Over 2018 EMS World, in conjunction with the National Association of EMTs, will provide detailed implementation strategies for key recommendations of the Promoting Innovation in EMS (PIE) project. The PIE project utilized broad stakeholder involvement over four years to identify and develop guidance to overcome common barriers to innovation at the local and state levels and foster development of new, innovative models of healthcare delivery within EMS. Each month we will focus on one or more recommendations and highlight the document’s actionable strategies to continue the EMS transformation.
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You and your partner respond to a victim of a fall. Your patient, a 25-year-old male construction worker, has possible bilateral tib/fib and pelvic fractures, as well as a possible head injury. After appropriate on-scene care and trauma alert activation, you safely transport him to the local Level 1 trauma center. The next day you and your partner are curious how the patient fared, what injuries were actually found, and whether your treatments were appropriate based on his outcome. You stop by the ED, but, citing HIPAA issues, no one is willing to share with you the patient’s current condition or status.
This is all too common of a frustration in EMS. It also inhibits the professional growth our profession requires to enhance clinical competency and critical decision-making skills. This is likely why the NAEMT’s EMS 3.0 Committee ranked “National EMS associations should promote efforts to integrate EMS and hospital records” as one of the top five recommendations contained in the Promoting Innovation in EMS (PIE) project.
Interestingly, this recommendation is found under the Improve Clinical Feedback heading of the Education section. At first blush it may seem an odd recommendation to be in the education section, but a deeper understanding of the value of integrating EMS and hospital records reveals why it’s an appropriate education strategy.
If field EMS providers can query the status of patients they’ve treated, they can learn a lot about their assessment skills, the success of their interventions, and the overall impact of their care on the patient’s outcome. This knowledge can help them sharpen critical clinical skills. More globally, access to patient outcomes could be used for quality assurance programs and to develop continuing education programs based on evaluations of what field assessments and interventions were completed by EMS and the patient’s actual diagnosis.
Let’s ponder some possible strategies and tactics national EMS organizations (the “actor” named in this recommendation) might employ to bring this recommendation to reality:
Members of the National Association of State EMS Officials (NASEMSO) could work to promote regulations that require discrete elements of health information data to be shared between hospitals and EMS agencies as a requirement for licensure. While this may seem an overreach of authority, there is precedent in some states for exactly this idea. Many state regulatory bodies, for both hospitals and EMS agencies, require data submission as a requirement for licensure. It’s not such a big step to do the same thing for sharing health data between EMS and hospitals.
Additionally, the American Heart Association could promote the inclusion of patient-level data sharing with EMS as a required condition for specialty cardiac or stroke accreditation. For example, one current requirement for cardiac center accreditation is that the hospital interface regularly with local EMS agencies. MedStar Mobile Healthcare has participated in several accreditation site visits for hospitals specifically to share with site reviewers how the hospitals integrate EMS into their operations. This information usually takes the form of meeting minutes with lists of attendees, as well as personal testimony from EMS agency representatives. Imagine if there were an added element in the accreditation standard that required hospitals to share data elements with EMS. If the hospital really wanted the Cardiovascular Center of Excellence designation,1 it would likely figure out a way to make the data exchange happen. The same concept could be applied to trauma center designations by the American College of Surgeons or in ambulance service accreditation by the Commission on Accreditation of Ambulance Services (CAAS).
The belief that HIPAA rules prevent the release of hospitals’ patient outcome data to EMS agencies is a unicorn. The “treatment, payment, and operations” provisions of the rule have specific allowances for sharing of clinical and outcome data with other caregivers of the same patient. Some would say the converse is more accurate: In many states hospitals may be required to provide EMS with requested data for quality assurance purposes. To overcome the HIPAA hurdle, national EMS associations could band together and ask the Department of Health and Human Services to update its 2011 letter from the Office of the Assistant Secretary for Preparedness and Response explaining that sharing patient data is specifically authorized by HIPAA.2
Your patient is a 70-year-old insulin-dependent diabetic who missed a meal and is suffering from hypoglycemia, with a blood sugar of 40. After a full assessment you initiate an IV and resolve the issue with an infusion of D10.
Knowing the dextrose infusion may be a short-term remedy, you and your partner make the patient two peanut butter and jelly sandwiches. Soon she feels better, and her repeat blood sugar is 105. She has capacity to refuse transport and instead arranges to visit her endocrinologist later in the day. She signs your AMA forms, and you return to service—a good outcome.
Under current payment policy, the care you just delivered is not eligible for reimbursement by Medicare. The Medicare benefit for ambulance service is a transportation benefit, so because there was not a transport to an ED, Medicare won’t pay for the service. If you had transported the patient to the ED, the staff likely would have performed some additional blood chemistry, including a third blood glucose check, educated the patient on why it’s important to not miss a meal, and recommended a follow-up appointment with the endocrinologist.
The expenditure to Medicare for that intervention would be close to $4,000 ($500 for the ambulance trip, a $1,500 facility fee for the ED, and the balance for the physician, labs, and such). Many of us have said for years that current policy paying only for ambulance transport supplied by ambulance services in essence incentivizes the ambulance supplier to spend Medicare’s money. The same is true for Medicaid: Since most commercial insurers use the Medicare guidelines for payment policy, this applies to many of them as well.
Another one of the top EMS 3.0 committee-ranked PIE recommendations is, “State Medicaid and other health policy committees should allow for EMS reimbursement for response and treatment, independent from transportation.” Many EMS responses could be safely and appropriately mitigated without a trip to the ED, but if ambulance agencies are only paid to transport, guess what we’re going to do.
Payment Without Transport
NAEMT and other national associations have been advocating for changes to federal legislation that would let Medicare pay for ambulance response and treatment without transport. This has proven to be a momentous task. However, there are other ways to facilitate this change.
State Medicaid offices can be more innovative with payment policy either through legislation or simply by being allowed to make ambulance response and treatment without transport a covered benefit. An example would be Arizona: The Arizona Health Care Cost Containment System (AHCCCS) has paid for EMS treat-and-refer services since 2016.3 It’s simple math: Pay EMS $203.80 to treat and refer appropriate patients to alternative destinations, and the downstream savings can be significant.
Similarly, commercial insurers can generally make payment policy changes more easily than governmental payers. Examples of this are the recent policy change by Anthem Blue Cross and Blue Shield to pay for ambulance response and treatment without transport4 and MedStar’s new contract with another large commercial payer paying a fixed amount per insured member per month, with no payments for the actual ambulance transport, but also paying for MIH services out of the monthly payment. This is all designed to incentivize the EMS provider to navigate patients, as opposed to always transporting to an ED.
A logical role for national EMS organizations would be to educate state Medicaid offices about the economic and patient experience benefits of patient navigation and advocate for them to change payment policy. The same organizations could work with state payer associations or directly with large payers on the value of patient navigation vs. ambulance transport. An example of the education could be distribution of the document EMS 3.0—Explaining the Value to Payers, dowloadable for free on NAEMT’s website. There are specific talking points for state Medicaid offices and commercial insurers.5
In anticipation of our next column, think about ways we can work together to implement the next two of the top five PIE recommendations: that local EMS agencies should reward EMS innovation and national EMS associations should champion the role of EMS in mobile integrated healthcare.
1. American Heart Association. Cardiovascular Center of Excellence Accreditation, www.heart.org/idc/groups/heart-public/@wcm/@hcm/@gwtg/documents/downloadable/ucm_494803.pdf.
2. Department of Health & Human Services, Office of the Assistant Secretary for Preparedness and Response. Personal correspondence to NAEMSP, Sharing Patient Health Outcome Information Between Hospitals and EMS Agencies for Quality Improvement, www.naemsp.org/Documents/HIPAA%20Letter-NAEMSP.PDF.
3. Arizona Health Care Cost Containment System. Treat and Refer Recognition Program, https://www.azahcccs.gov/PlansProviders/NewProviders/treatandrefer.html.
5. NAEMT. EMS 3.0: Explaining the Value to Payers, www.naemt.org/docs/default-source/2017-publication-docs/ems-3-0-talking-points-to-payers-2018.pdf?sfvrsn=952fcb92_2.
Matt Zavadsky, MS-HSA, NREMT, is chief strategic integration officer at MedStar Mobile Healthcare, the exclusive emergency and nonemergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas.