News & Updates

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.

Cathy Hostettler, DNP isn’t in EMS, but her indirect exposure to the industry over the years meant that teaming up with MedStar’s Mobile Integrated Healthcare program was an easy choice. The decision to do her Doctor of Nursing Practice dissertation research on MedStar’s Heart Failure Readmission Avoidance Program reflects the growing trend of collaboration across disciplines within the pre-hospital setting.

Hostettler ‘s retrospective research aimed to evaluate the MedStar program’s effect on readmission rates, costs of care and overall health status of enrollees who entered from October 2013 to September 2015. A total of 114 patients were originally included in the program, however 20 were unenrolled or died prior to completion and therefore were not included in subsequent analyses.

The median readmissions rate for heart failure patients across the United States is 23 percent, meaning that 22 patients in the program should have been readmitted within the first 30 days. In reality, only 18 patients were readmitted in that time frame, resulting in a rate of 19.1 percent and an almost $20,000 cost savings.

This cost savings were offset by higher than expected emergency department utilization. In fact, while the 94 enrollees were only expected to use the emergency department seven times in the first 30 days, they made a total of 53 visits for a cost of just over $56,000.

Hostettler hypothesizes that this higher than expected emergency department utilization rate was due to an initial underestimation that did not accurately reflect geographic patterns of emergency department use. She also expects that the number was confounded by enrollees who should have been jointly classified as high utilizers.

The health status of enrollees was measured using the EuroQol-5D-eL survey which provides a score of 0-100 based on patient responses to questions within five dimensions. Enrollees that graduated from the program saw an increase in their health status scores in all dimensions. There was one exception to this improvement, in which a subset of the enrollees saw a slight increase in feelings of depression and anxiety.

I asked Hostettler a series of questions on her decision to do research within EMS. Her responses have been edited for length and clarity.

COUNTS: AS A NURSE, WHY DID YOU DECIDE TO LOOK AT MIH/CP?
Hostettler: My experience with EMS goes back to my days as a staff ED nurse in an inner city, tertiary care hospital. A friend told me about the community paramedic concept. My knee-jerk response was that home visit nurses fulfill that role and paramedics need not apply. He persisted and helped me understand that home visit nurses are not usually available 24 hours a day and their agencies may not accept uninsured patients.

From my experience in the ED, I knew that patients in need often do not call their doctors, much less their home visit nurses when they need help; they call EMS. Because of this I realized that EMS was a very logical place for this intervention.

HOW DID YOU GET CONNECTED TO MEDSTAR?
MedStar is one of the premier implementers of mobile integrated health care. Since my project was for my doctoral program, I wanted to be able to narrow it down pretty well so that I could finish it and graduate in a reasonable period of time. MedStar’s Heart Failure Readmission Avoidance Program was much further developed than any of the others I did find, so I chose to study MedStar’s program as a possible prototype or basis on which other programs might be modelled.

Doug Hooten, Matt Zavadsky and Daniel Ebbett of MedStar were incredibly generous with their knowledge and data. Without them I would not have been able to do this project.

WHY DID YOU USE PDSA AS THE QUALITY IMPROVEMENT MODEL?
Because of the retrospective nature of my project, I was really looking at the success of the program, not at the philosophy of the program. As such, my project was more of a quality improvement project and the Plan-Do-Study-Act model is specific to quality improvement projects.

WHAT WAS THE EASIEST PART ABOUT RESEARCHING SUCH A NEW MODEL OF CARE?
The easiest part about researching this new model of care was the openness and transparency of MedStar.

WHAT WAS THE HARDEST PART ABOUT RESEARCHING SUCH A NEW MODEL OF CARE?
There is a lot of information available about mobile integrated health care, but very little of it is scientifically studied. Most of the more scientific studies are from the United Kingdom and some from Australia, New Zealand and Canada. A lot of the research I did to prepare for this project involved reading anecdotal reports. While these are great to read, they often do not help us understand what part of the intervention was useful and measure how useful it was.

The MIH-CP Performance Measurement project will be an incredible repository of information from across the country that will allow programs to benchmark their data against others and will provide documentation of measurable outcomes for programs.

WHAT DO YOU THINK THE MOST SIGNIFICANT FINDING FROM THIS RESEARCH PROJECT IS?
Mobile integrated health care programs are community-specific. They must address a community’s needs. The purse strings on health care are tightening. We are all called to do more with less. The EMS system is the way many patients access health care. For those who use EMS as their primary method of accessing health care, it is only logical that the EMS providers are perfectly positioned to help educate and link these patients to appropriate resources for continuity of care.

IF PEOPLE WANT TO LEARN MORE ABOUT WHAT YOU’RE WORKING WHERE SHOULD THEY LOOK?
I am hoping to present this at a national EMS conference soon. You can also read the full paper below.

WHAT ADVICE WOULD YOU GIVE TO A PROVIDER ATTEMPTING TO DO THEIR OWN RESEARCH?
I have five suggestions for EMS providers attempting research.

1. CHOOSE A TOPIC THAT INTERESTS YOU.
You are going to be working on this for a while, so make it something you are passionate about.

2. START WITH A SIMPLE PROJECT.
Sometimes you need to take baby steps in order to get to the destination. A quality improvement study is a great place to start and PDSA is a great tool for evaluating an intervention.

3. GET A MENTOR WHO IS EXPERIENCED WITH RESEARCH.
Formal research is a new world for most of us. The background research that must be done before trying to design a project is necessary and a good mentor will be able to help guide you to make sure you study what you want to study and how to study it.

4. FIND PEOPLE WHO AREN’T IN HEALTH CARE TO EDIT AND REVIEW.
The litmus test for understanding comes from whether or not someone with no exposure to the topic can understand what you are trying to say.

5. SHARE YOUR FINDINGS.
When you invest so much time and effort into creating a good project, you must share it with others. Sharing helps others with their work as well. Sharing more formal research helps others design their projects, benchmark their results against yours and replicate your study for reliability and validity.

Mobile Integrated Health Care: A program to reduce readmissions for heart failure

To view current outcome reports from MedStar’s MIH program visit http://www.medstar911.org/mobile-healthcare-programs

As President Donald Trump on Tuesday renewed his pledge to remake the nation’s healthcare system, GOP lawmakers are continuing to look for ways to build a coalition strong enough to repeal and replace the Affordable Care Act.

The latest salvo is a compromise idea being floated by Reps. Mark Meadows (R-N.C.) and Tom MacArthur (R-N.J.), which was first reported by Politico. While the draft amendment would retain the ACA’s provision that insurers cover 10 essential benefits, states would be able to seek a waiver to do away with that requirement. The draft amendment also aims to retool how premiums are set. Under the ACA, insurers calculate premiums using a community rating, which is intended to bring down costs for sicker members. Here too, the draft amendment would allow states to seek a waiver, freeing insurers to go back to using an individual rating system to set premiums.

The draft amendment, which hasn’t been vetted by GOP leadership, is an attempt to appease the conservative Freedom Caucus, which thwarted earlier efforts to vote on the American Health Care Act. At press time, it was unclear when a new draft of the AHCA would be available or if votes will occur next week, as has been reported.

“We’ve consistently said that everyone should be covered, and that guaranteed coverage for everyone, including those with pre-existing conditions, must be coupled with continuous coverage provisions to help keep premiums affordable for everyone,” said Kristine Grow, a spokesperson for America’s Health Insurance Plans, adding that the group does not have a formal position on the draft amendment.

This latest chatter about AHCA doesn’t seem to advance the ball very far, especially in regards to efforts to curtail Medicaid expansion, says industry analyst Paul Keckley.

“This will be the fourth iteration of the bill,” he said. “But there’s a point at which the 16 GOP governors who expanded Medicaid will say, ‘If you whack my funding, we are going to have a problem.’ Even if you give states more latitude on some of these issues, you can’t put Medicaid into a free fall.”

Tom Nickels, executive vice president of government relations and public policy at the American Hospital Association, said lawmakers need to move away from a construct that jeopardizes coverage for 24 million Americans who have benefited from the ACA’s insurance provisions.

He and Keckley also noted that stabilizing the individual insurance market should be a priority. The AHA, AHIP and several other organizations last week sent a letter to the president urging action on funding for cost sharing reductions.

Original article can be accessed here.

Chicago’s Fire Department has only half as many ambulances as it has fire vehicles, but it gets 20 times more medical calls than fire calls these days.

Let’s say you think you’re having a stroke and you call 911 for an ambulance.

In a lot of cities across the country there’s a good chance that a fire truck — with a full fire crew including a paramedic — will race to your door.

But that doesn’t mean they can deliver the emergency care you might need.

In Chicago, like many cities, the fire department oversees both firefighters and paramedics who work on ambulances.

When a medical call comes in, dispatchers usually prefer to send ambulances. But there are half as many of those as there are fire trucks. And fire department spokesman Larry Langford says those ambulances can be super busy.

“They’ll hit the street at 7 o’clock in the morning and may not come back to the firehouse at all until 7 o’clock the next morning,” he says.

Meanwhile, fire trucks are often much less busy and parked in firehouses, just minutes away from any given emergency.

So the 911 dispatchers make a choice.

A Chicago Fire Department ambulance and firetruck respond to a call in 2016.
Arvell Dorsey Jr./Flickr

“They save valuable time by sending the closest vehicle, which is usually a fire truck that has at least one paramedic and a lot of equipment on it,” Langford says.

That sounds logical until you ask why Chicago’s fire department still has twice as many fire trucks as ambulances, especially when the department gets 20 times more medical calls than fire calls.

Getting answers can be difficult. That has a lot to do with the political power of fire departments and their unions — and the challenge of trying to change that.

Chicago’s not alone in facing these challenges. Most cities are seeing big drops in fire calls and big jumps in medical calls. But few are really reforming their departments to meet this changing emergency landscape.

Portland State researcher Phil Keisling thinks that’s a mistake. He looked at why fire departments don’t just admit that they’re mostly medical services these days.

“And I keep getting answers that are really not a whole lot more than, ‘Well, that’s the way we’ve always done it,’ ” he says. Keisling says that’s not a good answer “in a world that has limited resources and you want to try to optimize the resources you’ve got.”

As more cities see the drawbacks of using giant firetrucks for medical issues, they’re facing calls for reform. That’s what Misty Bruckner found when she researched the problem at the Public Policy Center at Wichita State. While she didn’t find agreement on everything, she said there was some consensus.

“I think everybody can agree that the ladder truck responding to someone who may have a sprained ankle is not the best use of our public resources,” she says.

Langford disagrees. And he thinks people shouldn’t get so hung up on what kind of vehicle arrives. He’s even got a catch phrase for it: “Don’t look at the conveyance. Look at the care.”

Catchy or not, the conveyance can matter. Fire trucks aren’t equipped to take you to the hospital. Only ambulances are.

And this transport part can be crucial, according to veteran Chicago paramedic Rich Raney.

“When you get a stroke patient or a trauma patient, the most important thing is that they be transported to the hospital as quickly as possible,” he says. “As they say with stroke patients, time is brain, basically.”

Each city runs its emergency services differently, so solutions are going to vary. In Chicago, for example, paramedics want more ambulances and staffing.

New York and Wichita recently started deploying medics in SUVs for less urgent calls. And Washington, D.C., is trying something called nurse triage lines. They let callers talk through their problems with a nurse on the phone. But Keisling says some proposals should also look at moving resources from large firefighting staffs.

“And it’s not anti-firefighter, it’s not anti-union, and it’s not anti-government,” he says. “It’s just, why aren’t we taking limited resources and deploying them in a smarter way?”

While there’s no agreement on exactly what that smarter way is going to be, most agree it doesn’t involve sending a fire truck to treat someone with heartburn.

Monica Eng is a reporter with NPR member station WBEZ. You can follow her @monicaeng.

Original article can be accessed here.

Millions of Americans take an ambulance trip every year; others get rides from willing friends or, tempting fate, drive themselves.

But in recent years a new trend has arisen: Instead of an ambulance, some sick people are hailing an emergency Uber.

Though firm numbers are hard to come by, drivers for Uber and Lyft say it happens with some regularity.
In an online chatroom for Uber drivers, dozens of posters share experiences with passengers who hail a ride with bloody cuts, asthma, anaphylaxis, or broken bones.

The trend, experts say, is driven by a few key factors. Ride-hailing services are cheaper and more predictable than ambulance services. And it allows riders to choose the hospital they’re taken to. But emergency Uber and Lyft rides come with significant risks — to drivers, to patients, and potentially to the companies themselves.

‘There’s definitely a liability’

Francis Piekut, who drives for Uber and Lyft, recalled a passenger who requested a pickup at a Boston-area Starbucks last year. When Piekut arrived, he discovered it wasn’t a typical fare. “They were burned and wanted to go the emergency room,” he said. He treated the situation like any other ride, he said, dropping his passenger off at the hospital and not asking any questions. “I don’t know how bad it was, but I knew they were in pain really bad.

“I didn’t mind it,” Piekut added, saying that he would do it again. “I was already there, and I know the ambulance costs a lot.”

But that sentiment isn’t universal. Some riders have reported being turned down for an emergency ride.

On the web forum, some drivers shared stories of refusing passengers who looked like they needed emergency medical care. They cited reasons like not wanting to get blood on their car seats, or to be stuck with a dead body in their car.

One Boston-area driver for both Uber and Lyft, who requested not to be named for fear of hurting his business, recounted the story of a group of three people who hailed him last year. “The women tell me their friend is not feeling well, and they want me to take them to the emergency room,” he said. “I told them no and to just call 911. I have to respect the rules of the road; I can’t speed like an ambulance.

“And there’s definitely a liability thing,” the driver added. “If anything happened to the guy, it’s definitely on me and the insurance I have to carry.”

Officially Uber agrees that riders should call local police or emergency medical services for emergencies.

“It’s important to note that Uber is not a substitute for law enforcement or medical professionals,” said Uber spokesperson Brooke Anderson by email. “In the event of any medical emergency, we encourage people to call 911.”

Still, despite that official stance, the company does occasionally honor drivers on its website for providing emergency transport.

Emergency departments respond
A motivating factor for patients can be cost. The price of an ambulance ride to the hospital can range from $600 to $1000, according to the Department of Health and Human Services, while ride-hailing would rarely hit three figures.

Moreover, with ride-hailing, customers know the cost of a trip before they book it. Ambulance services, by contrast, send bills long after they are used, and often the final amount is unknown until the bill is received.

And using Uber or Lyft also lets users choose the hospital, said Chandra Steele, who wrote about taking Uber to the emergency room last summer in PC Magazine. Her medical emergency was severe bleeding, and she knew where she wanted to go.

“My brother was a doctor at the hospital I wanted, but ambulances have to follow certain protocols,” she said.
“Ambulances just take you to the closest hospital, which wasn’t the one I wanted to go to.”

And some emergency departments are even beginning to embrace the idea. Last summer, Washington, D.C., city officials began studying the use of ride-hailing to respond to what they describe as “non-emergency, low-acuity” calls, which accounted for nearly half the city’s 911 calls in 2015, according to a report released in February.

“In our research, we found that many of these calls did not require an ambulance,” said District of Columbia Fire and Emergency Medical Services Department spokesperson Doug Buchanan. In fact, he added, it would be better if more people used ride-hailing services instead of an ambulance. “We would love our residents to take that initiative,” he said.

Operators would route medical emergency calls to triage nurses, who would then determine whether the situation calls for an ambulance, a ride-hailing service, or something else altogether. It’s unclear whether drivers would get any special training for transporting such passengers.

The program is part of the mayor’s budget which will be voted on next month.

Dr. Mark Plaster, an emergency room physician in Baltimore, concurs that trips to the ER can vary greatly in severity — and that the transport options should as well.

“I would hope that no one who needed truly urgent medical attention would take an Uber,” he said. “If you need medical care en route, a private car is a bad idea, because you won’t have the personnel or equipment to treat you.”

He is not completely against the idea, however.

“Rideshares don’t take ambulances out of service, and not everybody coming into the ER is in a dire situation,” he said.
“And the ambulance can be expensive.”

“I don’t care how they get there,” he added. “Just get there.”

Original article can be accessed here.