Charting the course of community paramedicine

Experts discuss the challenges, opportunities — and, perhaps, inevitability — of mobile integrated healthcare and community paramedicine programs

Despite the unexpected snow outside, more than 100 EMS providers and administrators gathered in a Washington, D.C., ballroom on March 25, 2013, to learn more about mobile integrated healthcare — and how to get paid for it.

As mobile integrated healthcare (MIH) and community paramedicine (CP) programs expand around the country, so do the ways in which agencies get reimbursed for these programs. The path forward is at the same time murky — as almost no two systems seem to have the same funding model — but also promising, since so many have figured out ways to get paid for providing these innovative programs.

“Every patient coming into [our MIH] programs is now attached to a funding source,” said Matt Zavadsky, public affairs director for MedStar Mobile Health in Fort Worth, Texas.

Zavadsky and Eric Beck, D.O., associate chief medical officer for American Medical Response (AMR) and Evolution Health, opened up the meeting with a brief overview of some of the changes occurring in EMS and healthcare across the country. Beck talked about more than a dozen MIH programs currently in place or in development, while Zavadsky presented the results of a survey in which more than 230 agencies said they currently have some type of MIH or CP program.

The highlights of the summit — which was sponsored by EMS World and its new sister publication, Integrated Healthcare Delivery, in partnership with Medtronic Philanthropy, the American Red Cross and the National Association of EMTs — came during the second session, when speakers from across the country talked about their experiences with starting and funding MIH programs.

Challenges abound, yet payoffs loom

Chris Cebollero struggled to convince his hospital system that EMS could provide the types of services he was suggesting. Convincing them was critical not only because successful MIH programs rely on partnerships with hospitals but also because in his case, the hospital is also his employer. Cebollero is the chief of EMS for Christian Hospital in St. Louis County, Mo.

“My hospital system was not listening to me when I told them how I could help them and how we could move forward,” he said. “I was talking to the president, I was talking to the vice presidents.” One of those vice presidents was his boss, but even “she wasn’t hearing it,” he explained.

But when he met with a member of the hospital system’s process improvement team, Cebollero said, he gained some insights into how to convince those executives. In that meeting, he learned that more than half of the hospital’s patients stay too long, and that one extra day in the hospital was costing $4.4 million each year — significantly more than the readmission penalties.

“I finally sat down with the process improvement guy, and he said, ‘You’re looking at it all wrong,’” Cebollero told the audience. “You need to affect the length of stay. And that’s going to get you to the high-risk readmission people.”

Cebollero’s story, like others told at the summit, demonstrated the importance of meeting with the right people at the right time and bringing the right information. Some hospital executives, for example, might be less than thrilled to hear that a CP program will keep patients out of the emergency department. After all, the ED has traditionally been how the hospital brings in patients … and dollars.

“Right now, today, in the fee-for-service world? They get really nervous,” said Brent Myers, M.D., director of Wake County (N.C.) EMS.

And while the world where hospitals get rich from emergency patients may be nearing an end (“This is the end of fee-for-service” was a refrain heard more than once during the half-day session), some hospital executives are not quite ready to take that leap. So EMS systems may need to think of other ways to pitch these programs — such as reminding the hospitals that the Centers for Medicare and Medicaid Services (CMS) ranks hospitals based on some of these factors on its Hospital Compare website.

“The incentive [for hospitals] at the moment may not be financial,” Myers added, “it may be to keep yourself off the bad list.”

But if convincing the hospitals has its challenges, the insurers and accountable care organizations (ACOs) have been, perhaps surprisingly, very interested in what MIH can deliver. Cebollero, for example, said that five different payers are interested in what his agency is doing, and they have several contracts pending.

What do payers want?

A few of MedStar’s partners spoke at the summit, giving the audience a chance to hear from the payers themselves. Dan Bruce, the administrator of Klarus Home Care in Fort Worth, Texas, explained why his agency chose to partner with an EMS MIH program at a time when similar home health organizations across the country see these programs as a threat.

“We instruct our patients to call us, but they don’t always do that,” Bruce said. “They just call 911, and there they are, back in the hospital.”

Instead of simply increasing staffing to the point where each Klarus customer had a nurse in the home 24 hours a day, Klarus contracted with MedStar to help assess and treat those patients at home and, when possible, avoid trips to the ED. “That’s probably going to sound like treason in your community,” Bruce said. “There is a lot of turf, a lot of territorialism there. You need to break through those walls.”

But the partnership made sense for both Klarus and MedStar—MedStar has the staffing and the resources, and Klarus wants to keep its patients out of the hospital. While readmission penalties for home health agencies are not a reality yet, they may be soon. And hospitals want to refer their patients to agencies that will keep them from bouncing back.

So now Klarus is paying MedStar to help keep those patients at home, which makes the patients, the hospitals and both agencies happier. MedStar will send its advanced practice paramedics on 911 calls from any Klarus patient, and they will contact the Klarus nurse and access the Klarus medical records to try to avoid transporting the patient to the hospital if possible. If the patient calls the nurse instead of 911, Klarus may contact MedStar and request a home visit in order to do an assessment or provide treatment.

Bruce also suggested that EMS agencies hoping to partner with home care companies may have to think of other ways to sell their services, such as reminding the home health executives that MIH programs can bring in business, not drive it away. After all, EMS providers often see patients, whether through traditional 911 services or MIH programs, who are in need of home health. That can turn into referrals for the company, especially if they choose to partner with EMS on these innovative types of projects.

Options encouraging yet overwhelming

The wide range of MIH programs on display at the summit can be both encouraging and overwhelming to the EMS community. Overwhelming because there are so many different models, potential partners, roadblocks and unsettled questions. Encouraging, though, because while at one time it was thought that EMS reimbursement couldn’t change until Medicare and Medicaid changed, the changing healthcare marketplace has created incentives for other payers to become the innovators.

“Trying to change Medicare is going to take some time,” Myers said, suggesting that in this case, the private sector may be the ones who force the federal government to change how it reimburses EMS. Referring to those private insurers, ACOs, hospitals and other private entities, he added, “Those folks can see the value of what you’re doing.”

While significant policy changes may take time, CMS and state and federal Medicaid administrators have shown interest in exploring ways that EMS can help provide better care at reduced costs. Several conference presenters were scheduled to meet with top officials from CMS and other agencies in the days following the conference.

One speaker, Brenda Staffan from Reno, presented an update on her program, which is currently being funded by a $9.8 million CMS Innovation Grant. Another presenter, from Fort Worth, spoke about a Medicaid waiver program that is allowing her publicly funded health system to partner with MedStar to help patients navigate the healthcare system.

Dawn Zieger, a project director for community health with the JPS Health Network in Fort Worth, spoke about why her system chose to partner with MedStar, giving the summit audience a chance to hear what potential collaborators are looking for. One thing they learned:

EMS systems and their partners might have to invest in a program first before they can lock in external funding sources.

“It really helped us to leverage that pilot program to get the funding moving forward,” Zieger said. After a pilot program appeared successful, however, JPS and MedStar worked together to receive what’s known as a Medicaid Section 1115 Waiver, which authorizes experimental or demonstration projects. The JPS–MedStar waiver is for a five-year program that will try to decrease costs by using MedStar’s MIH program to help JPS patients avoid hospitalizations and other expensive and avoidable services.

Under the program, JPS pays MedStar a monthly fee for each patient in the program, as well as an annual payment based on the outcomes and savings created by the program. At the summit, Zieger announced that JPS had just made its first annual “outcome” payment to MedStar — for $189,000.

Other issues addressed at the summit included education and accreditation for MIH providers and programs, as well as state regulation of these programs. The paths forward on accreditation and regulation both remain uncharted, but the clear message was that in the future, EMS in general — and CP and MIH programs in particular — will need to be evidence-based and will need to measure outcomes.

Changes that hospitals and doctors are seeing today, such as outcomes data being made public on government websites and reimbursement being impacted by patient satisfaction scores, will eventually come to EMS as well, several panelists said.

Ed Racht, M.D., chief medical officer for AMR, put the summit in perspective when he asked members of the audience to take a mental picture of the meeting. “One day everyone in this room is going to be sitting around telling a story,” he said. “You’ll be able to say, ‘I remember when the concept of mobile integrated healthcare [was new] and there were no guidelines, there was no course.’”

Racht compared today’s discussions of community paramedicine to those half a century ago, when EMS transitioned into a system of care with standards for education, equipment and treatment. In 10 years, he said, the people sitting around the tables will be looking at mobile integrated healthcare systems and say, “I was in one of those meetings, where we were trying to plot out what it was going to look like.”

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