News & Updates

Say the word “paramedic” and most people think of the men and women who respond with flashing lights and screaming sirens when someone suffers a medical crisis.

But what if there were a way to provide help before the crisis happens?

Across the country, health care companies are implementing a new strategy to deliver help to the people who need it most, and in some cases prevent needless and costly trips to the emergency room. And it’s paramedics who are providing the help – without the drama of a speeding ambulance.

They are part of the emerging national trend called community paramedicine – an effort where licensed paramedics meet and treat the chronically ill where they live. In many instances they travel just about whenever and wherever needed, from the inner city to rural sprawl, from emergency rooms to homeless shelters.

A New Twist to an Old Tale
It’s a wrinkle in the customary role of paramedics rushing patients to the emergency room. This new model focuses instead on paramedics talking one-on-one with habitual ER users – those who often use costly ER services when a primary care doctor could handle their issue. The paramedics teach these new patients to address their health issues so they don’t require hospitalization and help those who have trouble managing chronic conditions.

In New Mexico the story began in 2014 when the state expanded Medicaid coverage. Suddenly, more than 130,000 adults were eligible for insurance. Some of the new recipients didn’t even have a primary care doctor. In January 2016, Blue Cross and Blue Shield of New Mexico (BCBSNM) began offering health insurance options to those who were eligible. Of the roughly 40,000 who enrolled with the insurer, 400 were flagged as habitually using the ER as their primary care provider.

“We saw people using the ER if not weekly, then up to two to three times a week, up to 27 or more times a month,” said Kerry Clear, who manages the insurer’s community social services program. “When we launched our program, we had 15 high-ER users during a six-month period who accounted for about 686 ER visits alone. Using the ER as a primary care doctor is very expensive.”

Providing a Solution
Realizing that prevention and education are critical to reversing costly, inappropriate ER usage and hospital readmission, the team at BCBSNM had a hunch. In a pilot program, it contracted with two state-based emergency medical service companies to assign a paramedic to each of the 15 members. It was one of New Mexico’s first ventures into community paramedicine, and it was a perfect match. Since they had frequently relied on paramedics to get to the hospital, these members trusted their new medical guardians.

Paramedics visited each of the 15 high-usage members at home for about 90 minutes. They discussed their patient’s medication needs, suggested home-health safety improvements, explained available assistance and checked their vital signs. They even helped find in-network doctors for members who didn’t have one.

The clients saw paramedics as healers rather than paper pushers, Clear said. The results were impressive. We were able to reduce ER visits for all 15 members from 686 visits to an average of 115 visits per month within the first couple of months.

The pilot project’s success prompted BCBSNM to extend community paramedicine outreach to other Medicaid insured who need it the most.

A New Chapter
Ranked in 2015 as the nation’s 37th overall least-healthy state, New Mexico represents a health care challenge. Aside from the obstacles to care created by poverty and other socioeconomic factors, the state faces steep rates of hospital admissions for chronic health issues. These issues include everything from diabetes and heart failure to chronic obstructive pulmonary disease, hypertension and more.

The predominantly rural state also has a shortage of primary care doctors. Recently, it averaged about one doctor for every 1,310 residents statewide. But some counties struggle with a ratio of just one for every 15,700 residents. No matter where they live – city or country – many Medicaid recipients face the isolation of time, distance and poverty when it comes to health care.

To serve its Medicaid members, BCBSNM has contracted with three ambulance companies – Albuquerque Ambulance, American Medical Response and Rio Rancho Fire Department. Currently 18 full- and part-time paramedics serve Medicaid recipients in areas most in need: Bernalillo County, which includes Albuquerque and the nearby East Mountains; parts of Sandoval County, which includes Rio Rancho, Corrales and Bernalillo; Valencia County to the southwest; and Doña Ana and Otero counties to the south, home to Las Cruces and Alamogordo. Their combined territories encompass more than 14,000 square miles – an area larger than Connecticut, Delaware and Rhode Island, combined – with about 5,000 square miles to spare.

According to a 2016 survey, the National Association of Emergency Medical Technicians found that 210-plus agencies in 40 states have created community paramedicine programs. More than 80 percent of the programs in effect two years or longer reported success in reducing costs, 911 use and ER visits, the survey found.

BCBSNM has seen similar success. Since January, contracted paramedics have visited more than 1,100 high-ER users and Medicaid recipients recently discharged from the hospital. Of those visited, repeat visits to the ER have dropped 61 percent while hospital readmission rates have dropped to where just 9.7 percent of the members are readmitted The company is hoping soon to expand community paramedicine to San Juan County and the cities of Santa Fe and Taos.

Riding into the Sunset
“As paramedics, we see people from all walks of life,” said Amy Kettleson, a paramedic with Albuquerque Ambulance.
“We’ve been asked by clients to meet at fast food restaurants because they live out of their car and that’s a convenient location for them. A lot of the people we meet have been in a difficult situation for a while. We are happy to meet with them where they prefer and to just talk.”

It’s not uncommon for paramedics to visit Albuquerque’s three homeless shelters. In fact, it can take a bit of sleuthing to track hard-to-reach members. Kettleson said a member repeatedly agreed by phone to meet but then always canceled the visit beforehand. Finally, Kettleson showed up at his home unexpectedly, introduced herself and he agreed to discuss his health. “He was so thankful afterward,” she said.

“If there is a common thread among the high-ER users we’ve seen, it’s that they are struggling with alcoholism or drug abuse and sometimes homelessness,” said paramedic Shelley Kleinfeld of American Medical Response. “The youngest I’ve seen is a 6-month-old and the oldest an 80-year-old. Just about everyone we meet to discuss their health and their options are thankful. They like the reassurance that someone cares and drops in on them to see how they are doing.”

Patients who visit freestanding emergency rooms in Texas should now have a better idea of whether their health insurance will cover the bill.

A new state law that took effect Sept. 1 requires the facilities — which resemble urgent care clinics but often charge hospital emergency room prices — to post notice of what, if any, insurance networks they’re in.

The new law is about “protecting consumers,” said Jamie Dudensing, chief executive officer of the Texas Association of Health Plans. Meant to prevent patients from surprising — and often debilitating — medical bills, freestanding ERs can comply with the new rules by posting the insurance information on their websites, as long as written confirmation is also provided to patients.

“We take educating patients very seriously,” said Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers, which represents such facilities in Texas.

In 2009, Texas became the first state to permit freestanding ERs, facilities independent of hospitals that provide acute care around the clock — and frequently aren’t in insurance networks. They have spread quickly across the state, profiting, their critics argue, by charging up to ten times more than urgent care centers to treat ailments like a fever or sore throat. These prices have blindsided unsuspecting consumers who realize too late that they were treated by an out-of-network provider.

Christopher Spector was startled to receive a $1,100 bill after visiting a freestanding ER in North Richland Hills for an eye injury. In a letter he wrote to contest the charge, Spector says he went to the facility after being hit in the right eye with a tennis ball and, after a series of tests, was told to see a nearby ophthalmologist for further treatment. He doesn’t remember asking if the freestanding ER was in or out of his health insurance network.

“For doing essentially nothing but giving me the name of an ophthalmologist,” he wrote in the letter, “First Choice billed my insurance (United Healthcare) an outrageous amount of $6,111. UH paid $4,400.10 (which is still a ludicrous amount) but First Choice isn’t satisfied. They say I’m responsible for $1,100.03 of the remaining amount.”

He called the charges “unreasonable, uncustomary and even predatory,” and described how the ophthalmology center he visited the next day provided him more comprehensive care at a fraction of the price.

“I wasn’t surprised to receive a bill,” he said, but freestanding ERs need to be more upfront about what care they provide and at what cost.

The new law aims to clarify a process all sides agree can be confusing.

State Rep. Tom Oliverson, R-Cypress, who authored the legislation, said it prevents Texans from being deceived. For the “90 percent of freestanding ERs that aren’t in the business of intentionally misleading people,” he said, “if it helps patients be less confused, they’re good with it.”

Shields said his group supported the bill through the legislative process. Most facilities are good actors, he said, that strive to inform consumers about what their insurance plan covers. The websites of some freestanding ERs in Texas, for example, advise that the facility may not be in-network and may charge rates comparable to a hospital ER. Some even suggest patients visit an urgent care clinic instead.

Shields said the benefit of freestanding ERs is that they provide more timely and convenient access to medical care. “Waiting in the hospital waiting room for five hours,” he says, “that doesn’t have to be the norm.”

The new law was one of several bills filed during the 85th Texas legislative session that took aim at freestanding ERs. Another that passed, authored by state Sen. Kelly Hancock, R-North Richland Hills, allows more patients to use a mediation system to dispute surprise medical bills, including those incurred at freestanding ERs.

Together, Dudensing said, the new laws provide better protection for consumers, who will have more information before making decisions about their treatment.

“We’re not trying to disrupt any business model,” she said.

Some of the hospital industry’s most active investing these days is happening outside the hospital.

Giant U.S. hospital operators, including Tenet Healthcare Corp., Dignity Health and HCA Healthcare Inc., are investing heavily in surgery centers, emergency rooms and urgent care clinics located outside hospitals, chasing after patients who increasingly want cheaper and more convenient care.

Insurers and employers that pay for health care are helping drive the change as they shift more Americans to high-deductible insurance plans, which require patients to pay more of their medical bills before insurance kicks in. That has pushed more patients to seek lower-cost options, says RBC Capital Markets managing director Frank Morgan, a hospital analyst.

Hospital demand slumped during the last recession, a trend that has continued even as the economy recovers, American Hospital Association data through 2014 show. Admissions growth at HCA hospitals has slowed in recent quarters to 1% to 2%, as a boost from the Affordable Care Act faded, while Tenet’s admissions have been flat or down 1% to 3% most quarters since late 2015.

In an effort to strengthen their hold on their markets and prevent rivals from siphoning off patients, hospitals are investing outside their own walls. They are “following the patient,” Mr. Morgan said.

The strategy also places hospital satellites closer to where patients live and work, which executives say they hope will win over new, loyal customers.

In July, Ashley Hammack rushed to a new free-standing ER in Spring Hill, Tenn., after growing weak from vomiting. The facility, a satellite of TriStar Centennial Medical Center, is a 10 minute drive from her home, about 20 minutes closer than the hospital where she delivered her daughter five months before.

Doctors saw her quickly. “I never even sat down,” Ms. Hammack recalled. She was treated for severe dehydration from what doctors suspected was food poisoning and sent home with medication.

Trevor Fetter, Tenet’s outgoing chief executive, says company executives have pursued rapid outpatient expansion partially out of necessity. Slumping admissions contributed to Tenet and HCA lowering their earnings estimates for 2017, which in turn hit stock prices.

It’s unclear how the shift to out-of-hospital care will affect long-term earnings. Non-hospital operations typically generate lower revenue than hospitals but produce higher profit and require less capital to build and run.
But “it’s happening anyway,” Mr. Fetter said. “Somebody else is going to do it to us if we don’t do it ourselves.”

Prices for common surgical care can be sharply lower outside of hospitals, which generally have higher overhead related to round-the-clock operations and the technology and specialists needed to treat more complex cases.

Cataract surgery and knee arthroscopy prices at ambulatory surgery centers were $5,000 to $2,500 less than at hospitals for employees and retirees with health insurance provided by the California Public Employees’ Retirement System, according to researchers at the University of California, Berkeley. Calpers changed its benefits five years ago to nudge patients toward the cheaper ambulatory option, a spokesman said, and will expand its plan to include a dozen more surgeries starting in January.

Tenet Healthcare, which operates 77 hospitals, is expected to spend up to $1.9 billion through 2020 to complete the buyout of private-equity-backed United Surgical Partners International, an operator of ambulatory surgery centers. The company acquired slightly more than half of USPI in 2015 and agreed to buy the rest over five years. Tenet said it would spend an additional $100 million to $150 million annually on other free-standing surgery centers, emergency rooms and satellite locations.

Business from outside hospitals accounted for 28% of Tenet’s earnings before interest, taxes, depreciation and amortization as of August, up from 5% in 2014. That business could be spun off or sold under pressure from an activist investor that is Tenet’s largest institutional shareholder, according to analysts.

Dignity Health, a nonprofit based in San Francisco, owns hospitals in three states. After a string of joint ventures and a 2012 acquisition, it also now operates more than 280 free-standing emergency rooms, urgent care and workplace clinics and so-called microhospitals, which have emergency rooms, fewer beds and more limited technology.

Peggy Sanborn, vice president of strategic growth, mergers and acquisitions for Dignity Health, said joint-replacement surgery outside a hospital seemed impossible a decade ago. Now, aided by technology that has improved implants and made procedures less invasive, Dignity Health is able to replace hips and knees outside the hospital in limited cases, she said. Patients who receive the outpatient procedures are relatively healthy and at low risk for complications.

HCA, the largest publicly traded U.S. hospital company with 172 hospitals, says it will operate 120 free-standing urgent care centers by the end of the year, an increase of 40% from two years ago. The Nashville-based firm has doubled the number of free-standing emergency rooms it operates since 2015 to 64, and expects to increase that number to 80 by early next year.

HCA plans to spend $3 billion on expansion this year, including on new satellite locations, according to Chairman and Chief Executive Milton Johnson.

Some hospital executives tout outpatient growth as a strategy to win market share for hospitals. Patients who seek care at a neighborhood retail clinic may choose a hospital owned by the same company, they say. Employers and insurance companies may also prefer hospital operators with an expansive outpatient network.

HCA’s hospital market share in Nashville grew to 35% from about 32% over the past five years as the company added three ambulatory surgery centers, four free-standing emergency rooms and 10 urgent care centers to the market. HCA also invested in its hospitals during that period.

Patients’ drift away from hospitals has focused executives’ attention on what hospitals should look like in the future.
Tenet is studying which services “over the next 10 to 20 years will stay in the hospital,” Eric Evans, president of hospital operations for Tenet, told analysts on a conference call last month. For now, that includes trauma care and neurosurgery.

“Technology continues to open the door for more things to be done on an outpatient basis,” Mr. Evans said. “Our goal is, as technology moves, is to be location-agnostic.”

Key Points
Question: Does ground emergency medical services transport confer a survival advantage vs. private vehicle transport for patients with penetrating injuries?

Findings: In this cohort study of 103,029 patients included in the National Trauma Data Bank, individuals transported by private vehicle were significantly less likely to die than similarly injured patients transported by ground emergency medical services, even when controlling for injury severity.

Meaning: Ground emergency medical services transport is not associated with improved survival compared with private vehicle transport among patients with penetrating injuries in urban trauma systems, suggesting pre-hospital trauma care may have a limited role in this subset of patients.

Abstract
Importance: Time to definitive care following injury is important to the outcomes of trauma patients. Pre-hospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in pre-hospital care policies across trauma systems, potentially affecting patient outcomes.

Objective: To evaluate whether private vehicle pre-hospital transport confers a survival advantage vs. ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems.

Design, Setting, and Participants: Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle.

Main Outcome and Measure In-hospital mortality.

Results: Of the 2,329,446 records assessed for eligibility, 103,029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR, 0.45; 95% CI, 0.36-0.56) and stab wound (OR, 0.32; 95% CI, 0.20-0.52) subgroups.

Conclusions and Relevance: Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

The CMS issued a “request for information” Wednesday from providers and patient advocacy groups on new ideas to bring to the Center for Medicare and Medicaid Innovation responsible for creating new payment models.

The notice came after CMS Administrator Seema Verma wrote in a Wall Street Journal op-ed Tuesday evening that the Innovation Center’s old policies led to consolidation that has been widely blamed for growing overall healthcare costs. She also said the policies burdened providers.

“Providers need the freedom to design and offer new approaches to delivering care. Our goal is to increase flexibility by providing more waivers from current requirements,” she wrote.

The CMS is asking for feedback on ways to promote competition in the market; enhance provider choice; encourage patient feedback and improve price transparency.

Verma’s op-ed and the CMS’ request for information likely eases concerns from some in the industry that the new administration was taking a step away from value-based care, said Gail Wilensky, who led CMS during the George H. Bush’s tenure and is now a senior fellow at not-for-profit Project HOPE.

The decision by the CMS this summer to make some previously mandatory bundled payments for replacing knees and hips, voluntary, likely spurred some of that concern. The agency also eliminated the expansion of bundled payments for heart attacks, bypass surgery, hip and femur fractures, and cardiac rehabilitation.

“Seema Verma has made it clear she recognizes the importance of moving away from a fee-for-service model to more value-based care,” Wilensky said.

The CMS notice did say it will focus on voluntary models instead of mandatory ones. Ways to “reduce burdensome requirements and unnecessary regulations” for physicians will be a focus too, the agency said.

HHS Secretary Tom Price, a former surgeon and member of Congress who is now Verma’s boss, has long criticized the mandatory nature of some of the payment models that came out of the Innovation Center.

“I think this (voluntary models) will be a welcome change for providers,” said Clay Richards, CEO of naviHealth, a healthcare consultant company part of Cardinal Health. “You’re letting the market work through what the innovation looks like with providers. Most people would find that as a positive.”

But other policy experts argue that without mandatory requirements providers might not have an incentive to choose alternative models and stick with more lucrative fee-for-service reimbursement.

David Muhlestein, chief research officer at Leavitt Partners, said making models voluntary when they are still experiments should not concern providers since they will always be interested in trying new ways to deliver care. But he said its concerning that the CMS has made no comment about how it will act if models are shown to be successful. The CMS will likely need to make successful models mandatory at some point in order to ensure widespread adoption, he said.

“There will be providers who are worried about new models and want to continue with fee-for-service,” Muhlestein said. Because of this, the CMS will likely have to make successful models mandatory.

A recent JAMA Internal Medicine study found that value-based payment models like accountable care organizations and bundled payment models netted $32 million in savings in 2015 among nearly 3,000 hospitals.

The CMS also said it’s looking for ways to promote price and quality transparency for consumers. The agency said it may release cost data and quality metrics publicly to encourage patients to shop for their care. One suggestion the CMS gave was to encourage beneficiaries to participate in arrangements that would allow them to reap savings if they shop for care and choose the lower-cost option.

Muhlestein said if the CMS makes an effort to promote price shopping among Medicare and Medicaid beneficiaries, it will motivate providers to think more critically about their prices compared to their competitors.

“When you get the consumers engaged on prices, you expand what providers are competing for, and today they don’t compete on price,” he said.

Suggestions on ways to reform Medicaid delivery and payment also were mentioned in the CMS request. The experiments from the Innovation Center have often focused on Medicare. Muhlestein said that was inevitable given Verma’s history drafting conservative state Medicaid programs with cost sharing and work requirements.

“We spend a lot of money as a country on the Medicaid program, and there is room for improvement,” Muhlestein said. “Administrator Verma is a great person to work on that because that is where she cut her teeth.”

The emphasis on stakeholders input is also unique, Wilensky said. Providers have notoriously complained that the Obama administration didn’t illicit enough provider insight on innovations.

“Whether or not there will be a lot of responses and how interesting they will be is another matter,” she added.

In a statement, the American Hospital Association said the group, “will continue to work with Secretary Price, Administrator Verma, and others at HHS to give hospitals the opportunities, flexibility, and predictability they need to improve care coordination and efficiency and deliver better value for their patients and communities.”

The CMS is looking for ideas through Nov. 20.

Robert Coward, a long-time company executive picked in December to lead the integration of Envision’s physician-staffing business with merger-partner Amsurg’s staffing division, is leaving to pursue other opportunities.

Envision had not signaled specific problems with the business during several recent earnings calls and analyst conference presentations, said Richard Close, analyst with Cannacord Genuity.

Additionally, Envision did not affirm earnings guidance that was lowered after the first quarter in the face of softening of hospital volumes, Close said.

That only adds to investor uncertainty about what might be behind Coward’s departure, he said.

“Bottom line, we view the news as concerning,” said Mizuho Securities analyst Ann Hynes in a note to investors Tuesday.

Envision’s shares were down about 9% at 3 p.m. Eastern time Tuesday after announcing Monday the departure of Coward and retirement of Chief Financial Officer Claire Gulmi.

An Envision spokesman did not return requests for comment.

But Envision’s statement released Monday said Coward’s decision was “not the result of a disagreement with the company on any matter relating to the Company’s operation, policies or practices.”

Coward will remain on board for two months to help with the transition.

At a Baird healthcare conference this month, Envision CEO Chris Holden said the integration between merger partners Envision and Amsurg is proceeding on schedule.

Envision merged with Nashville-based Amsurg in December to create the nation’s largest physician-staffing company with annual revenue of about $8.5 billion.

Since then, Envision has agreed to divest its ambulance business to a subsidiary of KKR to focus on its physician-staffing and its other major business line, ambulatory surgery centers.

Holden reiterated to Baird analysts that he believed physician staffing revenue would grow organically by 3% to 5% annually, with new contracts chipping in 1% to 3% of that growth.

Envision contracts with hospitals to provide physician staffing in emergency rooms and provide hospitalists, anesthesiologists and radiologists to hospitals and post-acute facilities.

Holden told Baird that Envision generates about 3.5% of its revenue in Houston, where hospitals were affected by Hurricane Harvey. About 30% of the company’s revenue is in Florida, which was awaiting the arrival of Hurricane Irma as Holden spoke at the conference.

Holden said Envision, like the entire industry, has seen some softening in emergency room visits over the past few quarters. But he said it was too early to say whether that’s a long-term trend or something cyclical.

Close said declining healthcare stock prices overall show investors are responding to that trend.

Add to that the revived efforts to replace Obamacare, and Envision’s management changes are magnified, Close said.

He added that new blood could build a strong bench at Envision. But the uncertainty generally is not good for investors looking for signs of future growth.

“Is it foreshadowing something?” Close asked.

The green light bulb glows over Kari Dawson’s desk, signaling she’s ready to take a call.

Dawson is a new addition to the Las Vegas Fire Department communications center, but her role is different from the rest of the call-takers whose voices fill the room.

“Las Vegas Fire and Rescue, this is Kari, I’m a registered nurse,” she says into her headset, pausing to listen to the man on the other end of the line. “I’m going to ask you some questions to make sure we get you the right kind of help.”

Dawson is one of eight registered nurses staffing the new nurse call line in Las Vegas, where some of the less severe medical calls are being sent. The pilot program kicked off last month.

A software program walks the nurse on duty through a protocol with a caller, prompting new questions based on the sick or injured person’s answers.

Dawson’s other two computer screens show the status of all the active 911 calls at the center, and the ride-sharing service Lyft’s website.

In cases in which patients need medical care but not necessarily an ambulance, the nurses can order a 21st-century alternative — a Lyft to pick the patients up and take them to a hospital or an urgent care facility.

Many of the people whose calls are sent to the nurse call line don’t have a primary care physician and might not be aware of the other options available in less acute medical situations, aside from taking an ambulance to the hospital, Dawson said.

The program means ambulances can be used less in cases where they’re not needed, Las Vegas Fire Department Assistant Fire Chief Sarah McCrea said.

Over-the-phone treatment
The nurse will urge the patient to seek care immediately, in four hours, 12 hours, one to three days or at home.

“We use our knowledge of how to treat these things in the ER,” said Dawson, who also works as a pediatric emergency room nurse at Sunrise Hospital and Medical Center. “I can’t see what it looks like. If you walk into the ER, I can tell that’s definitely broken, it looks broken, it’s not broken. You have to rely on what they’re telling you.”

Hoping for a year
One nurse is on duty from 9 a.m. to 6 p.m. daily. The number of calls sent to the nurse line vary, but Dawson estimates they get an average of five or six a day.

There’s $300,000 in the Las Vegas Fire Department’s regular budget to operate the pilot program, including training and pay for the nurses, who work one day a week, McCrea said.

The program is expected to run for about a year, or until that money dries up. During that time, department officials will evaluate data to determine whether it’s meeting the goals — curbing unnecessary ambulance dispatches and hospital trips, McCrea said.

It would take Las Vegas City Council approval to make the program and its staffing permanent.

The communications center is increasingly busy, taking roughly 600,000 calls per year. About 400,000 of those are medical calls, characterized in declining order of severity as echo, delta, charlie, bravo, alpha and omega. The alphas and omegas are the calls that can be transferred to the nurse call line, McCrea said.

Certain thresholds are in place: Callers complaining of chest pain won’t be sent to the nurse call line. Callers with minor injuries might not be sent over if they have potentially more serious risk factors. And if the caller insists on an ambulance or is uncomfortable with a Lyft, the nurse on duty won’t try to deter them from an ambulance, Dawson said.

The nurses take calls only within the city of Las Vegas jurisdiction now. But because the program is new, some of the kinks are still being worked out. A Clark County call slips through to Dawson’s line. In the meantime, an ambulance was dispatched to the man.

“This is a labor of love right now,” McCrea said.

Checking in with callers
The nurses make follow-up calls the next day for anyone they don’t send an ambulance to. During a follow-up call on Tuesday, Dawson asked the patient if he had gotten any medical attention the day before, after he called 911.
He hadn’t yet, but said he planned to later that day. Dawson put another alert in the system, so the nurse working the next day would call to see if he sought medical care.

The software program also creates patient records, so if someone calls a second time, their medical information and last call record can be accessed.

The Regional Emergency Medical Services Authority in Washoe County allows residents to call its nurse health line directly. Las Vegas Fire Department Chief Willie McDonald envisions giving Las Vegas residents a direct line they can call to speak to a nurse in the future, if the call line here becomes permanent, he said.

“I think it’s a really innovative service, that’s also a better use of resources,” McDonald said.

Mount Sinai Health System’s St. Luke’s Hospital has been looking for a way to decrease readmissions among its recently discharged heart failure Medicaid patients.

The hospital’s 30-day readmission rate of 20% to 25% among such patients was comparable to national statistics within national averages. But a growing Medicaid patient population in New York’s Harlem neighborhood coupled with a systemwide push to incorporate more population health strategies within its clinical settings led to a search for a better way to help heart failure patients manage their conditions outside of the hospital.

“It was a good and important time to make sure that we were integrating some of these social need interventions as well as connection to the community in really trying to address root causes,” said Dr. Theresa Soriano, senior vice president of care transitions and population health at St. Luke’s.

That was the impetus behind St. Luke’s pilot program launched in July aimed at reducing hospital readmissions among Medicaid beneficiaries with congestive heart failure by educating patients how to better self-manage their conditions at home.

The program will provide individualized health coaching to 100 Medicaid beneficiaries in three adjacent city neighborhoods: Harlem, the Upper West Side and Washington Heights. Community health workers trained by nurse specialists on St. Luke’s cardiac-care team will provide individualized coaching to patients on the health issues and warning signs related to heart failure, such as the importance of checking weight and limiting fluid intake.

The one-year initiative is a collaborative effort between Mount Sinai and City Health Works, a Harlem-based not-for-profit organization started in 2012 that trains community members to be health coaches. Coaches meet patients at their homes or within the community and work with clinicians on care plans. CHW currently works with about 400 patients, with coaches also serving as a bridge between healthcare professionals and the community by communicating with clinicians about any social factors they find that may be hindering a patient’s progress toward achieving their health goals.

City Health Works founder and Executive Director Manmeet Kaur said the collaboration with St. Luke’s came about as a result of CHW’s past success working with outpatient providers on improving their patients’ management of conditions like diabetes, hypertension and asthma. According to CHW, health coaches were responsible for helping to identify a medical issue unknown to a provider in half of patients they served.

She said the hospital will evaluate the program over the next six months to measure primary and secondary outcomes. Mount Sinai hopes to expand the service across the entire system based on the results. Kaur said plans were already underway to scale up CHW to offer its services to providers in areas of Brooklyn and the Bronx.

Kaur said CHW has to date been largely funded with philanthropic support as the organization developed its care model, but she said the organization is prepared to make the transition of scaling up to take on contracts for its service.

She saw CHW as an ideal service for those healthcare providers that have already transitioned a significant share of their patients covered in risk-based contracts.

“We’re now at the stage where we’re operationally preparing for that type of scale-up in other states in addition to growing in New York,” Kaur said.

Within 10 minutes of receiving a 911 call that a 61-year-old man had passed out, a paramedic and a doctor pulled up outside J.K. Lewis Senior Center in a red SUV.

The health care duo checked the patient’s heart rate, blood pressure and temperature.

Last year, the man would have been taken by ambulance to the ER to receive treatment for his dehydration.

Memphis Fire is one of several agencies across the country that is rethinking 911 services for non-emergency calls like this and at the same time addressing health care needs of patients they are called to assist.

The city has the largest 911 EMS/ambulance service in the state. Last year, the fire department had 130,000 EMS calls and of that number 25,000, or about 1 in 5 were categorized as non-emergency.

“That doesn’t mean they are not urgent to the people who are calling, it means that 22 percent were non-life threatening. So we recognized those kinds of calls were tying up our resources, so we wanted to make sure we have the right resource available at the right time,” said Memphis Fire Department Director Gina Sweat.

In April, the fire department launched the “Right Response” a pilot program that pairs a doctor and a paramedic for non-emergency calls.

“We recognized that with our EMS system the call volume continued to increase year after year and city budgets don’t always increase in line with that need, so we recognized that if this continued it would be a point to where we wouldn’t be able to provide efficient service,” Sweat said.

‘The Right Response’
Memphis paramedic/firefighter Rebecca Luckey drives the rapid response SUV on a recent Tuesday morning as Dr. John David Williamson with Resurrection Health navigates through the 911 calls on a laptop.

Since 8 a.m., the two have been on three house calls. Sending an ambulance to those calls instead would have cost the patient $850 to go to the ER for non-life threatening illnesses.

After treating the patients, the two provide them with information about a primary care doctor if they need one, and most do. They also secure them a ride to a doctor’s office.

Since the “Right Response” program launched five months ago, the doctors and paramedics have responded to more than 600 calls. The pilot program costs roughly the price of two firefighter/paramedic salaries -which is about $55,000.

The fire department has partnered with Resurrection Health who provides doctors to ride with the paramedics on the calls. The Plough Foundation provided grants that bought the two SUV’s that are used on house calls.

Other health care organizations have provided staffing or funding for the initiative including the Assisi Foundation, Saint Francis Hospital, Baptist Memorial Healthcare, Regional One Health, Christ Community Healthcare, Methodist Le Bonheur Healthcare and Innovate Memphis.

“Right Response” is a pilot project now, but fire officials hope to make it permanent.

‘Can I speak with the nurse?’
This month, another phase of the project will launch and will have a nurse working at the 911 dispatch center to talk with residents and assess their health care needs.

“We realize those residents are calling us because they don’t know where else to turn,” said Sweat. “If it is not an emergency, residents can speak directly with the nurse.”

The community paramedicine or telemedicine concept is gaining momentum across the country, said Matt Zavadsky, president-elect of the National EMT Association.

Zavadsky said their data shows that 210 EMS systems in the United States have programs operating as “mobile integrated health” and they coordinate house calls and telemedicine through 911 systems, fire departments and local health departments.

Zavadsky, who is the chief strategic integration officer for MedStar Mobile Healthcare in Fort Worth, Texas said their mobile integrated health project started in 2009. It includes a nurse in the 911 center and an 11-person team of paramedics and a nurse case manager who manage the high utilizer group or HUGS – patients who frequently call 911 for non-emergencies.

“We have seen, with the high utilizer program, there is about a 55 percent reduction in 911 and emergency department use with the patients who enrolled in the program,” Zavadsky said. “With our nurse in our communication center, about 33 percent of the calls go to the nurse. They don’t even get an ambulance response because people will say “can I speak with the nurse?”

He added that the programs are helping patients avoid costly and time-consuming trips to the emergency room and helping improve their health care needs.

“Nationally, these programs are taking off primarily because of the economic incentives today for hospitals. Third-party payer insurance companies are really focusing on value,” Zavadsky said. “I will be the first to tell you, I have been in EMS for 37 years and there is more value in navigating someone through the health care system than just simply schlepping every person that calls 911 to the emergency room.”

Though many emergency rooms are overcrowded and some patients may not have urgent needs, just a fraction of visits are truly “avoidable,” according to a new study.

Researchers examined data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011 that included more than 115,000 records representing 424 million emergency department visits, and found that only 3.3% were avoidable. The study team defined avoidable visits as those that did not require diagnostic tests, screenings, procedures or medications.

A number of these avoidable visits were for concerns that the ER is not equipped to treat, like dental or mental health issues, according to the study. Of the avoidable visits, 6.8% were for alcohol- or mood-related disorders, like depression or anxiety, while 3.9% were for dental conditions.

The findings, published in the International Journal for Quality in Health Care, challenge the commonly held belief that many people visit the ER needlessly, said Rebecca Parker, M.D., president of the American College of Emergency Physicians, in an announcement.

“Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” Parker said. “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that—myths.”

The ER has been a frequent target for initiatives seeking to reduce overuse and the costs associated with emergency care. However, the researchers said that their findings point more toward the value in programs to improve patient access to services like mental health and dental care.

The study found that 10.4% of visits from patients with alcohol-related disorders and 16.9% of visits from patients with mood disorders were avoidable, suggesting that policymakers could do more to increase access to the services that would keep those patients out of the ER.

“Our findings serve as a start to addressing gaps in the U.S. healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits,” the authors wrote.