The quest of American EMS providers for more sensible reimbursement reached a key threshold on January 1, 2018, when Anthem BlueCross BlueShield began paying for treatment without transport for patients in states where it offers commercial coverage.
The major insurer’s new policy marks a vital step toward the goal of sustaining community paramedicine and mobile integrated healthcare programs that have sometimes struggled to find ongoing financial footing.
“We spend a lot of money in this country on healthcare, and our quality outcomes are not as good as other industrialized countries that spend less,” says Jay Moore, MD, senior clinical director for Anthem in Missouri. “We need to figure out a way to get a handle on that. We want to be able to provide healthcare in a way that’s affordable for people and sustainable for the future, and I think the only way to do that is to involve people at all levels of healthcare. Whether it’s physicians, nurses, paramedics, EMTs, whomever it might be, it’s something all of us are going to have to work together to solve. In my view this is definitely a step in the right direction.”
The reimbursement will be offered for HCPCS A0998-coded 9-1-1 responses in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, and Wisconsin. The company hopes to include its Medicare and Medicaid plans as well, though there are varying state requirements to navigate first. Due to those differences, not all 14 states officially began January 1.
Payment will be at around 70% of the average reimbursement for an ambulance run in each state—“Less than the payment for an emergent response with transport, but not a lot less,” says Moore. “And the resource utilization is presumably lower.”
While similar efforts have been piloted here and there, Anthem is the first major insurer to take such a global approach to compensating care that doesn’t culminate at the emergency department. The implications for EMS are large.
“Ever since the EMS Agenda for the Future was published in 1996, EMS has been striving to enhance our role in the healthcare system from being merely a supplier of transportation to a provider of healthcare,” says Matt Zavadsky, chief strategic integration officer at Texas’ MedStar Mobile Healthcare and president-elect of the NAEMT. “Anthem’s decision is a major step toward us being considered a provider of healthcare.”
“For the first time we have a major private payer who’s looking to give reimbursement to EMS for services we normally don’t get paid for,” says Chris Cebollero, a veteran EMS leader and consultant who worked with the company on developing the plan. “This is really major in the EMS world and for the transformation of EMS into its new environment. This is the moment we’ve been waiting for.”
High Numbers, Low Acuity
The new policy grew from a collaboration between Cebollero and Moore that began when they both worked for hospitals in the St. Louis area. Moore noticed high numbers of low-acuity patients coming through his ER at SSM Health DePaul Hospital. Questioning it, he discovered carriers didn’t commonly compensate for calls under A0998, which covers ambulance response and treatment without transport. That forced EMS to bring patients to hospitals to get paid.
As head of Christian Hospital’s EMS division, Cebollero was well aware of that as his organization worked to build a community paramedic program aimed at curbing heavy users. “I wanted to collaborate not only with our ED, but with other hospitals too,” he says. “If the frequent flyers we stopped taking to our emergency department started showing up at other emergency departments, we wanted to stop that too. We didn’t want to just shift high utilizers from one ED to the other.”
Moore’s 2014 move to Anthem BlueCross BlueShield provided the opportunity for a bigger approach. He wanted to invest in community paramedicine; Cebollero became a consultant in building such programs. Moore initially sought Cebollero’s collaboration in developing CP programs for certain hotspot areas—then they realized they could aim higher.
“We started looking,” Moore says, “at how we might be able to implement this in all our Anthem states across the country.” And he found Anthem’s leadership open to trying alternative approaches: “We’re interested and willing across the company,” he adds, “to engage with progressive providers who are interested in doing things besides the traditional fee-for-service model.”
In the future that might involve procedures such as non-9-1-1 home visits, medication checks, and more, but for now the hope is a modest reduction in unnecessary ED transports, which Moore hopes to trim by 5%.
Meanwhile, for EMS, a long-sought opportunity is finally at hand. Now the onus moves back to us to take advantage of it.
“We have to be able to step to the table and use the code so Anthem can see the value and want to invest in the next pieces as well,” says Cebollero. “Community paramedicine has been going on for some time, and there have been a lot of great programs that failed because of financial sustainability. We have to be able to end our dependence on CMS and look more globally. We have to be proactive and engage the payers, the hospital systems, the ACOs, and say, ‘Look what we can do for you, but more important, what we can do for our patients.’ Even though this is a small component of our reimbursement model right now, the dominoes are all set up, and the finger is ready to flick. If you have a CP program, it’s time to put it into the next gear.”
Sidebar: How to Get Ready
If you run 9-1-1 responses in the states in which Anthem offers commercial policies, you’ll need to get ready to take advantage of this landmark change in policy. Here’s a quick to-do list:
Start talking to your medical directors. How ready are they for this change? Protocols may need implemented or updated. Additional training may be required. QA mechanisms will need put in place. “We don’t want to put anybody at risk,” says Moore. “We want to make sure the medical directors are involved and protocols are well thought out. Sometimes those do need to be updated, because this isn’t the mind-set EMS has had in the past.”
Once you have things hashed out with the docs, go to your workforce. They’ll likely have questions about training, protocols, and processes. Their support is essential for change.
If you haven’t already, start developing lists of community resources to which patients can be referred for assistance when you’re not transporting them. They may require additional care or help with needs such as transportation, food, and utilities. “Knowing care resources that are willing to accept referred patients from EMS and which of those are in-network for the payer is very important,” notes Zavadsky. And in your agreements with such resources, make sure they’ll provide outcome data back to you. As an example, say you refer a caller with a minor complaint to urgent care. “For patient safety and quality assurance,” Zavadsky says, “they should agree to let you know, in relative real time, if the patient is seen and sent home or referred to an ED or admitted to a hospital. That way you can include outcome data as part of the program quality assurance process.”
Finally, whether you bill in house or use a contractor, make sure your billing processes can bill under the A0998 code for treat-and-refer patients. This will require differentiating payers (Anthem vs. others) and, if you bill a token amount expecting it won’t get paid, possibly reflecting the actual cost of service.
John Erich is senior editor of EMS World. Reach him at email@example.com.