Getting the Payers to Play

Getting the Payers to Play

By John Erich Apr 04, 2013

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UPMC and Highmark are two of the Pennsylvania healthcare system’s heavyweights. UPMC, the University of Pittsburgh Medical Center, boasts a sprawling network of 20 hospitals, 400 doctors’ offices and outpatient sites, 54,000 employees and even a health insurance division. Highmark is the largest health insurer in the commonwealth and also next door in West Virginia, and one of the largest not-for-profit health insurers in the U.S.

These leviathans are currently locked in a bristly dispute over Highmark’s attempts to acquire the financially troubled West Penn Allegheny health system. But that hasn’t stopped them from cooperating to support a unique community paramedic venture beginning this summer in the Pittsburgh area.

Between them, UPMC and Highmark are funding a $600,000 pilot project that will bring CP care to the homes of at least 1,000 patients across Pittsburgh and three dozen neighboring communities. The effort also involves the University of Pittsburgh’s Congress of Neighboring Communities (CONNECT), the Allegheny County EMS Council, and the Center for Emergency Medicine of Western Pennsylvania (CEM).

“The unique thing about this project is that it’s the first time you really have multiple payers and multiple hospitals involved in a community paramedic initiative,” says CEM Vice President and COO Dan Swayze, DrPH, MBA, MEMS. “There are lots of models out there that involve one or two agencies, but with this one I think we’re really covering most of the insured population, with a mechanism to cover the uninsured as well, and working collaboratively with all the hospitals in the area. It’s a much broader project than others.”

CONNECT was created to facilitate cooperation among Pittsburgh and its suburbs, which combined have around 700,000 residents. The community medic idea arose among CONNECT members years ago as they confronted troubles in supporting their ambulance services. When they began weighing the CP option, Highmark and UPMC seemed to have a stake. “With the changes of healthcare reform,” notes Swayze, “there was a thought they might have some interest in doing something to help these EMS agencies.”

In fact UPMC, which itself insures more than a million people, has been supporting community paramedic efforts through CEM for years. And Highmark, which serves the 29 counties of western Pennsylvania as Highmark Blue Cross Blue Shield, also saw the potential benefit. “It’s partnerships like this one…that will improve healthcare in the community well into the future,” the company’s Aaron Billger told the Pittsburgh Tribune-Review.

The community medics will work to prevent 9-1-1 calls and hospital admissions and readmissions by helping patients do things like fill prescriptions, get to appointments and comply with physicians’ orders. They’ll focus on those with chronic and high-readmission conditions (e.g., asthma, diabetes, CHF), on EMS frequent flyers and on others at risk. Patients will be referred to the program by hospitals, the payers and the EMS agencies that witness their daily problems.

“It includes members of the community EMS providers themselves are worried about,” Swayze says. “People who needs lift assists or maybe an elderly patient where you have concerns about their living conditions. There’ll be an opportunity for EMS agencies to refer those types of patients into this program.”

Patients will get a 10-digit nonemergency number to call for help or with questions, and CPs will work with primary-care physicians and social service agencies to meet their needs.

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The goals of the project are reduced use of EMS and emergency departments, smarter use of EMS resources, improved connections among participating agencies and better care and follow-up for patients.

There’s reason to be optimistic. The CEM, which is training the new community paramedics, has seen promising results from its previous CP efforts. Its data, according to President Douglas Garretson, show patients getting help from community paramedics can better manage their conditions.

This project’s community medics should hit the streets in June, and the program will run for two years. If it’s successful, it could be expanded throughout the county or even state. And it could provide a valuable proof of concept for major insurers to sink some investment into CP efforts that could save them money later.

“One of the goals of this,” says Swayze, “is changing the mind-set of the payers to accept this new role for EMS agencies—to show them there’s value in having this workforce out there working on their behalf in a role other than just medical transportation.

“If we can show—and I’m confident we will—that community paramedics can help patients manage their chronic illnesses and transition from the hospital to home, and that paying EMS for that type of service increases the quality of care the patient receives, then this is a value not only for the health plans and the hospitals, but for a lot of patients as well.”

Sidebar: The Barrier of Data

One of the challenges of emerging community paramedic programs is collecting data. “One of the limiting factors we’ve found so far,” says Swayze, “is that most EMS patient record systems are designed to be episodic in nature. They’re not designed to follow a patient for a month. So what we have to do is find a way to track all the different contacts we have with the patient, and all the different organizations and physicians we may talk to on that patient’s behalf, in one system that can show their progress and ultimately show whether we were able to affect their healthcare utilization and quality of life.”

Sidebar: How to Evaluate Your CP Program

Is your community paramedic program well constructed? It’s probably hard to tell. Every one is different, and we lack much in the way of accepted benchmarks by which to assess them.

An initial effort at such a mechanism came last year from the Health Resources and Services Administration, which assembled an expert team to develop a Community Paramedicine Evaluation Tool (available at www.hrsa.gov/ruralhealth/pdf/paramedicevaltool.pdf). It is intended to provide a common scoring framework for a number of key elements by which CP programs can be measured and evaluated.

The tool is broadly divided into areas of assessment, policy development and assurance, and within each provides benchmarks to attain, supporting indicators that define each, and parameters for scoring your system. It suggests a consensus-based model scoring process using multidisciplinary input. No system will get a perfect 5 on every indicator, the authors warn, but the tool can help programs identify their stengths and weaknesses, prioritize action and measure progress over time.

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