The quest of American EMS providers for more sensible reimbursement will reach a key threshold on January 1, 2018, when Anthem BlueCross BlueShield begins 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 will begin January 1, though most will.
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 ED.
“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.”
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, for 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 he worked to launch a community paramedic program. “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 was 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 things like 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.”