A few years ago, Doug Key, senior vice president of operations for TransCare in New York City, was intrigued by a new model of health care called accountable care organizations, or ACOs. ACOs bring together hospitals, physicians and other health care providers that agree to take responsibility for the health of a group of patients. The goal is to better coordinate care to improve patients’ health while reducing costs. To accomplish that, ACOs target such issues as making sure patients are properly dealing with chronic conditions so they don’t end up needing more expensive care and reducing unnecessary hospital readmissions by checking up on patients after discharge.
The reward for hospitals and their partners that participate in ACOs is a share of the savings realized by the payer, which can be a private insurer or Medicare/Medicaid. But ACOs aren’t all carrot—there’s a stick, too. Hospitals and their ACO partners may also share in the risk and be subject to financial penalties for not meeting whatever targets are set for patient health and cost reduction.
Key saw ACOs as having the potential to fundamentally change the way ambulance services interact with hospitals—and he wanted to be sure TransCare didn’t miss the boat.
“ACOs represent a monumental shift in thinking that somebody has to be sick and we have to do something to them to get paid, to instead, somebody is going to pay us to keep [patients] well and keep them from accessing expensive services,” he says. “Hospitals are realizing they don’t have the mechanisms in place to be able to do that. Doing this is going to require lots of partnerships, and we need to make sure EMS is one of them.”
So Key, whose organization has 1,500 employees and handles 250,000 emergency, interfacility and specialty transports annually, started arranging meetings with hospital executives to educate them about what EMS has to offer—and how EMS would make sense as an ACO partner. His legwork paid off, as TransCare is now a partner in a large New York City HMO’s ACO. He’s also in the final stages of an agreement to participate in a second ACO.
“The hospitals are not thinking of us as a solution provider. They see us as providing transportation, and transportation is costly, which is what they are trying to avoid,” Key says. “So what we need to do is get hospitals to see us differently. We need to leverage what we’re good at. We have call centers. We have vehicles and personnel who are ready if there’s an emergency, but we can also do routine visits. We’re mobile. We’re in the community. And we do assessments every single day.”
A ground-floor opportunity for EMS
As health care costs have risen over the past several decades, the federal government and insurers have been looking for ways to contain those costs. HMOs such as Kaiser Permanente were among the first such attempts to get doctors to better coordinate care.
In recent years, as it’s become increasingly clear that rising costs are unsustainable and the fee-for-service model is partially to blame, cost containment and payment reform efforts have picked up. In the mid-2000s, the Centers for Medicare and Medicaid Services (CMS) and private insurers started experimenting with ACO demonstration and pilot programs to determine if the model worked and to define exactly what an ACO should be.
ACOs got a big boost this month, when two major initiatives authorized by the Affordable Care Act took effect. The first is the Medicare Shared Savings program, in which an estimated 75 to 150 groups nationwide will form ACOs, receive an estimated $800 million in bonuses over three years and enroll some 1.5 million to 4 million Medicare patients.
Don’t Get Left BehindNow’s the time for EMS to get involved with ACOs, but how to get on the radar? EMS experts offer these tips. Privates, take note Initially, at least, ACO opportunities will be most realistic for private ambulance services, says Rick Keller of Fitch & Associates. Many municipal EMS agencies serve only specific jurisdictions or have specific service areas, while a hospital’s patient roster may stretch across cities, counties and even states. EMS services that already have relationships with hospitals will also have an in. Think about what you have to offer Your mobile workforce. A fleet of vehicles and equipment. Perhaps a call center. ACOs need to move patients cost-effectively and efficiently to where they need to be—often from primary care to the right hospital—and ambulance companies can do that, says Doug Key of TransCare. And don’t think only about transporting by ambulance: If a patient doesn’t need the bells and whistles of an ambulance, you can offer up other vehicles to take patients where they need to go. Start getting meetings to share your capabilities Bill Gerard, an emergency physician at Palmetto Health System and medical director of Richland County EMS in Columbia, S.C., and LifeNet South Carolina, got involved with the Palmetto Health Quality Collaborative, a group made up of 500 doctors interested in exploring a more integrated model of care. Gerard started talking up what EMS had to offer. “Hospitals are mostly blind to the resources of EMS, but I could see a lightbulb going off in people’s heads, saying, I hadn’t thought about EMS. It’s so obvious. Why didn’t we think about that?” he says. Ideas tossed around include getting the fire department involved by offering exercise classes to ACO patients. Palmetto has applied for an Innovation grant, and Gerard believes EMS and perhaps fire will be one of the partners when the ACO is finalized. Keep challenges in perspective Of course there will be challenges, even after you’ve gotten buy-in from the hospital, with reimbursement, as always, being one of them. There could also be scope of practice issues, but experts advise not getting bogged down in that. Many arrangements won’t require EMS to change its scope of practice, and as has been proven with community paramedicine, when scope of practice does need to be addressed, it can be, such as through state legislation. “It’s not insurmountable,” Keller says. “There is precedent for it. That’s what’s important.” Be clear about your intentions When talking up EMS’s potential, be careful to make clear your intentions to be a partner to, and not supplant, home health nurses and others. “We’re not positioning ourselves to replace other practitioners,” Key says. “They will come gunning for you if they think you’re trying to replace them.” At its heart, he adds, making ACOs work requires partnerships: “This is about integrating partners that already exist in the system and linking them together in that continuum of care.” — Jenifer Goodwin |
The second major initiative is the Pioneer ACO model, a three-year pilot program involving 32 ACOs. Those ACOs will receive an even higher proportion of the savings than ACOs that are part of the Shared Savings program, but they will also take on some risk of financial penalties for not meeting savings targets. CMS estimates the Pioneer program will save Medicare $1.1 billion over five years.
A third boost came from the Health Care Innovation Challenge, which involves up to $1 billion in grants for “the best projects that doctors, hospitals, and other innovators propose to deliver high-quality medical care and save money,” according to a statement from CMS Administrator Donald Berwick, when the grants were announced in November 2011.
To ensure that patients are getting adequate care, Medicare ACOs will be monitored under specific quality criteria ranging from the patient and caregiver’s experience to patient safety.
With all of this so new, and with many dozens of private health insurers experimenting with their own ACO-type programs, EMS experts agree: Ambulance services need to get in on the ground floor.
“This is an opportunity for ambulance services to be much more integrated into health care services,” says Rick Keller, a partner at Fitch & Associates, a Platte City, Mo.-based EMS consulting firm. “But unfortunately, it’s not high on the radar screens of either ambulance service providers or the health care systems that are developing ACOs.”
Even ambulance services that would prefer to keep things the same will have to adjust eventually, Keller says. Across the health care spectrum, there’s a growing movement to get rid of fee-for-service payment schemes, which drive up costs by incentivizing health care providers to do more procedures, to order more tests and, in the case of ambulance services, to transport more people to the hospital.
“If you’re not part of the solution, you must be part of the problem,” says Andrew Rand, CEO of Advanced Medical Transport, a not-for-profit ambulance service in Peoria, Ill. “If you are just part of the cost—you call, we haul and we send a nice, big $950 bill—the value proposition is not well understood and you can easily get cut out.” Rand is in talks with a local hospital system to use his staff to do home visits to follow up on patients after discharge.
Any health care provider that is unable to show it’s part of the solution—that is, improving health and reducing costs—runs the risk of being seen as a commodity, with one ambulance service interchangeable with the next and low cost being the prime determinant of who gets the business, Keller says.
“This is the new reality,” he adds. “Your reimbursement and payment are going to be largely determined by how well you do.”
How TransCare makes it work
The ACOs that TransCare is in partnership with (or is in the process of formalizing a partnership with) view what they’re offering as a competitive advantage and do not want to be named. That said, the first is part of an HMO that serves Medicare Advantage Plan patients and is run by a hospital group in the New York City area. When patients need to be admitted to the hospital from one of the HMO-affiliated specialty centers or physician’s offices, that staff calls TransCare’s call center directly, and TransCare does the transport, ensuring that patients stay within the HMO’s network. TransCare staff also e-mail the primary care physician and the HMO alerting them that they’ve picked up the patient so that both can start managing the case from the get-go. The primary care physician, for example, might see the patient in the hospital and follow up after discharge, with everyone involved having access to all medical records and tests to avoid duplication that runs up costs.
The second partnership is with a large hospital group that’s partnering with clinics and specialty centers to form an ACO and has applied for an Innovation grant. The hope is that TransCare will be assigned a group of older, chronically ill patients at high risk for being readmitted to the hospital. Paramedics would schedule weekly wellness checks in patients’ homes to make sure they are taking their medications, take vital signs and conduct basic health assessments. If paramedics were to see red flags, they would either schedule an appointment for the patient to see his or her primary care doctor, or if a patient had mobility issues or was bed-bound, the paramedic would call another ACO partner, such as a home health nurse or physician house-call service. The last resort would be to transport the patient back to the hospital.
What hasn’t been decided yet is how TransCare will share in the cost savings realized by the ACOs. Yet Key says it’s important not to get bogged down in details. First he wants to prove that his service is valuable; then he’ll work out the details of what percentage of the savings is attributable to EMS.
“You have to be able to prove that you’re a valuable partner before you can start demanding payments,” he says. “If you get hung up on those negotiations at the outset, you will never get to the table, or you will be seen as a competitor for the dollars that are available.”
Paramedics will handle wellness checks during times when they’re not answering emergency calls or otherwise engaged. So the costs to TransCare are relatively minor—and Key believes well worth it in the long run.
“You will not be able to keep an organization viable on ambulance transports alone,” he says. “You’ve got to look for other revenue sources. And these new models are a perfect opportunity where we can start to get reimbursement for a portion of the health care savings, which is much better than being on the cost side of the equation.”.
Are you involved with an ACO or other arrangement to better coordinate care? We’d like to hear about it! Please send an e-mail to jenifer.goodwin@sbcglobal.net.
Read more about ACOs at healthaffairs.org/healthpolicybriefs/brief.php?brief_id=61.
An in-depth discussion of this topic will be featured at the 2012 Pinnacle EMS Leadership Forum, from July 16–20 in Colorado Springs, Colo. For information, visit pinnacle-ems.com.
