News & Updates

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.

CHICAGO — Massive disruptions are ahead in health care, including blowing up the fee-for-service model and making care more affordable, Bernard Tyson, chairman and CEO of Oakland, Calif.-based Kaiser Permanente, told attendees at the American College of Healthcare Executives’ 2017 Congress on Healthcare Leadership on Tuesday.

Tyson challenged ACHE members to use their “firepower” to take health care to the next level and to invest in a system that provides something better than “episodic care after something has gone wrong.” This includes early diagnosis and treatment and helping patients with the behavior modification needed to manage chronic conditions.

“This is on our collective watch,” Tyson said. “We need to turn up the volume [about moving] from a sick-based system to a health-based system.”

Tyson noted that he was a supporter of the Affordable Care Act and was applauded when he said that it does not meet his definition of “disaster,” even though some politicians describe it as such.

Tyson told of how he met with President Donald Trump and said the president listened intently and asked “great” questions. Tyson didn’t dwell on the American Health Care Act, the GOP’s repeal-and-replace legislation, but told ACHE members that it was up to them to “pick up the pieces and move forward.”

“It looks like the Affordable Care Act will have another day,” Tyson said. “My hope is that, with whatever we come up with in Round 2, we don’t lose ground.”

He described the ACA as a “great step forward” in providing care to the working poor, and Tyson pledged to work toward further reducing health care disparities.

This means everyone having access to the health care system’s “front door,” Tyson said.

The future of health care also involves addressing the social determinants of health and recognizing that a person’s family history, personal behavior and where they live can have more influence on their well-being than anything that can be provided in a hospital or physician’s office, he added.

Tyson closed by recalling his own short hospitalization and how fortunate he was that he didn’t have to ask, “Am I going to be broke after this?”

Gina Calder, vice president of ambulatory services for Yale New Haven’s Bridgeport (Conn.) Hospital, said she was glad to hear Tyson speak to audience members about their collective responsibility to the country and their communities to provide care that is accessible to everyone.

“It doesn’t stop at our front door,” Calder said.

She also noted that value-based care “is here to stay.” In reference to Tyson’s comment about blowing up fee for service, Calder said, “I’m not sure that’s something we can avoid.”

Being reimbursed for outcomes allows organizations to invest in things like information-technology systems that provide data on what strategies produce the best outcomes, Calder said.

One recurring problem payers and providers grapple with is 30-day readmissions, and the financial penalties associated with them. To help address this issue, and improve patient outcomes, more organizations are turning to community paramedic (CP) programs that enlist the services of EMS teams to answer calls and offer short-term interventions that help divert patients away from emergency departments and funnel them back into appropriate care channels.

Kevin McGinnis, MPS, program manager of Community Paramedicine-Mobile Integrated Healthcare and Rural Emergency Care for the National Association of State EMS Officials, says community paramedicine got its roots in the late 1990s in the Northeast United States and Canada but didn’t come to prominence until the mid-2000s. There are roughly 170 documented CP programs nationwide.

“We can start to help the health system affect savings where others in the traditional healthcare system can’t because we’re in the community 24/7 and we’re used to being in patients’ homes,” McGinnis says. Data suggests CP programs are effective in reducing repeat ED admissions and 30-day hospital readmissions, he adds. “… This is one small solution that the healthcare system can invoke.”

Diversion tactics
CP programs work by allowing EMS personnel to answer emergency calls and assess patients’ needs to determine whether less-costly, more beneficial interventions are appropriate. Patients may need a quick fix for low blood glucose and a referral to an endocrinologist, for example. “They can take care of the issue right then and refer the patient for primary care at a future date. Or they can refer patient to a higher level of care more immediately,” McGinnis says. “It’s very powerful. It’s that triage force. You don’t want triage being done in the ED, you want to come out in front of the ED to do that.”

CP programs are also offering additional services. Dan Swayze, DrPH, MBA, MEMS, vice president and chief operating officer of the Center for Emergency Medicine of Western Pennsylvania, Inc., says that while community programs vary from state to state, most utilize the services of community paramedics for areas within their scope of practice where there are gaps in traditional care, such as for patients without insurance who don’t qualify for home health nurse visits. “Some home nursing agencies are actually contracting with CP services to supplement their care, to help reduce the likelihood their patients will be readmitted to the hospital,” Swayze says.

CP programs are also helping bridge the gap between health and human services, he says. They can provide patient navigation and patient advocacy services for patients who can’t get them on their own or who need help finding the right program.

“Our CPs often accompany patients to their providers’ visits so we can reinforce and translate the next steps in ways the patient will understand when they get back home,” Swayze says. “Once we address the underlying social determinant issues facing the patient, we find that their dependence on 911 and the local emergency department goes down drastically. It’s much more effective to have a paramedic call these patients than it is to continue to react as we have traditionally done.”

He adds that more CP programs are coming from hospitals that operate their own ambulance service. “The medics are already FTEs in the healthcare system and hospital administrators are beginning to realize it’s more cost effective to deploy the medics to the patient based on their predictive and risk stratifications models rather than waiting for the patient to call 911,” he says.

Financial drivers
Matt Zavadsky is director of public affairs for MedStar Mobile Healthcare, a governmental agency that is the regional 911 EMS provider for 15 Texas cities, including Fort Worth. MedStar also operates a CP program. Zavadsky says EMS teams have traditionally only been paid for transporting patients to the hospital or ED, with no reimbursement for patients treated on the scene without transport. “So we transport them to pay our employees and that’s just silly,” Zavadsky says.

Now, hospitals and payers are using incentives from the ACA earned through lower ED admissions and hospital readmissions to change the reimbursement structure. “Any health system migrating to a population health strategy has to recognize that all their efforts can be thwarted by the patient with a quick call to 911. As systems consider how best to transition to value-based care, they should take a serious look at their local EMS agencies as partners in the process,” Swayze says.

MedStar is paid primarily for 911 ambulance service, Zavadsky says. It also is paid for CP services. Hospitals and other agencies, such as an IPA, pay an enrollment fee for the enrollment. It also receives per member per month payment from hospice agencies. Third party payers are negotiating with the cost savings plan, though it was not yet in effect at press time, says Zavadsky.

Filling an unmet need
Zavadsky says that patients who are surveyed after hospital stays say they only understand their discharge instructions 40% of the time. They may have questions that only come up after they leave the hospital, then forget by their next appointment. These things that can lead to ED visits and readmissions.

“It’s not that they want to be noncompliant, it’s just that they don’t know any other way to be. Nobody has the time to sit with that patient in an area that’s comfortable for that patient and explain,” says Zavadsky. “We’ve put 3,000 to 5,000 patients through these [CP programs] and 80% of what we’re doing with these patients isn’t clinical. It’s educational.”

Zavadsky says his agency has tracked 475 patients using the CP mobile healthcare services for 24 months and found that EMS calls were reduced by about 55% in patients enrolled in the CP program. That translates to an estimated $8 million cost savings to health systems thanks to the change in the patient’s utilization of services. That estimate, Zavadsky says, is based on ED facility payments and Medicare cost savings and isn’t inclusive of additional costs for lab work or specialist care.

Original article can be accessed here.