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Association Update: NAEMT Advances Nontransport Payment Reform

During a recent conversation with a reporter, I was asked why EMTs and paramedics aren’t paid more. It was a unique opportunity to share the fundamentals of EMS economics—and what NAEMT is doing to try to change EMS payment models to help our members and their patients.

For more than 50 years, payment for ambulance transport has been one of the only ways to generate nontax EMS revenue. Fee-for-transport has been the foundational economic model for EMS since the passage of the Social Security Act in 1965, which included the provision that ambulance transportation was a covered benefit for Medicare and Medicaid beneficiaries. Limiting payment to transportation has had the unintended consequence of undervaluing the medical care provided by EMTs and paramedics.

The U.S. healthcare system is undergoing a deliberate transformation away from transactional, fee-for-service payment models to economic models based on quality and value. This represents significant opportunities for EMS to fundamentally change our role in the healthcare delivery system. 

To advance the EMS profession, including enhancing pay rates for EMTs and paramedics, we need to transform the economic model to compensate EMTs and paramedics as healthcare providers. NAEMT has been the leading voice for the EMS 3.0 transformation, which promotes payment for the value of the medical care EMS practitioners provide, not just the transportation they supply.

CMS and the Center for Medicare & Medicaid Innovation (CMMI) reached out to NAEMT in June 2018 to engage in a process to evaluate alternative EMS roles such as treat-and-refer services, transport to alternative destinations, community paramedicine, and 9-1-1 nurse triage. We participated in four conference calls with CMS and CMMI leaders and provided sample training programs, protocols, quality assurance processes, outcome measures, and examples of payers currently paying EMS for services other than transport to an emergency room. Potential new EMS payment initiatives were expected to be announced at a February meeting involving CMS and CMMI and numerous EMS organizations.

Defining and paying for quality medical care is part of the shift to value-based payments. NAEMT recognizes the importance of being on the forefront of creating the value metrics that may serve as the basis for EMS payments in the future. It is for this reason that NAEMT is a founding member of the National EMS Quality Alliance (NEMSQA), an industry-led organization designed to create and adopt quality measures for EMS. 

As we work toward the longer-term goal of a value-based EMS economic model, we also need to focus on our low reimbursement rates from Medicare, Medicaid, and commercial insurance, coupled with the high number of uninsured patients we treat, which places exceptional financial pressure on many EMS agencies.

NAEMT, the American Ambulance Association (AAA), the International Association of Fire Chiefs (IAFC), the International Association of Fire Fighters (IAFF), and other national associations worked feverishly to assure the Bipartisan Budget Act of 2018 (BBA) included provisions for the continuation of the Medicare extenders (add-on payments) for ambulance services, helping maintain a consistent revenue stream.

The BBA instructed CMS to analyze costs and revenues related to ambulance service provision to determine the adequacy of the current Medicare ambulance fee schedule. CMS contracted with the RAND Corp. to help guide the development of an analysis tool. NAEMT worked with RAND and CMS to host several focus groups to help build the cost and revenue analysis model.

Two were held at EMS World Expo (one for EMS managers and one for EMS practitioners), and three more were held via teleconference (focusing on rural and volunteer EMS agencies and those who participate in current cost data collection processes). Because NAEMT’s membership is truly representative of all delivery models, we are the only national association able to bring virtually every type of EMS system to the table for RAND—public, private, hospital-based, urban, rural, and volunteer.

NAEMT also understands the significant challenges faced by rural EMS agencies. An example was our work on the Supporting and Improving Rural EMS Needs (SIREN) Act. NAEMT worked side by side with congressional sponsors, the IAFC, IAFF, and National Volunteer Fire Council to help pass this important initiative. The SIREN Act reauthorized a federal grant program to directly support rural EMS agencies in recruiting and training personnel and purchasing equipment such as naloxone and first aid kits, power stretchers, and new ambulances. We are now working to get this bill funded in Congress. 

We are at a very exciting time for the EMS profession. Decades of work have led us to the brink of completely changing the payment models for EMS and being compensated for the care we provide, not just the transport we supply. It is NAEMT’s mission to advance the EMS profession. One aspect of that is transformation of the payment model to appropriately compensate EMTs and paramedics for the value they bring to the healthcare system. We encourage you to join us in this effort by continually seeking new opportunities to educate local, state, and federal officials and our other stakeholders on the current and expanded role of EMS. 

Matt Zavadsky, MS-HSA, NREMT, is president of NAEMT.


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