News & Updates

ALBUQUERQUE, N.M. — Getting the people who overuse emergency services under control has been an uphill battle, but one major health insurer has been teaming with metro area emergency medical services agencies for over a year to put a dent in the numbers of ER visits by some of its Medicaid members.

During that time, a handful of Albuquerque paramedics have been making house calls through a program designed to reduce hospital readmission rates while helping discharged patients stay on the road to good health.

It seems to be working.

The Community Paramedicine initiative, launched in January 2016 by Blue Cross Blue Shield of New Mexico, has moved from pilot program status to an ongoing service helping more than 1,100 Medicaid members, mostly in the Albuquerque area. The insurer saw an almost 62 percent drop in emergency room visits and a 63 percent decrease in ambulance use by frequent flyers, many of whom live alone, have a limited support network, lack transportation or have a housing situation that’s in flux.

Community paramedics from Albuquerque Ambulance and American Medical Response go into the patients’ homes to check on their overall health issues as well as factors like safety precautions and nutrition, said Kerry Clear, Blue Cross’s manager of community social services and coordinator of the program. Blue Cross estimates that the program in its first year saved $1.7 million that would have been spent in the ER.

The insurer is in contract talks with ambulance and fire agencies to expand the program to other New Mexico communities.

Reducing visits to the ER by what the Centers for Medicare and Medicaid Services calls “super utilizers,” typically defined as those who use 911 or visit hospital emergency departments four or five times a year, starts early.

Five nurses employed by Blue Cross assess Medicaid enrollees slated for discharge from a hospital and who may be at high risk for readmission. That includes people being treated for chronic illnesses like congestive health failure, pulmonary disease, asthma, diabetes as well as those recovering from hip replacements.

The assessments may trigger a referral to the paramedic services in the Blue Cross Blue Shield program.

The paramedics are dedicated to the program and do not respond to 911 calls, said Clear.

Shelley Kleinfeld, a paramedic for AMR, visits 10 to 12 patients a week, coaching and educating and taking vitals. She helps clients manage their medications, ensures they are properly using medical equipment and devices, coordinates appointments with primary care providers and looks to see if there is enough food in the house.

If she encounters a minor health issue, she’ll transport patients with conditions like flu or minor wounds to clinics or urgent care centers rather than to the ER.

Kleinfeld said she likes seeing her career shift “from emergency response to proactive response.” She said community paramedicine is healthcare on a grass roots level, which she prefers. “It’s nice to interact with someone other than from the back of an ambulance.”

Original article can be accessed here.

Next to human capital, community trust is one of the most valuable assets for an EMS agency. Building your agency’s community trust takes a concentrated effort and a specific strategy. Richmond Ambulance Authority and MedStar Mobile Healthcare are two examples of AIMHI member agencies that have developed robust community relations. Here are our top 10 strategies to help you build community trust.

1. Deliver Rock-Solid Service

All the PR in the world will not help you if you routinely have service failures. While response times (the historical service benchmark used by most communities) have been proven to have minimal to no impact on patient outcomes, they do have a customer experience impact. Response times that are exceptionally long are typically the source of complaints and even news articles. For example, you can meet or exceed a 90% fractile response time standard and be “late” to 10% of the calls. However, if one of those 10% is a 19-minute response time to an injured child in a public place, it’s likely to cause enough angst to prompt a phone call to an elected official, or your local “I-Team” reporter. In Fort Worth, MedStar has focused on minimizing extended response times by geographically positing units in parts of our service area that are hard to reach, which arguably goes against the standard practice of high-performance EMS of dynamically posting units to cover predicted call volume. This practice has essentially reduced MedStar’s response time complaints to zero.

2. Know Your Community

All politics are local. Knowing the landscape is essential to building community trust. What are the healthcare needs of the community? What are the key organizations to join and support? Are the cell phone numbers of the hospital CEOs, nursing directors, city council members, local important non-profit directors and the assignment desks of your local media outlets programmed into your phone? Do you belong to the local chambers of commerce, send representatives from your organization to your local leadership programs? This type of community involvement and volunteerism keeps you aware of things happening in the community that you or your organization could support. More important, this involvement helps build relationships with local leaders whom you can partner with for community benefit.

3. Create a Community Advisory Board

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Following the advice above, invite local leaders to become part of a community advisory board for your organization. This group could periodically meet at your facility to learn what’s happening with your agency. You can also seek their advice and counsel about ways your agency can partner with the community. MedStar started a CAB several years ago comprised of representatives from local hospitals, chambers of commerce, homeless services agencies, Salvation Army, Meals on Wheels, interfaith council, Area Agency on Aging, United Way, Red Cross and other similar organizations. The agency typically hosts a breakfast meeting twice a year, and through these meetings, learns about things the agency can do for the homeless and homebound, elderly residents of our community.

4. Conduct an EMS Citizen’s Academy

Many police and fire agencies conduct citizen’s academies designed to educate residents about the rigors, challenges and benefits of their agencies. If you are a stand-alone EMS agency (i.e., not part of a police or fire department), you can host and conduct an EMS academy for your residents. Some of the things participants can learn are the structure and governance of your EMS system and how you deploy resources. They can also learn CPR and first aid, try to start IVs and do intubations, go on ride-alongs with ambulances and sit with your communications team plugged into the phone console listening to 9-1-1 calls. The Richmond Ambulance Authority (RAA) partners with its police department to provide “EMS Night,” when the attendees get a hands-only CPR class and an understanding of how emergency medical response works. The EMS night can be delivered in English or Spanish, depending on the audience. In addition, RAA also operates an annual youth academy.

5. Be Accessible for the Media

We’ve heard from many EMS leaders that they have a difficult relationship with their local media. While writing press releases, conducting media interviews and allowing the media to do ride-alongs can be nerve-wracking, the media can be a powerful partner in your community relations strategy. News always happens. Knowing what and how to let your local media outlets know about breaking news can be invaluable. It is always important to keep patient-protected information HIPAA-compliant. There are general newsworthy events you can communicate to your local media. Equally important is your availability for requests for media information. The best way is to have a 24/7 public information officer with a well-known phone number and e-mail address for the media to reach.
Another way to be a good media partner is to have a list of media ideas handy. It is not unusual for a reporter to call on slow news days and ask if there is anything they can report on as their deadline approaches. Ideas to keep on hand include new equipment, interesting call types, seasonal stories such as heat- or cold-related emergencies, or even human interest stories about EMS agency team members.
6. Leverage the Power of Social Media

One of the most powerful tools in your communications arsenal is social media. Twitter, Facebook and Instagram are effective platforms to share information about your agency. The key is followers, and you develop them by posting timely, relevant and useful information your local community members find valuable. Examples could include health and safety tips, healthcare-related items of interest, or just fun facts. MedStar recently used social media to conduct an AED scavenger hunt during National Heart Month. Local media participated with announcements and information on how to report found AED locations using Instagram, Facebook and Twitter. This resulted in the locating of over 100 AEDs and dramatically increased the number of MedStar followers.

7. Host Community Benefit Events

By combining your community relations, social media and traditional media prowess, you can host blood drives, blood pressure screenings and other community benefit events. MedStar recently hosted a bone marrow registry drive at its facility. Local media supported the event by broadcasting the date, time and location leading up to the event. MedStar employees and community members came to the event in support of the effort. Media outlets then reported the results from the event. RAA hosts a “big push” campaign to teach hands-only CPR—anytime, anywhere and in any language. RAA discovered that the most successful way to train many citizens is to take CPR on the road and deliver it to churches, youth groups, community organizations and the biggest travelling event of the year—National Night Out. The visibility that participation brings is worth every minute spent.

8. Share Outcome Dashboards
The healthcare system is moving from volume to value. EMS needs to prepare for that by finding outcome metrics that are meaningful and reportable. One of the first performance-based outcome metrics hospitals were accountable for was patient experience. If you are not tracking patient satisfaction scores, start now! If you are, publish the reports on your website and through social media. You should even build an e-mail distribution list of local stakeholders so you can share the reports electronically. In addition to patient experience reports, you can track and publish meaningful outcomes the community will understand, such as cardiac arrest survival, scene times for trauma patients and even spikes in certain types of calls.

9. Publish Annual Reports

Annual reports, both in person and in print, can be powerful tools. They summarize pertinent and notable achievements by your agency over the past year. Printed reports can include fun facts, photos of your team members in action or doing community benefit events, and other contributions throughout the year. Include comments from patients that you glean from patient experience surveys, or thank-you notes from patients and families. A good time of year to provide in-person reports is during National EMS Week. You can request a proclamation for your area’s governmental agencies, and at the meeting you will be presented with the proclamation and can give an annual update about your agency.

10. Host EMS-Themed Birthday Parties

Who doesn’t like a good party, especially if it’s unique and educational? Parents can be very competitive when it comes to finding memorable birthday parties for their kids, so why not consider a “Junior Paramedic Party”? Imagine an ambulance with safety clowns, coloring books with safety information, toy stethoscopes and even junior paramedic badge stickers. Kids can learn important safety and first aid information while being entertained by the safety clowns. The parents will get gold stars from their kids and other parents for an innovative and fun way to celebrate birthdays!

Sweeping Up the Media
Have you ever wondered why TV news stations in your local area seem to field big stories, high investigative drama and heart-wrenching tales at certain times of the year? The timing of most of these releases is far from accidental as TV stations, while syndicated to major networks, are franchised out to media management companies and their viewer ratings are hugely important to them. To measure how well a TV and news station is doing, certain periods of the year are designated as the “sweeps.” During this time, audience viewing figures are determined using the Nielsen audience measurement system. Information collection devices are placed in selected homes and viewing habits are measured.

Against this backdrop, stations plan sweeps campaigns and work in the preceding months to prepare their stories before “teasing” them—giving snippets of the story to increase viewer interest and subsequent ratings. To be on the right side of a sweeps story, follow all the advice offered in the main article and work with your local stations to provide a great story that helps both them and you. Reuniting crews with a cardiac arrest survivor attracts attention and attests to the professionalism and credibility of your organization. For a harder hit, facilitate a ride-along for reporters and attach a number of GoPro-type cameras to a vehicle to record how other road users interact with a vehicle responding with lights and sirens. Sweeps dates for the next 12 months:

June 29–July 26, 2017
October 26–November 22, 2017
February 1–February 28, 2018
April 26–May 23, 2018
The Word on the Street

Five years ago at the Richmond Ambulance Authority, a staff welfare meeting raised the issue of improving internal communications, as staff felt they weren’t fully informed about what was occurring in the organization. As a result, for the following week, the RAA team undertook to publish one piece of news a day. The format was simple, two paragraphs and a few photos contained in a PowerPoint slide that was then printed and published at eight locations around the RAA headquarters. The PR team realized that there was so much to share that the project continued beyond that first week.

With RAA’s eventual expansion into social media via Twitter, Facebook and LinkedIn, WOTS became a cornerstone of not only its internal communication strategy, but external as well. The daily news has attracted readers and followers from all over the world. The successful format of two paragraphs and photos has not changed, although the challenge for the contributors and WOTS editor is to be succinct.

Staff are encouraged to submit stories and ideas to WOTS. To assist them, an e-mail address was created to allow them to send in (non-HIPAA) photos of their daily activities to supply fresh images for both WOTS and other RAA-related reports and presentations. Over time, the keen photographic eye of some staff has resulted in their work being used in various publications.

Original article can be accessed here.

Since 1997, Spectrum Health in Grand Rapids, Mich., has provided community-based care through its Healthier Communities initiative. Developed through the merger of two previous programs, Core Health was added in 2008 to provide in-home education on general wellness, including weight and stress control, for patients with early-stage chronic conditions, such as diabetes, heart failure and chronic obstructive pulmonary disease.

Eventually, it became evident that Core Health, as originally designed, was not serving some of the communities’ neediest members, those with more advanced disease, some of whom also had cognitive and behavioral challenges that made it difficult to benefit from the home-education curriculum.

“We realized that, wow, we’re saying, ‘No’ to a cohort of people who don’t have anywhere else to go,” says Core Health Program Supervisor Bethany Swartz.

Accommodating advanced disease
“We were challenged to shift the program to be able to serve those folks who were a little more clinically complex, a sicker population, those not so much in early-disease state,” Swartz says, “and also those who cognitively didn’t have the same capacity for learning and might have behavioral health issues that impede their ability to focus on their health first.”

Like its predecessors, Core Health employs community health workers, or CHWs, who make home visits to at-risk populations in Spectrum’s Grand Rapids and Greenville, Mich., markets. The program has been instrumental in improving patient health and reducing hospitalizations and emergency department visits among its participants.

Core Health tailored its services to the needs of its clients by adding a bilingual, licensed social worker and behavioral health screens for depression and anxiety. Core Health staff also developed a health risk assessment to better identify how social factors, such as housing, transportation, finances, food access, education, immigration status and relationship status, affect a client’s health.

The original Core Health curriculum was modified to reflect clients’ cognitive abilities and pace of learning. As in the original program, the Core Health curriculum includes lessons on healthful eating, stress management and portion control. However, the order and topics are determined by client goals and not by a pre-designed curriculum, Swartz says.

While the original was a yearlong program, in its new iteration, there is no defined timetable. The program is deemed successful when clients demonstrate necessary self-care management skills.

“We changed how we define success,” Swartz says.

How it works
Core Health is staffed by six CHWs, three full-time-equivalent registered nurses who function as care managers, and a full-time licensed social worker, in addition to Swartz. The CHWs visit three to four clients in their homes each day, spending about an hour with each, Swartz says, which allows them to see each of its approximately 300 clients about once a month.

During the visit, the CHW monitors the client’s condition and helps to set goals, such as eating healthier foods or exercising more.

In addition, a care manager performs medication reconciliation with each client about every three months.

The CHWs maintain contact with a client’s care manager and primary care physician. For example, if a client’s blood pressure is higher than a certain level or blood sugars are too high or too low, the CHW will call either the care manager or the PCP for further instruction. “Our ultimate goal is to get the client to a place where they’re using their primary care doctor to make their health decisions,” Swartz says.

The CHW also documents the visit as part of the client’s care plan in Spectrum’s electronic health record, which is then routed to a Core Health care manager, who must approve the plan within 24 hours after it’s sent.

CHWs are selected for their ability to relate to community members. They are intimately familiar with the barriers and struggles of the target population, says Mark Lubberts, R.N., manager of community health education for Spectrum Health’s Healthier Communities outreach program. “You’re not looking for the person with the master’s degree in public education,” he says. “You want somebody who has lived the life of many of our clients.”

Once selected, CHWs undergo rigorous training in a certification program developed jointly by Spectrum Health’s Healthier Communities and the Grand Rapids Community College to provide the Michigan Community Health Worker Alliance standardized curriculum. Upon completion, the student will receive a certificate from GRCC. To become certified for the Core Health program, CHWs are tested in eight competencies, including advocacy and outreach; community and personal strategies; legal and ethical responsibilities; teaching and capacity building; communication skills and cultural competencies; coordination, documentation and reporting; healthy lifestyles; and mental health. The eight-week onboard training includes classroom work, scenario precepting, job shadowing and peer mentoring, after which CHWs understand the nature of diabetes, heart failure and COPD, as well as the resources to manage them.

Newly minted CHWs also undergo Spectrum’s systems, department and program orientations.

Swartz notes that CHWs are being used more frequently by hospitals these days, and that it has become a coveted career in the region. Often, there are more applicants than job openings. “I think that is in part due to the training and certification and the amount of attention that this position is getting at local, state and national levels,” she says.

Outcomes to date
In 2016, Core Health had the following results in client engagement, and health and cost efficiency:
Success for the client is measured using a patient activation measure, or PAM, score, which assesss a client’s competence and readiness to manage his or her condition and engagement with primary care. In 2016, 70 percent of clients had a mean increase in their PAM scores of 26 percent. The client satisfaction rate was 97 percent.
Objective measures of patient health indicate an improvement as well; more than 52 percent of diabetes clients decreased their A1c levels by an average of 17.2 percent during the period they participated in Core Health.
Clients reduced the number of hospital stays and visits to the ED, which dramatically reduced Spectrum’s costs to care for these patients.

Lessons learned
The major takeaway, Swartz says, is the extent to which factors other than physical health affect the client’s ability to manage a chronic condition. “Looking back at the original design of Core Health, the behavioral and social health needs of our clients were probably underestimated,” she says.

Core Health staff have come to appreciate the complexity of chronic conditions, especially for the program’s target clientele. The acuity level of the clients’ conditions and the number of community members who were not receiving appropriate care services were unexpected, Swartz says.

Modeling the program around the client’s needs and capabilities is also much more productive than trying to mold clients into a certain approach, she says. This means that work with the clients is more intense, but often not as long.

“Our caseloads might be smaller, but we’re discharging clients more successfully at a faster rate, so we can open that slot to somebody new,” Swartz says.

Next steps
One future objective is to incorporate technology into home visits. Swartz perceives a great need for pharmacy services, especially medication reconciliation for clients who are seeing providers from multiple health systems. Managing medication prescribed from non-Spectrum providers is often challenging, she says.

The solution most likely involves virtual visits, Swartz says. Spectrum has a new online platform called MedNow that enables patient visits with a primary care physician or advanced practice provider via online access. Pharmacy visits might one day be offered through MedNow, as well. Virtual nurse visits would allow care managers to “visit” more patients, expanding the effective client base of the program.

Whatever the approach, the goal is to keep evolving. “I think we can get creative,” Swartz says.

“This has been an incredibly exciting program over the years,” says Lubberts.

“It has impacted a lot of outcomes,” Swartz says, “but still the most impactful elements within this program were the times when I would receive phone messages from clients describing how a community health worker made all the difference in their lives.”

Original article  can be accessed here.

For people living in cities, the constant sight of red lights and sound of sirens can be taxing. Their omnipresence can be particularly frustrating given that around 80 percent of calls to 911 aren’t actual emergencies.

To cut back on these expensive and often unnecessary trips to the hospital, cities are revamping their emergency services programs. Houston, a sprawling metropolis made up of more than 2 million people, is leading the charge.

A fire truck in Houston

In 2014, the city launched a telemedicine service that has reduced 80 percent of the number of unnecessary emergency visits. The program is called ETHAN, which stands for Emergency TeleHealth and Navigation. It works like this: When paramedics arrive at the scene of an emergency and realize a patient doesn’t need to be rushed to a hospital, they use a tablet to video chat with a specialist. For instance, a patient can chat with a nurse to get a prescription refilled or get an appointment scheduled on the spot with their primary care doctor for joint pain.

Michael Gonzalez, ETHAN’s program director, says the program is approaching its 10,000th patient encounter and has prevented 6,000 unnecessary ER transports. The average teleconference visit clocks in at about seven minutes, and the cost of treating a patient virtually is around $220 — substantially less than the $2,200 it costs to transport someone to the ER.

As a result, Houston’s use of telemedicine in emergency services is catching on. Gonzalez says he’s had about 300 teleconferences with health agencies from around the world since ETHAN launched. A handful of American cities are also about to launch their own EMS telemedicine programs similar to Houston’s.

“It’s very clear to us that telemedicine has a place in EMS,” says Vince Robbins, president of the National EMS Management Association. “It depends on the agency, and how effective it would be for them, but it’s a good technology and can have good value.”

This is Houston’s third effort in a decade trying to modernize emergency services. In the first iteration in the early 2000s, the city went with a hotline, where chronic 911 users could call and chat with a nurse. The problem, however, was getting someone who normally calls 911 to dial a whole new number.

“It was like fitting a square peg in a round hole,” says Gonzalez.

Houston then created a computer-based algorithm to triage patients. Once paramedics arrived at a scene and again realized it wasn’t an emergency, they would connect a patient with a paramedic at headquarters. But it turned into a headache for paramedics: It was time-consuming and often required immediate transport to a hospital anyway.

While Houston’s latest approach to redirecting people away from the ER is novel, Robbins says there are other ways to use telemedicine that can make emergency care better for everyone.

A couple of localities — including Minneapolis and Berks County, Pa. — use telemedicine to treat stroke victims en route to the hospital. These programs can shave 20 minutes off of a patient’s treatment time once at a hospital, which is important because “in a stroke, time is of the essence,” says Robbins. “If you can intervene early enough, you can even reverse the symptoms.”

The goal behind these efforts is not only to reduce the number of “frequent fliers” — those who repeatedly show up at the ER — but also to reduce the overall number of “red lights and sirens” that residents have to deal with on a daily, sometimes hourly, basis.

“There’s a public expectation when you call 911 that you want an immediate response, so we as an industry need to re-educate the public,” says Robbins. “We need to let people know that there is strong medical literature that shows there are some instances where your condition is not going to get any worse, and we have time to better help you.”

Original article can be accessed here.

Hospitals and health systems have been slowly wading into alternative payment models and many expect to take a deeper plunge in the next few years.

About half of respondents to Modern Healthcare’s most recent CEO Power Panel survey said less than 5% of their revenue is currently tied to alternative payment models. Within two to five years, nearly 40% of the CEOs expect more than 25% of their revenue to be tied to bundled payments, accountable care organizations, population health initiatives, value-based contracts and other payment reforms.

“This (higher) level of risk accelerates improvements in quality and cost, and that’s good for patients.” –Dr. Mark Harrison, Intermountain Healthcare

“We’ve moved toward taking on more risk, now about a third of our total volume,” said Dr. Marc Harrison, CEO of Salt Lake City-based Intermountain Healthcare. “This level of risk accelerates improvements in quality and cost, and that’s good for patients.”

Hospitals have traditionally operated in a world that rewarded them for each procedure and test performed. The push toward value-based payment models has caused providers to make larger investments in information technology, improve coordination across the continuum and deliver better outcomes at lower costs. Ideally, successful payment reform translates to reduced variation, the elimination of unnecessary tests and procedures, and managing a patient’s total health, rather than doing it episode by episode.

“It forces us to look at the care continuum differently,” said Julie Taylor, CEO of Alaska Regional Hospital in Anchorage. “If you are going to get the best outcomes from a value-based purchasing perspective, it can’t be done in a silo.”

The shift to value isn’t easy, though. Nearly two-thirds of the CEOs surveyed said they are still wary of the financial risk involved across all payment reform. Engaging physicians and staff (63%) and revamping clinical processes (57%) were the next biggest obstacles in implementing new models, executives said.

Nonetheless, executives are managing the growing pains.

“We reorganized, particularly with our population health division, so we can comprehensively look at how we are doing payment reform,” said Dr. Rod Hochman, CEO of Renton, Wash.-based Providence St. Joseph Health, a 50-hospital system created by last year’s merger of Providence Health & Services and St. Joseph Health. “It is a journey.”

The CEO Power Panel surveys executives and leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups. Of 123 queries sent, 57 responded to Modern Healthcare’s second-quarter survey on payment reform.

Nearly half of the respondents said they have formed accountable care organizations or are linking with other healthcare providers to coordinate care and share financial responsibility in quality outcomes.

“New payment mechanisms like ACOs and bundled payments, as long as there are quality indicators and not just cost measures, can be effective vehicles for driving change,” said Cathy Jacobson, CEO of Froedtert Health, a Milwaukee-based system.
ACO proponents argue that they have great potential to ensure care is delivered at the right time while avoiding redundant or unnecessary treatment. Yet, wide variation exists in how ACOs take on financial risk and set benchmarks for costs and patient outcomes.

“ACOs through the Medicare program have had limited success in producing savings and the savings generated that have been shared with providers are often inadequate to cover the investments providers had to make to be an effective ACO,” Jacobson said. “Obtaining timely claims data, whether from a commercial insurer or Medicare, is still an obstacle we have experienced. Without this information, it is very difficult to identify high-cost areas to address or to show you are making progress.”

About 43% of survey respondents said their organizations have value-based contracts in place; roughly 40% have implemented bundled-payment initiatives. Nearly 3 out of 4 CEOs said they would continue to support bundled payments as long as they were voluntary.

The CMS in March delayed expansion of a major bundled-payment pilot, the Comprehensive Care for Joint Replacement, and the implementation of its bundled-payment initiatives for cardiac care from July 1 to Jan. 1, 2018. The agency also delayed the effective date for joint replacement and other bundled-payment programs, from March 21 to May 20.

Hospital groups have lobbied for making the programs voluntary, arguing that many hospitals don’t have the resources to effectively tackle the care-management services and health information technology the models require.

“Payment reform may hurt some health system providers within the industry that cannot meet the bundled-payment obligations in terms of cost or quality standards,” said Curt Kubiak, CEO of the Orthopedic and Sports Institute of the Fox Valley, based in Appleton, Wis. “High infrastructure costs related to facilities or administrative expenses may make it difficult for certain health system providers to compete in this new payment structure.”

Even so, mandated change is coming. The Medicare Access and CHIP Reauthorization Act requires physicians to participate in one of two reimbursement tracks: the Merit-based Incentive Payment System or advanced alternative payment models. About 60% of respondents said they expect most physicians to participate in the former.

While MACRA could reduce variation and drive quality outcomes over time, it also poses challenges for physicians in small practices, said Dr. Gary Kaplan, CEO of Seattle-based Virginia Mason Health System.

“It could lead to consolidation of small practices, as they may not have the size needed to drive alignment of quality measures and information systems,” he said.

As healthcare leaders search for payment models that best fit their organizations, they are keeping a close eye on how new policies and regulations could transform the healthcare landscape. Around 83% of the CEOs expect the current administration to bring more uncertainty into the picture.

“We really don’t know what elements of the Affordable Care Act will be sustained or modified,” Kaplan said. “We just need to focus on our patients and create value.”

Article can be accessed here.

“EMS is available in every community, EMS is fully mobile, EMS can address patient needs 24/7, and EMS is expected, respected and welcomed.”

With these words Matt Zavadsky, chief strategic integration officer for Texas’ MedStar Mobile Healthcare, kicked off the 2017 EMS 3.0 Transformation Summit on April 24 in Arlington, VA. Zavadsky continued his long-standing advocacy and leadership with words of inspiration for those looking to move EMS toward an outcomes-based healthcare economy.

Various major national players in mobile integrated healthcare and community paramedicine took the stage at this event, offering best-practice advice and motivating the eager EMS audience to continue to strive for what the National Association of EMTs (NAEMT) calls “EMS 3.0.”

NAEMT defines EMS 3.0 as a way to “contribute to our nation’s healthcare transformation by filling gaps in the care continuum with 24/7 medical resources that improve the patient care experience, improve population health and reduce healthcare costs” (the Institute for Healthcare Improvement’s Triple Aim).

Aligning the Incentives
A major reform thrust discussed this year is changing EMS’s billing status from “supplier” to “provider” so home visits and other MIH services can be compensated. Many summit attendees participated in the EMS On The Hill event the following day, walking miles and miles of the U.S. Capitol building to visit lawmakers and press for the cause. Currently most insurance rules only allow billing for transporting patients.

“This is a misaligned incentive,” said Zavadsky. “Right now EMS is a ‘transportation’ benefit, not a medical benefit.”

MIH data geeks, policy wonks and transformational leaders like Zavadsky gave updates on the progress of many of the country’s earliest MIH adopters: MedStar, San Diego Fire-Rescue’s (SDFR) Resource Access Program and Reno’s Regional Emergency Medical Authority (REMSA).

Bradford Lee, MD, REMSA’s medical director, presented impressive results from his agency’s 2012 $9.9 million CMS Innovation grant. REMSA mined its data and found that 953 unique individuals were costing the system $65 million in EMS services. Upon receiving the grant REMSA instituted a number of MIH components, such as a nurse health line, alternative-destination transport and community paramedic (CP) home visits for patients discharged from the hospital. So far, REMSA has reduced its readmission rate for CHF patients to 12% versus the 25% national rate.

REMSA CPs enroll discharged patients as they leave the hospital. “Our community paramedics provide follow-up for 30 days, medical care plan adherence, medication reconciliation, point-of-care lab tests and personal health literacy,” Lee said.

While it’s impressive how these new initiatives have driven down costs, Lee stressed that what’s more important is that REMSA had no adverse events and very high patient satisfaction.

In California state officials issued waivers to various EMS agencies in June 2015 to test various CP concepts. The agencies have instituted MIH programs in discharge follow-up, frequent-user reduction, tuberculosis therapy, home hospice and alternative-destination transports. These results are also promising, showing no adverse outcomes, improved patient safety and large decreases in avoidable ED visits.

“Our data collection and results reporting on these programs is helping move the programs faster through the state,” said Cynthia Wides, who works at University of California, San Francisco (UCSF) as a Healthforce Center researcher alongside Janet Coffman, PhD, the principal investigator tracking California’s programs.

Satisfied Customers
With many speakers displaying high marks from patient satisfaction metrics, it is clear the move to EMS 3.0 is working. CMS is already basing some of its reimbursements on patient surveys, and Zavadsky stressed that EMS must work on adopting pay-for-performance and value-based purchasing reimbursements linked to clinical outcomes.

Theories that paramedics aren’t highly trained enough or that the only safe destination for patients is the hospital were also debunked. Mark Conrad Fivaz, MD, who chairs the Council of Standards for Emergency Nurse Triage at the International Academy of Emergency Dispatch (IAED), detailed the elements of nurse triage at the dispatch level. Fivaz presented statistics that show striking increases in 9-1-1 call demand in most major U.S. cities. He said nurse triage can be a solution for this “supply and demand mismatch.”

“You need clinical governance of these systems, with clinically sound medical protocols,” said Fivaz. “There should be a trained RN housed in a PSAP with medical oversight.”

These nurses provide an appropriate, safe resource to many 9-1-1 callers. MedStar surveyed patients who used its 9-1-1 nurse triage and found a 90% satisfaction rate. MedStar also recently announced a partnership with Lyft, the ride-hailing service. Zavadsky explained that MedStar’s nurse triage line uses Lyft when appropriate, and that his company is pleased with Lyft’s driver screening process, liability provisions and the ability for the dispatcher to follow the progress of the Lyft car once a patient is picked up.

Another common theme was the importance of gathering good data, analyzing it to determine gaps, and then using it to evaluate a program’s success. Paramedic Anne Jensen, Resource Access Program manager at SDFR, showed the success of her city’s data collection and analysis efforts but stressed that they always strive for more.

“Integrated healthcare needs data management methods to meet patient needs,” she said. “But we are not yet all the way there.”

SDFR’s Street Sense program is an alerting system and has a robust, bidirectional health information exchange with various community partners. Jensen has made sure the software program collects and disseminates data fast enough so providers are informed in a timely manner, not after the chance to intervene has passed.

Stacy Elmer, Kaiser Permanente’s director of medical device integration and special programs, recounted similar efforts at appropriate data analysis within her company. Kaiser was deliberate in its process to address patient needs. Elmer detailed the process of trying to gather the hospital leaders, formulate a working group, pull the necessary data and then decide on what program to launch.

“You have to be able to ask, ‘What is the problem?’ first,” Elmer advised the audience. “To do so, make sure you look at the right data and consider which patient groups have the best chance of success in an MIH program.”

Utilize Your Opportunities
Clearly many of the summit speakers have the staying power to not give up in the quest to transform EMS. Zavadsky noted that reforms take a long time but are worth it. He ended the summit with an inspirational call to action for the audience to continue lobbying, especially at the state level, where reforms can happen more quickly.

“Some of us in this room have been lobbying Congress since when we still had hair, and very little has happened,” he said. “Utilize all the opportunities you have to advocate how EMS 3.0 supports the healthcare transformation.”

Original article can be accessed here.

U.S. physician practices with superior operational and financial performance are preparing for value-based care, adopting new technology and improving patient experience, according to the 2017 Practice Performance Index.

The PPI study, conducted by CareCloud and UBM Medica, examines survey responses from more than 2,000 physicians and practice administrators. In the study, practices were designated as high-performing, managing or falling behind based on their financial and operational performance over the last three years, researchers said.

Financial and operational performance was designated based on increases in practice collections, number of practice locations, number of providers, total patient volume and provider satisfaction, among other criteria.

Here are five study findings comparing high-performing practices with those falling behind.

1. More than half (56 percent) of high-performing practices have a plan for the shift to value-based care, the study found. This compares to 32 percent of falling behind practices.

2. More than half (53 percent) of high-performing practices also strive to earn a full or partial Medicare Access and CHIP Reauthorization Act incentive this year, according to the study. This compares with only 35 percent of falling behind practices.

3. When it comes to adopting new technologies, high-performing practices are twice as likely to do so than falling behind practices.

4. The study found more than two-thirds of high-performing practices embraced patient portals. Researchers also said these high-performing practices were leading in technological innovation, adopting advanced population health analytics, telemedicine, iPad-based intake forms and check-in kiosks.

5. The study found high-performing practices are significantly more likely to survey patients and use online review sites. More than 80 percent high-performing practices do so, compared to almost 50 percent of falling behind practices.

Original article can be accessed here.

Freestanding emergency centers are not solving the cost of healthcare in Texas. They are multiplying it.

By locating primarily in areas with high incomes and multiple hospital-based emergency rooms and urgent care clinics, freestanding emergency centers increase the cost of healthcare. A recent study from Rice University found that for conditions that could be treated in an urgent care center, but were instead seen in a freestanding emergency center, the cost was more than 10 times higher. Blue Cross Blue Shield of Texas data shows that 75 percent of freestanding emergency center patients could have been treated in an urgent care center or doctor’s office at a much lower cost.

To increase profits, many independent freestanding emergency centers choose to stay out-of-network with insurance companies. Being out-of-network allows freestanding emergency centers to charge whatever they want for their services, leading to exorbitant bills to unsuspecting Texans.

Recently, a BCBS TX member went to a freestanding emergency center with a sore throat and was diagnosed with tonsillitis. The facility charged more than $45,000 for the visit.

Yet another of our members arrived to a freestanding emergency center with nausea and vomiting. The patient was diagnosed with stomach flu and was discharged. The bill for this visit? $51,000.

In circumstances like these, patients are often responsible for a large portion of the bill. By choosing to remain out-of-network, freestanding emergency centers are able to bill the patient for the difference between what insurance pays and their inflated charges. That difference leads to the patient receiving a “surprise bill,” which can run in the thousands of dollars.

And make no mistake, these centers are choosing to remain out of network. In 2016, BCBS TX contacted all known out-of-network freestanding emergency centers in the state, hoping to bring their facilities into our network, to protect our members from surprise bills. The overwhelming majority of them declined to even look at our contracted rates, preferring to remain out of network.

This issue now has the attention of lawmakers in Austin, and eleven proposed laws have been filed to address complaints about the business practices of freestanding emergency centers. Several proposed laws would require full disclosure and transparency of billing practices of freestanding emergency rooms, and two–SB 2064 by Sen. Hancock and HB 3867 by Rep. Smithee–would authorize the Texas Attorney General to take action in cases of “unconscionable pricing,” commonly called gouging. Contact your state senator or your state representative and ask them to support measures that will protect Texans from exorbitant charges at freestanding emergency centers.

It’s our responsibility at BCBS TX to provide our members access to quality, cost-effective healthcare. Texans deserve quality, affordable care with no surprises, and no unconscionable bills.

Dr. Paul Hain is North Texas market president for Blue Cross and Blue Shield of Texas and is a board certified pediatrician.

Original article can be accessed here.

Anthem’s top executive says the health insurer is paying out 58% of its reimbursements via value-based care models that are quickly dominating the U.S. medical system.

Anthem, which operates Blue Cross and Blue Shield plans in 14 states, this week opened a window into the health insurance industry’s shift away from the traditional fee-for-service approach that is based on volume of care delivered and can lead to overtreatment and unnecessary medical tests and procedures. Rival insurers, including Aetna and UnitedHealth Group, are also moving aggressively away from fee-for-service medicine.

But of the health insurers reporting first-quarter earnings so far, Anthem offered perhaps the most detailed insight into its value-based contracts with doctors and hospitals.

“Aggregate spend regarding value-based contracts tally up to about 58% of our total medical spend across all lines of business, and over 75% is represented by shared savings agreements, shared risk arrangements [and] population-based payment models,” Anthem CEO Joe Swedish told analysts on the company’s first-quarter earnings call earlier this week.

Value-based pay is tied to health outcomes, performance and quality of care of medical care providers who contract with insurers via alternative payment vehicles like accountable care organizations (ACOs), a delivery system that rewards doctors and hospitals for working together to improve quality and rein in costs. In these models, doctors and hospitals take on more risk that they can streamline the care, improve quality and eliminate bureaucratic inefficiencies.

Swedish said Anthem now 159 ACO agreements. “We’ve got over 64,000 providers now engaged in ACOs and patient-centered medical homes who are accountable for cost and quality of care for over 5.5 million commercial members, which is a huge uptick compared to prior years,” Swedish said.

Original article can be accessed here.

Fully a third of all the Medicare beneficiaries transported to a hospital emergency department by an emergency medical services ambulance could have been treated safely in an alternative setting, according to recent studies.

If Medicare beneficiaries with low-acuity needs were taken by EMS to a clinic or doctor’s office instead of an emergency department — or, better yet, treated more comfortably and conveniently at home, if appropriate — an estimated $600 million could be saved annually. If the same patient-centered policy were approved by third-party payers as well, estimated annual savings for the health care system could reach $1.2 billion.

“Discontinuities in health services are commonplace for patients who live at home,” observes Eric Beck, D.O., assistant director of the emergency medical residency program at the University of Chicago Medical Center. “For the chronically ill, the frail elderly and the mobility-impaired, care gaps such as lack of post-acute transitional care make preventable readmissions a virtual inevitability.”

Many single-purpose providers offer niche care for the homebound, Beck notes. But they often have restricted hours of operation. Patients are routinely referred to hospital emergency departments when problems arise outside normal business hours “even though it is common knowledge that the ED is an imprecise match to their needs,” he says.

Meeting in Chicago under the aegis of the American College of Emergency Physicians a little over four years ago, a consortium of 10 EMS-affiliated physicians and health care strategists from around the country, including Beck, proposed a new model for delivery of appropriate, around-the-clock, comprehensive, planned or unplanned care outside the hospital, using interprofessional medical teams.

They called it mobile integrated health care practice, or MIHP. The P has since been dropped as confusing. But as MIH, it’s an idea that is already recording encouraging results.

Community paramedicine
Reimbursement for ambulance services has been based on the life-support procedures performed and miles driven. But the movement to pay-for-performance rather than fee-for-service throughout the reformed U.S. health care system has changed the focus of EMS as well. The watchword today is “outcomes”.

“That doesn’t mean, ‘We get there in eight minutes, 59 seconds, 90 percent of the time,’” said Edward Racht, M.D., chief medical officer of American Medical Response, the nation’s largest private ambulance service, in an interview with the magazine EMS World in 2013. Racht explained that EMS providers were beginning to measure things like improvement in pain management and the survival rate of heart attack victims — which meant redefining what EMS does, and retraining emergency medical technicians and paramedics to take on new roles based on community need.

Indeed, in many American municipalities a new concept has been put into action: community paramedicine. Ambulance crews of technicians operated by private companies and public agencies have been beefed up to include an advanced practice provider — a registered nurse, a paramedic with an additional credential in community paramedicine or a nurse practitioner. They still scramble to answer 911 calls, but they also, depending on state licensure and scope-of-practice regulations, make home visits to instruct patients in the use of drugs or medical devices, draw blood for lab tests, or transport patients with conditions like flu or minor wounds to clinics or urgent care centers rather than to the ED.

Reno 911
In Reno, Nev., for example, most congestive heart failure, chronic obstructive pulmonary disease, post-myocardial infarction and post–cardiac surgery patients discharged from any of three major hospitals are given a direct phone number they can call at any time during the next 30 days to seek the advice of or summon a community paramedic. Reno’s nonprofit Regional Emergency Medical Services Authority also staffs a free, all-day, every-day nurse health line with nurses who’ll answer medical questions from anyone who dials and follow up when appropriate.

Busy local doctors can request a home visit to a patient by a REMSA community paramedic, who’ll evaluate the patient’s condition on-site. And paramedics are empowered to choose the most appropriate point of care for patients, especially for frequent visitors to the ED.

REMSA crews, for example, had transported one indigent, uninsured, panic attack–prone man to a Washoe County emergency department 23 times over a period of just three months in 2013, they reported. Under the new community paramedicine program, REMSA paramedics redirected him, with his consent, to a local clinic. There he reconnected with his primary care physician and was re-enrolled in Medicaid. Over the next 20 months he was seen in the ED only three times — and zero times the following year while keeping his doctor appointments.
Calling central command

“There are lots of examples of local community paramedicine pilots, and they’re doing good work,” acknowledges Beck.

“But they face challenges. In larger markets serving multiple communities, scale becomes an issue. As local exercises, with their own features, they may not align with other [players]. And many EMS systems don’t have the budgetary support to employ advanced practice providers.”

A truly comprehensive, accountable mobile integrated health care program, as outlined in the consortium proposal, will have 12 essential features:
• Cataloging of provider competencies and scopes of practice.
• Medical oversight, both in program design and in daily operation.
• Population needs and community health assessment.
• Strategic partnerships with stakeholders, engaging a spectrum of health care providers including, but not limited to physicians, advanced practice nurses, physician assistants, nurses, emergency medical services personnel, social workers, pharmacists, clinical and social care coordinators, community health workers, community paramedics, therapists and dietitians.
• Patient access through a patient-centered mobile infrastructure.
• Coordinating communications, including biometric data.
• Telepresence technology, connecting patients to resources, and permitting consultation between in-home providers and those directing care.
• Capacity for patient navigation.
• Transportation and mobility.
• A shared and integrated health record.
• Financial sustainability.
• Quality and outcomes performance measurement.

A pioneer in designing and partnering MIH programs across the country has been Evolution Health, based in Dallas. It’s a subsidiary of Envision Healthcare, of Greenwood Village, Colo., which is also the parent company of American Medical Response. In addition to his clinical practice in Chicago, Beck is Evolution’s president and CEO.

At the heart of Evolution’s MIH network is a mobile command center in Dallas. Working through this communication hub, cross-trained community MIH teams in nine states last year coordinated at-home integrated acute care, chronic care and prevention services in response to more than 2 million calls, Beck reports. More than half of those patients received a home visit from a team member, he adds. Others were assisted by phone or telemedicine, or were met by a provider at a “pop-up clinic” in a convenient park or coffee shop.

“We’ve created an MIH core curriculum for all the disciplines,” he emphasizes. “Everyone needs to be recalibrated in understanding the roles and capabilities and expertise of the other team members. Everyone takes the same course.”

EMS — the focal resource
While operating as multiagency community partnerships often led by hospitals or health systems (examples include Beck’s University of Chicago Medicine, Barnes-Jewish Hospital in St. Louis and Banner University Medical Center in Tucson, Ariz.), at the core of most MIH programs is the local EMS provider (examples include American Medical Response in Arlington, Texas, MedStar Mobile Healthcare in Fort Worth, Texas, and Wake County EMS in Raleigh, N.C.).

The EMS agency is an ideal focal resource, Beck explains, because virtually every community has one, it’s linked to all levels of care through its 24/7 capability for mobility and readiness, and its workforce is already expert in planning, coordination and communications.

Moreover, he points out, EMS systems possess a capital-intensive, difficult-to-replicate readiness infrastructure ideally suited to MIH. EMS providers already have vehicle fleets, robust voice and data communications systems and electronic health record systems, and have portable biometric and sophisticated treatment equipment on board. And since much of this infrastructure comes with the redundancies and excess capacity essential to emergency preparedness, EMS systems are well-suited to absorb the additional loads arising from the new mobile health strategy with minimal marginal cost. (Since 2014, Evolution MIH partners have been reimbursed through a bundled payment structure agreed to by cooperating health insurers, Beck notes.)

“When linked with request-for-service information from dispatch systems, geographic information systems and population health data, the existing EMS infrastructure provides a powerful tool for launching and supporting an MIH program,” Beck suggests.

Looking outward
At Banner University Medical Center in Tucson, readmissions for participating Medicare Part B patients have been reduced by more than half through intensive follow-up by MIH nurse practitioners and case managers, reports Phillip Factor, D.O., professor of medicine and neurology at the University of Arizona College of Medicine. In fact, the readmission rate for those patients now stands at less than 6 percent.

“It makes a big difference for the patients to have an advanced practice provider go to their home after they’ve been discharged and look around,” he says. “In almost all cases, something’s not right. Patients are given a number to call if they have problems, and we have a multi-triage system to decide whether they can wait or need an ambulance immediately. Their discharge summary lists the physician who’s responsible and, if appropriate, that’s where we take them.”

Says Beck: “Some hospitals are trying to manage the present. They’re caught up in working their way through the challenges of the near term. Others have a strategy that’s more outward looking. They’re pursuing value-focused care. For them, mobile integrated health is coming into focus pretty quickly. It’s a new iteration of a familiar set of players … and a pretty exciting new set of menu choices for hospitals and health systems that are thinking holistically.”

David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.

Original Article can be accessed here.