Brave New EMS World: ACA

The Mobile Integrated Healthcare in Virginia

By Alan Perry
updated June 24, 2018

Introduction

I embarked on a journey to explore what has come to be known as Mobile Integrated Healthcare Practice (MIHP) several years ago. The concept was outlined in the National Academies Institute of Medicine book Emergency Medical services at the Crossroads and The National Highway Traffic Safety Administrations publication EMS agenda for the future, but not named or structurally defined by either. The concept has been under development by a number of hospital and pre-hospital systems for several years with some success. With the passage of the Affordable Care Act and the formation of Accountable Care Organizations (ACO’s), additional monetary incentives have been created, and the concept has gained significant momentum and support. I have, for several years, realized that the future of EMS rested in the improvement of the relationship and integration between healthcare providers and systems across the continuum of patient care. An article I wrote in early 2012, EMS Manifesto describes my vision then as it does now. I am very excited to see the concept taking shape, of course this type of concept will have application in very different ways depending on patient population, the type of EMS and hospital systems that are involved, and the input and participation of local and state governments.

The goals of Mobile Integrated Healthcare

The general goals of Mobile Integrated Healthcare are: to reduce healthcare costs, decrease inappropriate system use, prevent emergent hospital re admissions and improve hospice results through appropriate use of the whole spectrum of healthcare. The “triple aim” as described by the Institute for Healthcare Improvement (IHI) , improving the healthcare experience, improving health and reducing costs are met as well as the defined goals of Accountable Care Organizations (ACO’s), delivering high quality care and reducing costs. Patients should receive the care needed in the most appropriate way, improving health and the quality of the experience. For providers it should produce greater job satisfaction, greater flexibility in providing care and more options for professional development. For EMS services this will require additional responsibility and integration within the healthcare system. It should produce a reduction in non-emergency calls, frequent users, and permit cost recovery for alternative service delivery such as treat and release, or transport to alternative treatment centers. For hospitals it will require more cooperation with local EMS and medical record sharing. The benefit to hospitals and healthcare systems should include reduce inappropriate ER visits, reduced re admissions and availability of resources for true emergencies. Insurers, including medicare and medicaide have to start looking at EMS as a useful partner in achieving the IHI triple aim. EMS is well positioned to make this all happen but legislation and cooperation with the other players is proving to be the greatest obstacle. With cooperation, the entire system should work more smoothly, costs will be reduced and quality of care improved.

Who will play a part in Mobile Integrated Healthcare?

Patients, healthcare providers, EMS & fire chiefs, physicians, administrators, politicians, EMS agencies, regional EMS councils, hospitals, ACO’s, public health, social services, mental health, state EMS offices, insurers, Medicaid, Medicare and the public will all have to contribute, collaborate and cooperate to develop a Mobile Integrated Healthcare Practice (MIHP) that accomplishes the goals described by the IHI as well as addressing local needs. I suspect that the diversity of the stakeholders will play a large role in the ability, or inability, of any locality to reach an agreement and develop a meaningful program. ACO’s that fall under one organizational umbrella will have a much easier time developing and implementing a MIHP provided they have all, or a majority of the required components to make it work. In the TEMS region of Virginia there are several independent hospital systems, volunteer, public and fire-based EMS systems, various private ambulance and home health organizations, local and state government entities that provide components of the system we will need to build.

Some potential obstacles

Politics, power, money, ignorance and apathy frequently prevent progress. The primary stakeholders in MIHP will be the EMS systems, hospitals, home health agencies, social services, public health, legislators and insurers. Our region has several EMS systems that are very diverse in their basic structure. We also have multiple hospital systems in the region that have differing organizational goals and strategies. Success may require funding through insurers both public and private who have been slow to adopt, and pay for, alternative treatments or destinations for EMS other than an ER. Our biggest challenge will be reaching agreements that will allow us all to work together cooperatively and creating a legal framework that supports it. We have now been through the first two stages of grief, denial and bargaining, and must now move on to acceptance, eventually reaching a point where we are anticipating the benefits of our success.

Success stories in Mobile Integrated Healthcare Practice

MedStar-Fort Worth, Texas

http://www.medstar911.org/community-health-program

Public utility model EMS system providing service to a large metropolitan and suburban area.

Wake County, NC EMS

http://www.wakegov.com/ems/about/Pages/default.aspx
Public Utility model EMS system

Alexandria, VA Fire Department

https://www.alexandriava.gov/fire/info/news_firedisplay.aspx?id=97911

Fire based EMS system

How should or local system proceed?

I will not represent myself as knowing enough about every aspect of this subject to try to write an implementation guide for localities, Tidewater or the State of Virginia. To my knowledge there is not a universally applicable model or implementation guide that will work for every system. We must find our own way together, with every stakeholders input, to find the application that works best for our patient population, healthcare facilities, legislators, emergency services and healthcare providers. There are some general first steps and considerations needed to begin putting it together. The majority of functional MIHP programs are hospital based or public utility model EMS systems, neither of those models is universally applicable to the current system in the Tidewater EMS council. At this point, with a lack of favorable legislation, insurance billing practice reform, and sincere commitment from the State office of EMS, solving the problem currently rest with individual localities. The good news is that the body of literature and evidence surrounding MIH programs have improved greatly and many brave and determined souls in the realm of EMS are finding creative ways to start chipping away at this issue. It all starts with discussion and identifying the needs of the patients and the system. Stakeholders will make or break you, do not fail to include them in the discussion early. Stakeholders hold the key to enabling a working solution.

Conclusion

The tidewater region has unique challenges to the implementation of MIHP. The need for a program such as MIHP has been acknowledged for several years with little action. Changes in healthcare law, specifically the affordable care act, provide sources for funding with collaboration across healthcare disciplines. Until a Statewide or Regional solution can be developed, it will be up to individual agencies to start working with their stakeholders to develop solutions that work for that system. Our sacred oath as healthcare providers is to do no harm, by that we must infer that we do what is best for the patient, in this case correcting the known problems in our delivery model. By doing so, we will improve the quality of the experience, the health of the patient, and the sustainability of our system.

References:

Institute of Medicine, Emergency Medical Services at the Crossroads weblink
http://www.iom.edu/Reports/2006/Emergency-Medical-Services-At-the-Crossroads.aspx

National Highway Traffic Safety Administration, EMS Agenda for the Future weblink
http://www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf

Institute for Healthcare Improvement website

http://www.ihi.org/Pages/default.aspx

Accountable Care Organizations, Centers for Medicare and Medicaid Services website

http://innovation.cms.gov/initiatives/ACO/

NAEMT website, Community Paramedicine

http://www.naemt.org/about_ems/CommunityParamedicine.aspx

Virginia Office of EMS, Division of Community Health and Technical Resources

http://www.vdh.virginia.gov/emergency-medical-services/ems-technical-assistance-and-consultation/

Another White Paper

By Alan Perry
August 18, 2013

In case you missed it, the two government bodies that are most affected by proposed changes to the delivery of emergency medical services (EMS) have recently weighed in with their joint assessment of the situation. On July 15, 2013 the National Highway Traffic Safety Administration (NHTSA) and offices of Health and Human Services (HHS) released a joint statement in the form of a draft white paper entitled Innovation Opportunities for Emergency Medical Services. The document does not contain any new data, but expresses the desire of these two organizations to promote their vision of health care reform as it pertains to EMS, and proffers a generic model of cost savings that can be realized by making a few changes that have already been identified in other publications by the Institutes of Medicine (IOM) and NHTSA. While the paper certainly focuses on the cost savings and the strategies required obtaining them, it leaves the process in the vague hands of a number of “possibilities”. As we have seen from the activity following the previous attempts at reforming healthcare, and EMS in particular, this falls short and. The final conclusion being that Americans deserve a better system that saves money improves care and creates less of a burden on critical resources…. Duh.

As an industry, EMS recognized over a decade ago that our delivery model is inefficient; this is confirmed in this white paper and identifies by name the root source of the problem which we have known for years, it’s the federal government. Medicare and Medicaid reimbursement schedules are driving the inefficient allocation of EMS resources by only paying for patients who get transported to a hospital, which is not always a reasonable or cost effective choice. The paper goes on to address the specifics of the potential cost savings in what it characterizes as a conservative methodology, identifying the potential savings to be somewhere in the range of half a billion dollars. Since we live in a democratic capitalistic society it should come as no surprise that the biggest incentive for change will always be a monetary one. From my perspective of relative ignorance, I must conclude that the quickest and most effective way to change the system would be to change the way it is paid for.

Unfortunately individual EMS systems lack the clout to confront the Centers for Medicaid and Medicare Services (CMS) and challenge the current fee for service schedule. This process is typically worked out between CMS, physician and large healthcare organizations. Equally unfortunate is the Patient Protection and Affordable Care Act (Obamacare) which does not acknowledge the fee for service problem directly, but instead offers incentives based on cost savings to encourage larger healthcare systems to prove a different model works better. The combination of these two circumstances favors large for-profit healthcare organizations with the clout and money to have their preferences considered. I fear it will leave many public safety organizations at a disadvantage in having their concerns heard since few have the resources to effectively form and fund an Accountable Care Organization (ACO) that can deliver the required savings to get paid. We will be left to work out whatever deal we can with a much larger organization if we are to survive at all. The Federal Government, through Obamacare and CMS, has effectively shut out all small and moderate size public, private and non-profit EMS providers out of the process and the discussion.

Our best hope at this point is the Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013. This bill is currently in committee with 10 sponsors, it will move the national office for EMS to Health and Human services, which more accurately reflects the realm in which we operate, it acknowledges and incorporates the concepts and goals of the EMS agenda for the future, addresses the concerns of the IOM report EMS at the crossroads, provides funding for study and implementation of new delivery models, and directs CMS to include field EMS models in their testing. This bill will provide the needed framework, funding and focus needed to move EMS forward in a logical and responsible way without depending on Obamacare, ACO’s or some other magic pill. This bill will achieve many of the goals of Obamacare and healthcare reform in general as they pertain to EMS functions, but it will also add the stability needed for 911 EMS systems to plan and sustain operations while making these needed changes without selling them out. The draft white paper produced by NHTSA & HHS does not articulate a strong desire to maintain 911 EMS capabilities or identify how to accurately account for its cost although other NHTSA publications, such as the EMS System Performance-based Funding and Reimbursement Model by the National EMS Advisory Council do. Perhaps once all realize that EMS is both public safety and public health we can realize some progress.

Be Safe,

References;

EMS Agenda for the Future, NHTSA 1996

http://www.nhtsa.gov/people/injury/ems/agenda/emsman.html

EMS Agenda for the Future- Implementation Guide, NHTSA 2010

http://www.nhtsa.gov/people/injury/ems/agenda/

EMS at the Crossroads, National Institutes of Medicine 2006

http://www.iom.edu/Reports/2006/Emergency-Medical-Services-At-the-Crossroads.aspx

Innovation Opportunities in EMS- A Draft White Paper, NHTSA/HHS 2013

http://www.ems.gov/pdf/2013/EMS_Innovation_White_Paper-draft.pdf

H.R.809 - Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013, 113^th U.S. Congress 2013

http://beta.congress.gov/bill/113th/house-bill/809