Policy: Community paramedic-type projects require ongoing support.
Strategy: Entrench in law; seek other novel sources of funding.
Vision: Broad-based programs with demonstrated benefits reducing 9-1-1 use and hospital admissions.
Minnesota led the nation in embracing the idea of community paramedics. Now it’s leading the way in getting them paid.
A bill passed last year in the Minnesota legislature established reimbursement through the state’s Medicaid program for a range of common CP-style activities. And with a final blessing in February from the federal Centers for Medicare & Medicaid Services (CMS), those first community medics to hit the streets can now get paid by the state for the care they’re providing.
Covered activities include health assessments, immunizations and vaccinations, chronic disease monitoring and education, collection of lab specimens, medication compliance checks, hospital discharge follow-up care and minor medical procedures approved by a medical director. Community medics must work under the supervision of an ambulance service medical director, who, with an order from a patient’s primary-care provider, then bills Medicaid for the services delivered.
“We felt that unless we had a secure reimbursement source, the idea of community paramedics would be slow to catch on, or there wouldn’t be any interest at all,” says O.J. Doyle, a longtime lobbyist for the Minnesota Ambulance Association who helped get the legislation passed. “There was support for it conceptually, but without the revenue it would have been tough to do.”
The 2012 bill, SF 1543, followed 2011 legislation that defined community paramedics in law and directed the state to identify services to be covered by Medicaid. The state submitted that list for CMS approval last August. It’s also developing a fee schedule that will ultimately serve as a basis for other health plans to develop managed-care rates.
The only community medics currently working in Minnesota are from the Minneapolis-area North Memorial Medical Center, which fields nine in the northwest Twin Cities area. More have been trained, and other deployments are coming. North Memorial’s CPs work from primary care clinics in north Minneapolis and target patients considered at high risk for medical recall—those on 10 or more medications or medications with tight therapeutic windows; those with multiple chronic diseases; those with mental health/disability issues.
They’ll be able to bill Minnesota’s Medicaid program, Medical Assistance (MA), retroactively to July 2012, when the law went into effect. “There’s quite a period we can do retroactive billing for,” says Buck McAlpin, North Memorial’s director of government affairs.
Minnesota’s efforts to realize community paramedics go back nearly 15 years, when leaders first started looking at unmet healthcare needs, mostly in rural areas of the state. The idea of filling them by expanding the roles of paramedics was slow to catch on, but funding from the state Office of Rural Health and Primary Care let a curriculum be developed and pilot program launched, which suggested feasibility on a larger scale. Over subsequent years, as coverage gaps emerged and dollars grew scarcer, the political climate became more hospitable; meanwhile, bill supporters courted allies, assuaged opponents and, 19 drafts later, finally got a CP bill passed in 2011.
If it seems like a long road, it was; the biggest challenge since the beginning has been that no other state had previously set forth CPs in law, so there was no model or template for establishing them and getting them paid.
Given that, supporters in Minnesota laid substantial groundwork. They broadly shared the first bill language they drafted before the 2011 legislative session with other healthcare system players, including groups they saw as potential adversaries. They worked to dialogue with those groups about concerns, address their issues and refine the bill’s language. This tempered any surprise that might have greeted its introduction and ultimately resulted in legislation that was stronger and more broadly palatable.
Eventually there was widespread support. Nursing groups were the biggest early impediment in Minnesota, but their concerns were effectively assuaged. Home-healthcare providers have been a tougher sell, and work continues to flesh out coexistence with them.
Meanwhile, CP efforts grow. A program starting in Faribault will focus on geriatric, mental-health and chemically dependent patients; partners include a local hospital, clinic and county public health, with funding from insurer Medica (for more on the involvement of insurance companies in community paramedic efforts, see the other main feature in this month’s EMS 2020 section). Another in rural Park Rapids (population 3,700) in western Minnesota involves public health and the Essentia Health system.
The sense is that these programs can effectively fill gaps in the healthcare system, but there remains the matter of proving it. To that end Minnesota’s leaders are working on a template to collect data from CP encounters and try to quantify their cost savings. “We hope to have data available in the next few months,” says McAlpin; a report is due to the Minnesota legislature in January 2014.
In the meantime, in anticipation of success, a $250,000 grant from the Department of Labor will train 100 more community medics over the next three years, and a CMS Innovation grant to the state Department of Human Services may also help expand their use.
Sidebar: Keys to Success
Four keys to the success of Minnesota’s community paramedic program outlined by North Memorial’s Marc Conterato, MD, at this year’s EMS State of the Sciences Conference:
1) Recognition of community paramedic as a provider in law;
2) Certification necessary to begin payment model discussions;
3) State agency recognition of CP and a recourse for complaints and continuing education;
4) Verification and certification of CP curriculum by a state agency.
Sidebar: Partners in CP Programs
• Medical directors
• Primary care
• Home health
• Public health
• Affiliated clinics
• State departments of health/human services
• Federally qualified health centers
• Community health center lookalikes
• Payers (commercial & government)
• State EMS board
• SNFs/Transitional care
Sidebar: Tips for EMS Success at the Statehouse
As a longtime lobbyist for the Minnesota Ambulance Association, O.J. Doyle was key in helping get that state’s community paramedic legislation passed, as well as numerous other measures benefiting EMS. He offers the following tips for success at the statehouse:
• Have a presence and develop relationships. All issues bring out unique advocates, but for sustained success it’s better to build long-term bridges. The MAA has had its presence in St. Paul for three decades; lawmakers know its faces and issues.
• Be patient. Getting what you want takes time. “Decisions are made by the people who show up, and that’s really the case here,” says Doyle. “You have to show up year after year, because then when you have the big ask, you’re already established.”
• There’s no substitute for EMS experience, which lends credibility and first-hand knowledge to pleas made to legislators. Says Doyle,“When you’ve been in the back of a rig, they tend to defer to that expertise.”
• Don’t forget the executive branch. Know top honchos at places like human services departments and others central to executing bills that are passed. “The legislature can pass a law,” warns Doyle, “but if the state agency that’s affected isn’t interested in executing it, they can drag it out forever.”
• Be adaptable. The winding journey of Minnesota’s CP bill (19 drafts) is the stuff of legend, but hearing and addressing the concerns of stakeholder groups and skeptics gained support and made for a stronger bill.