We may have reached the tipping point for EMS-based mobile integrated healthcare and community paramedic (MIH-CP) programs. That may seem like a bold statement, but consider the following:
In 2009 there were only a handful of these programs across the country, in places like Pittsburgh; Wake County, NC; Eagle County, CO; and Fort Worth, TX. Today, according to the NAEMT MIH-CP survey, there are more than 130 active, formal MIH-CP programs in the United States.1
The Center for Medicare & Medicaid Innovation has granted over $30 million for innovations that include various forms of MIH-CP.2,3
In the industry release announcing the formation of the Healthcare Leadership Alliance, Donald Berwick, MD, the developer of the Institute for Healthcare Improvement’s Triple Aim, refers to community paramedicine as an example of a healthcare innovation that’s emerging faster than the regulatory environment can address.4
USA Today5 and Kaiser Health News6 profiled the REMSA Community Health Program in national publications.
The Agency for Healthcare Research and Quality has profiled three separate MIH-CP programs as part of its Healthcare Innovations Exchange.7–9
Despite growing evidence that these programs improve patient outcomes and reduce cost, many are threatened. The most common challenge for EMS-based MIH-CP programs continues to be financial sustainability. A recent survey of more than 100 EMS-based programs revealed that 89% of agencies operating them identified financial sustainability as a significant hurdle. Further, 62% reported they received no revenue from their programs, and 78% of programs generated less than $100,000 annually.
Let’s lay out the foundation of our healthcare economic environment today for each of the potential payers for MIH-CP services.
Hospitals are at risk for up to 4.5% of their total Medicare payments based on readmissions (3%) and value-based purchasing (VBP) measures (1.5%). All-cause readmissions are measured for patients discharged with MI, heart failure and pneumonia diagnosis related groups (DRGs). In October 2014, COPD and hip and knee replacements were added to that list of DRGs. The three-year trend for most hospitals has seen increasing readmission penalties. The VBP measures are things such as the clinical process of care, patient outcomes and the patient’s experience of care.10 This year CMS added the metric of Medicare spending per beneficiary (MSPB). This evaluates the average spent by Medicare for the three days preadmission, during the inpatient stay and for 30 days postdischarge. If the MSPB is higher than the state or national average, the hospital may face additional financial penalties. For some hospitals, the financial incentive to reduce high readmission penalties may outweigh the actual payments they receive for the admission.
The motivation to improve patient outcomes, reduce readmissions, improve the patient’s experience and reduce the MSPB drives hospitals to fund EMS-based MIH-CP programs. Dawn Zieger, community health project director for Texas’ John Peter Smith Health Network, explains why it’s funding an MIH program: “JPS saw an opportunity to expand our reach into the community with [Ft. Worth-based EMS-MIH service] MedStar,” Zieger says. “Their community health program is able to assess things we will never see in the hospital, such as how people get to primary care. They are able to assess their diet and what’s really going on in the home, not necessarily what they tell the doctor. They can extend the reach of the hospital to meet people where they are and help change behaviors.”
With specific regard to the economic model JPS uses to fund MIH-CP activities, Zieger explains: “We’ve really structured this program to be outcome-focused, so if we really get folks into primary care and avoid those unnecessary emergency department visits, we all share in an outcome pool that’s shared between JPS and MedStar.”
A further demonstration of the desires of hospitals to find and fund innovative ways to deliver effective postacute care comes from Valley Hospital in Ridgewood, NJ. It launched a mobile integrated healthcare program in August 2014 to provide proactive postdischarge home checkups to patients with cardiopulmonary disease who are at high risk for readmission and either decline or don’t qualify for home care services. In the program, a team composed of a paramedic, an EMT and a critical care nurse conducts physical exams of the patient, offers medication education, reinforces discharge instructions, completes a safety survey of the home and confirms the patient has made a follow-up appointment with a physician.11
Integrated Delivery Systems
An IDS is a coordinated group of providers, in some cases including a payer component, who have aligned missions to improve patient outcomes while reducing the cost of care. Many groups have the desire to improve patient outcomes and right-size utilization. They are often in the unique position of being both a payer and a provider, such as with the University of Pittsburgh Medical Center (UPMC) or the Presbyterian Health System in New Mexico. The unique perspective of an IDS makes it a logical funder of MIH programs. One of the most recognized in the nation is Kaiser Permanente. In the recently published book Mobile Integrated Healthcare: Approach to Implementation, Rahul Rastogi, MD, director of operations for continuing care services and quality value management at Kaiser Permanente Northwest, highlighted the reasons it’s been partnering with local EMS providers on MIH-CP programs:
“At Kaiser Permanente Northwest, we see expansion of our delivery system in the area of prehospital care, integral to and aligned with our mission to transform care and achieve the Triple Aim,” Rastogi says. “We recognized there is a tremendous information gap between hospital and clinic-based care teams, and the scope and skills of the EMS and prehospital care teams. In order to close that gap and build trust, we used the ‘plan, do, study, act’ methodology. By using a series of PDSAs, we were able to develop much greater understanding, respect and team strength to launch our expansion and to see past the traditional ‘Johnny and Roy’ perception of EMS providers. By looking for small possibilities and taking small steps that centered on the needs of the patient and healthcare system, pathways to success became clear, making alignment easier and increasing the chances for others to see successful opportunities and value.”
Home health agencies have a unique set of challenges. Due to the focus on preventable readmissions, hospitals refer patients to home health agencies that can ensure a low readmission rate. Those agencies that, in the hospital’s perspective, are not achieving the goals of preventing readmissions may not receive referrals from the hospital. Further, the Medicare Payment Advisory Commission (MedPAC) recently recommended that home health agencies be placed on financial incentives to reduce preventable readmissions, much like the hospitals have been since 2013.12
This creates a logical alignment of incentives for home health agencies to partner with EMS-based MIH services to help navigate home health patients in the event they call 9-1-1. J. Daniel Bruce, administrator for Klarus Home Care in Ft. Worth, explains in a recent interview: “Our partnership with EMS allows us to enter into their database all our patients within their service area, so that when our patient calls 9-1-1, the EMS team knows it’s a Klarus home health patient, and they can call the Klarus nurse, whether it’s 3 in the morning or 2 in the afternoon. That nurse and the paramedic can work together to triage that patient in the most effective way to help them.”
Bruce goes on to explain the economic impact home health and partnerships between home health and EMS-based MIH programs can have on healthcare expenditures: “The average cost of a patient going back to the hospital in our area for congestive heart failure is $9,203. So every time we can partner with EMS or have our nurse go see a patient for CHF and treat those symptoms and keep them in the home, we’ve saved the healthcare system $9,203.”
Hospice is one of the fastest growing components of our healthcare delivery system due to the recognition that palliative care is an appropriate and humane part of healthcare delivery. It also has a significant impact on healthcare system expenditures. Thirty percent of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with a third of that cost occurring in the last month of life, often with little or no impact on the patient’s outcome.13 A recent study published in the Journal of Clinical Oncology found the average Medicare expenditure for a patient in hospice is $6,537, while the Medicare expenditures for a patient who disenrolls from hospice total $30,848.14
When a patient is enrolled in hospice, the hospice fee (typically a per-diem payment based on the care setting and patient diagnosis) covers all hospice-related care. The hospice provider is at financial risk if the cost for delivering the patient’s services in the hospice plan of care exceeds the revenue generated from the hospice payment.
The clinical, emotional and economic incentive for home hospice is to help the patient transition to their next care setting peacefully at home. Consequently, ambulance trips to high-cost care settings such emergency departments or inpatient hospital stays for hospice-related episodes of care are not in the best interests of the patient, family or hospice agency.
These challenges also make a logical case for hospice agencies to partner with EMS to fund MIH programs designed to help patients transition to death comfortably.
In Mobile Integrated Healthcare: Approach to Implementation, Monica Cushion, director of market development for VITAS Healthcare, writes: “VITAS is so proud to work with MedStar and its community health program. Over the past two years, MedStar and its mobile health paramedics have proven to be a great support for and partner to VITAS hospice staff as we endeavor to care for the community’s most medically complex patients in their own homes. The MedStar/VITAS community collaboration has enabled VITAS-Fort Worth to keep our revocation rates well below the national average and our family satisfaction high. We are grateful for our collaboration with MedStar.”
Here are some key points to consider when engaging in conversations with potential payers for EMS-based MIH-CP programs.
The realignment of fiscal incentives within the healthcare system has created an environment that encourages providers and payers to work together to right-size utilization.
Providers and payers are often unaware of the true value EMS agencies can bring to their patients through proactive and innovative patient navigation services. You need to tell them—or, better yet, show them. You may need to do a small demonstration project with a handful of patients to prove you can make a difference.
In order to understand the new environment, you need to become well-versed in healthcare metrics, specifically as they relate to the partners to whom you’ll be proposing. Be sure you know things like readmission rates and penalties, value-based purchasing penalties, HCAHPS scores, MSPB and other motivating factors you can use to help build the business case for your audience.
For many in EMS, crafting partnerships for payment of services not related to ambulance transport is a new and scary thing. Hopefully the examples provided here from payers paying for MIH services have demonstrated that their perspective is not much different from ours. We are all trying to do the right things for our patients, improve their experience of care and reduce the cost of the healthcare system.
13. Barnato AE, Mcclellan MB, Kagay CR, Garber AM. Trends in Inpatient Treatment Intensity Among Medicare Beneficiaries at End of Life. Health Serv Res, 2004 Apr; 39(2): 363–76.
14. Carlson MD, Herrin J, Du Q, et al. Impact of hospice disenrollment on health care use and Medicare expenditures for patients with cancer. J Clin Oncol, 2010; 28: 4,371–5.
Matt Zavadsky, MS-HSA, EMT, is the public affairs director at MedStar Mobile Healthcare, the exclusive emergency and non-emergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas and the recipient of the EMS World/NAEMT 2013 Paid EMS system of the Year.