Responding to real time-critical emergencies isn’t a big part of EMS providers’ jobs. Most of what we do, truth be told, is provide access to the healthcare system, primarily through transport to an emergency department.
That gives EMS a unique ethical burden. Callers to 9-1-1 don’t have a choice of ambulance providers; rarely can the direly hurt or ill offer informed consent. This means EMS bears much of the responsibility for ensuring its care is appropriate. In turn, that has obviously large implications for the use of health systems’ finite resources.
While the latter hasn’t historically been their purview, emergency medical services are well positioned to shape stewardship of those limited dollars. At the junction of planned and unplanned care, hospital and out-of-hospital, EMS is optimally suited to reach patients early, establish directions for further care, and impact much that happens downstream.
Modern efforts at healthcare reform have increasingly given them such opportunities. CMS’ ET3 plan, announced in February, is a major step in that direction. And in Northeast Ohio, a new EMS-led accountable care network will provide a first-of-its-kind platform to facilitate the movement.
Led by Cleveland-based University Hospitals—which has an integrated network of 18 hospitals, more than 40 outpatient health centers, and 200 physician offices across northern Ohio—the EMS Accountable Care Network (EMS ACN) will join EMS and fire departments with other players across a 17-county region with common protocols and quality measurement in an effort to provide better and more innovative care.
“There are essentially two horizons” to the project, says Eric Beck, DO, MPH, EMT-P, president of University Hospitals’ innovation arm, UH Ventures, and a former firefighter, paramedic, and EMS medical director in Chicago. “First, how do we really align and incentivize traditional EMS systems of care around evidence-based performance measures, and get all the feedback loops and information sharing in place that allow us to do that? Secondly, how can we use EMS as an agent of value creation for our ACO and population health activities?”
At least until recently, EMS’ strong footing to participate in such efforts has been grossly underutilized. “As our frontline team, EMS providers have an important and largely untapped role in improving our healthcare system,” UH’s chief clinical transformation officer, Peter Pronovost, MD, PhD, told HIT Infrastructure earlier this year.
The Affordable Care Act provided a foothold to start demonstrating that potential. Data developed around community paramedicine and mobile integrated healthcare-type programs over the last decade—readmission prevention, alternative dispositions, etc.—suggested promise. Given the right circumstances and support, trained providers, it became clear, could safely manage a lot of patients in ways besides toting them to an ED.
The EMS ACN, Pronovost said, “formalizes a vehicle to activate EMS providers in our shared pursuit of high-value and person-centered care.”
UH’s 17-county region includes about 300 EMS agencies, mostly fire-based and around half volunteer. Roughly 100 sent members to a kickoff summit—along with representatives from the state, county, local health information exchange, and other health systems in the market—at which Beck; Mark Schario, RN, UH’s vice president for population health and accountable care; and Brent Myers, MD, chief medical officer for ESO, overviewed the changing landscape and described the new venture.
EMS ACN leaders hoped to solidify participants by June, at which point work was to begin on a quality agenda and payment innovation efforts.
“We see two big potential opportunities,” Beck says. “One is, how do we incentivize and reward high-quality performance with traditional EMS activity—such as in, for example, STEMI, stroke, trauma, cardiac arrest, and sepsis; those sort of traditional quality bundles that have been well studied in the literature?
“The second is, how do we do some more innovative things in partnership with EMS? With a decade of experience now, the community paramedicine concept and mobile integrated healthcare system model can be engaged around target populations for many interventions, including readmission prevention, hospice/unplanned care, and alternative destinations and dispositions.”
In Pursuit of Quality
EMS’ journey with quality measures has been a long one, from a misguided initial emphasis on response times to later work by the NAEMSP and Eagles Coalition to the more recent EMS Compass initiative. The latest iteration involves the National EMS Quality Alliance (NEMSQA), which released some starting draft measures for comment this year. ESO, working from its massive amounts of prehospital data, has proposed six more—things CMS will likely be interested in, Myers said at the summit, as it transitions to quality-based EMS reimbursement.
Tinkering with those will refine the numerators of quality calculations, but the EMS ACN also recognizes differences in denominators when populations become the unit of analysis. Within the same service areas will reside discrete cohorts bounded by geography, different health systems, and different payers.
To provide value across those groups, the model had to be scalable. Individual, one-off fire/EMS programs require the constant development of standard measurements, tools, workflows, and processes. The EMS ACN approach provides all that for any organization wishing to join, including systems beyond those for which UH provides medical control.
“In fact, we hope the other health systems will replicate or adapt the model over all their affiliated agencies as well,” says Beck. “Each of these departments is responsible for a jurisdiction with patients who align with different local health systems. So the real need is one set of tools, one set of models, one set of workflows for EMS to serve all the patients in its geography and each of the health systems that are responsible for their attributed population. The denominators are different, but the EMS ACN framework helps you reconcile the two.”
ACOs: A Brief History
ACOs began in 2011, spurred by the ACA, as an effort to help doctors, hospitals, and other healthcare providers better coordinate care for Medicare patients. While they come in various forms, they’re meant to incentivize the multiple healthcare players in patients’ lives to work in a coordinated way to streamline care, reduce duplication, and produce better outcomes at lower costs. ACOs that can deliver high-quality care and reduce expenses for Medicare can share in the savings; fail to do so, and they may share in the risk.
ACOs typically cross care settings and encompass players besides physicians and hospitals—specialists, long-term care, home health, and sometimes EMS. Common CP/MIH activities like postdischarge followup, ongoing wellness visits, medication checks, and other interventions for high-risk patients fit well within this framework by reducing complications and rehospitalizations, saving money across systems.
It’s more than just MIH, though; to share savings, ACOs must meet quality standards in five key areas: patient/caregiver care experiences, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. Fail to meet those standards, and they don’t get a piece of the pie—hence the accountable.
“An ACO will be rewarded for providing better care and investing in the health and lives of patients,” then-CMS administrator Don Berwick, MD, said when the model debuted. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”
Today there are 538 Medicare ACOs, per the National Association of ACOs, serving more than 12.3 million beneficiaries, as well as hundreds more commercial and Medicaid ACOs (the model is not limited to Medicare patients) serving millions of additional patients. In 2017 Health Affairs counted 923 active public and private ACOs across the U.S., covering more than 32 million lives.
That number has fluctuated over time, but the total number of ACO contracts has grown, as individual ACOs may enter into contracts with multiple payers. Per Health Affairs’ tally, a plurality of contracts and majority of covered lives are with commercial payers. Medicare represents fewer contracts and 29% of covered lives; Medicaid fewer still and just 12%.
Most ACOs have developed in populous states and metropolitan areas. By 2017 two states, Rhode Island and Maine, had more than 30% of their populations covered by an ACO. Wyoming and West Virginia, conversely, were under 2%.
There are several varieties of Medicare ACOs, including the Medicare Shared Savings Program (for fee-for-service beneficiaries); ACO Investment model for MSSP ACOs (to test prepaid savings in rural and underserved areas); Advance Payment model (for certain providers already in or interested in MSSP); Next Generation ACO model (for ACOs experienced in managing care for populations); Pioneer ACO model (for organizations and providers already experienced in coordinating care for patients across care settings); and more. In addition there are other alternative payment models based around accountability for person- or episode-level outcomes and costs.
Despite the Trump Administration’s hostility to the ACA, it has largely continued payment-reform efforts. However, there’s still a need for evidence regarding which approaches yield the best results. There’s evidence that different types of ACOs can improve quality measures, but fewer have shown better outcomes while reducing costs. “Given the challenges of reforming care delivery to improve outcomes and lower spending,” Health Affairs concluded, “there is an increasingly urgent need for better evidence about what has worked for the variety of ACOs that have succeeded.”
An Important First
In its effort to contribute that, the EMS ACN plans to start engaging patients by July. The ACO and health system will be able to place work orders EMS and fire crews will execute within their scopes of practice.
“For example, we may choose to focus on a CHF readmission prevention program,” says Beck. “For each patient we expect x, y, and z interventions. There’s a real need for those interventions, and we’re willing to push EMS a list of patients in their jurisdiction who need that care and then fund the activity.”
Telehealth capability will supplement in-person patient interactions. UH’s system, historically used for stroke triage, permits video and audio connections with patients in the ambulance or their home. The network will also tie in Ohio’s major health information exchange, CliniSync, to link prehospital, hospital, and ACO claims data to help document cost reductions.
As the EMS Accountable Care Network gets off the ground, many will be watching with interest. The UH team is keen to engage anyone having similar conversations and get as many parties as possible to the table.
“This works best when it’s not about a single health system,” says Beck. “It’s really about the community and how we make it work for all patients in a given EMS agency’s jurisdiction.”
Whatever its ultimate trajectory, the EMS ACN represents an important first: It’s the most bona fide endorsement from a health system to date of the importance of EMS and potential value it can bring to the changes coming to healthcare.
Sidebar: Accountable Care Organizations—A Primer
ACOs began in 2011 as an effort of the Affordable Care Act.
They incentivize patients’ healthcare players to work in a coordinated way to streamline care, reduce duplication, and produce better outcomes at lower costs.
Common CP/MIH activities fit well within this framework by reducing complications and rehospitalizations.
To share savings, ACOs must meet quality standards in five key areas: patient/caregiver care experiences, care coordination, patient safety, preventive health, and at-risk population/frail elderly health.
Today there are 538 Medicare ACOs serving more than 12.3 million beneficiaries.
In 2017 Health Affairs counted 923 active public and private ACOs across the U.S., covering more than 32 million lives.
Most ACOs have developed in populous states and metropolitan areas.
There are several varieties of Medicare ACOs, including:
The Medicare Shared Savings Program (for fee-for-service beneficiaries);
ACO Investment model for MSSP ACOs (to test prepaid savings in rural and underserved areas);
Advance Payment model (for certain providers already in or interested in MSSP);
Next Generation ACO model (for ACOs experienced in managing care for populations);
Pioneer ACO model (for organizations and providers already experienced in coordinating care for patients across care settings).
John Erich is senior editor of EMS World. Reach him at firstname.lastname@example.org.