and subsequent transport of a patient from an ED to an inpatient psychiatric facility.

Alternate Destination – Urgent Care

·       The three Alternate Destination – Urgent Care projects enrolled 48 persons from September 2015 through November 2017.

·       One of the Alternate Destination – Urgent Care projects closed in May 2017, and the other two projects closed in November 2017.

·       Enrollment in the Alternate Destination – Urgent Care projects was substantially lower than anticipated because fewer 911 calls than expected met the strict inclusion criteria and many calls for eligible patients occurred at times of the day during which urgent care centers were closed. In addition, clinicians at urgent care centers were reluctant to treat some conditions, such as a dislocated shoulder, that could be treated safety and effectively in that setting.

·       Most patients enrolled had a laceration or an isolated closed extremity injury.

·       During the time period in which the Alternate Destination – Urgent Care projects enrolled patients, two patients (4%) were transferred from an urgent care center to an ED within six hours of arrival at the urgent care center. Nine patients (19%) were transported to an urgent care center and then rerouted to an ED because clinicians at the urgent care center declined to treat the patient.

Alternate Destination – Sobering Center

·       San Francisco’s Alternate Destination – Sobering Center project enrolled 1,627 persons from February 2017 through March 2019. Two hundred and thirty-three patients (14%) were treated at the sobering center more than once.

·       97.9% of patients enrolled in the Alternate Destination – Sobering Center project were treated safely and effectively at the sobering center. Only 34 patients (2%) were transferred to an ED within six hours of admission to the sobering center, and only two (0.1%) were rerouted from the sobering center to an ED because registered nurses at the sobering center declined to accept them. Only two patients were admitted to a hospital for inpatient medical care.

·       Community paramedics participating in the project provide feedback to paramedics on 911 crews on how to screen acutely intoxicated persons to determine if they are candidates for transfer to the sobering center. They are also collaborating with homeless outreach workers to encourage people who use the sobering center frequently to seek treatment for chronic alcoholism, housing, and other services.

·       San Francisco’s Alternate Destination – Sobering Center project avoided potential costs of $551,257 by replacing ED visits with sobering center services. The majority of potential savings accrued to Medi-Cal because the majority of patients enrolled in the project are Medi-Cal beneficiaries.

·       The Santa Clara County EMS Agency and the Gilroy Fire Department launched a new Alternate Destination – Sobering Center project in June 2018, but the project had not enrolled any patients as of March 2019.

·       The City of Los Angeles launched an Alternate Destination – Mental Health project in late June 2019 and will be included in subsequent updates to this report.