With the early end to the Emergency Triage, Treat, and Transport (ET3) pilot program by the Centers for Medicare and Medicaid Innovation, a new conversation has emerged about how EMS agencies can be reimbursed for the services they provide other than transporting patients to hospitals.
The general sentiment is that agencies should not give up on the search for systemic solutions and should seek one-off funding sources by negotiating with individual payers. The question, however, comes down to whether this is practical and results in any sort of reasonable reimbursement.
There is a more fundamental reset needed in healthcare related to the importance of the full range of services provided by EMS. Rather than being truly “integrated,” EMS is generally regarded as a mobility service – “you call, we haul.” This is far from the truth, as any basic EMT could tell you. Here are some factors that counter a “keep at it” approach.
1. Funding Mobile Integrated Health (MIH) Programs Overall
Running alternative programs (Mobile Integrated Health, Community Paramedicine, treatment in place, transport to alternative destinations such as urgent care or mental health facilities –collectively referred to as MIH) is expensive. These programs require additional training, protocols, medical oversight, and sometimes additional vehicles and personnel.
Digitech has numerous clients that have some form of MIH in place, some with extensive programs and others with narrowly focused programs. In all circumstances, funding is challenging. Typically grants are the core funding source, sometimes supplemented by direct arrangements with select private insurance companies, hospitals, or physicians’ groups. As noted by Dr. Allen Yee, medical director for Chesterfield County Fire and EMS’s award-winning MIH program, other agencies have employed a cost savings model to direct resources toward preventing future needs for service expansion, thus preserving the agencies’ finances.
2. Percentage of Medicaid/Medicare Patients Receiving MIH Services
At least two-thirds of patients receiving alternative services and treatments from EMS are covered by Medicare or Medicaid. Because Medicare has now withdrawn the ET3 program, there are no current avenues for reimbursement for the largest group of users of alternative EMS services.
Even when ET3 was in place, the requirements were so restrictive that very few EMS provider agencies were able to take advantage. For example, most municipal departments did not have the ability, in a cost-effective way, to ensure an advanced level practitioner was involved in every treatment in place. Dr. Yee also reminds us that medical necessity was still a required component of that program.
With rare exceptions, Medicaid programs do not cover alternative services by EMS. This is unlikely to change quickly or easily, especially when it is up to individual EMS agencies to band together to lobby their State Medicaid and State legislatures to expand Medicaid coverage. Medicaid programs are notoriously slow to make changes.
3. The Challenge of Engaging Commercial Payers
A piecemeal approach to engaging commercial payers creates uneven results and favors the savviest payers. EMS providers are not typically experienced in negotiating contracted rates for services, particularly services they have never provided before. Municipal providers are not equipped to navigate multiple payers to negotiate rates for alternative services. Municipal agencies are also disadvantaged in negotiations, as commercial payers can push providers to the lowest negotiated level since they have full transparency into their numerous contracts (e.g., if one agency agrees to be reimbursed for a particular service at $100 that really costs $200, other agencies are unlikely to get the payers to negotiate above $100).
What would be a preferred approach?
First, there needs to be an acknowledgement that MIH benefits all participants in the healthcare system – patients, payers, and downstream providers.
The benefits need to be quantified, and the downstream providers need to pass along a substantial portion of their savings. Some of those savings include:
- Insurance companies save thousands of dollars per emergency encounter when a patient does not end up in the Emergency Room or the hospital.
- Hospitals avoid overcrowding ERs with low-acuity patients. This allows hospitals to focus on high acuity patients, as well as avoiding long wait times and poor patient experiences – today, low acuity patients often end up with long waits as higher acuity patients are triaged ahead of them.
- Other providers (urgent care, physicians, etc.) improve their utilization by seeing patients they can treat.
- Patients get the right care at the right time and the right place, all of which saves substantial money for all parties and improves the overall quality of the healthcare experience.
Second, there needs to be a concerted effort to engage Medicare and Medicaid about the benefits of MIH to their programs and to patients. Judging by the setup of ET3, which required an advanced level practitioner to “see” the patient prior to allowing them to be released without a transport, there is a clear concern about patient safety; however, this overlooks the fact that EMS already operates under medical direction and oversight.
Stakeholder concerns need to be identified and addressed prior to setting up these reimbursement models. There needs to be true stakeholder buy-in that MIH programs can and will provide safe and effective clinical treatments to individuals. After that is achieved, reimbursement levels should be established that appropriately compensate EMS for their services. Downstream providers and patients’ payers should share a large portion of savings derived from delivering cost-effective treatment back to EMS, which will encourage agencies to enter the space.
Over time, as upfront investments are paid for and efficiencies are developed, there will be an opportunity to lower reimbursement levels. CMS and other payers should promote ways to optimize this space, not entrench the status quo. Additionally, downstream providers – hospitals, physicians’ groups, urgent care facilities, mental health treatment centers, skilled nursing facilities – need to invest real dollars into MIH reflective of the substantial savings and benefits that MIH services deliver.
The EMS industry is experiencing a fundamental shift in how out-of-hospital care is delivered in our country. EMS providers play an important role in the health and safety of their communities and many EMS agencies have built innovative programs to better meet the needs of those they serve. Just as EMS has evolved, the reimbursement model must also evolve.
-Kevin Spratlin, Division Chief of EMS Administration at the Memphis Fire Department
A holistic approach that incorporates how timely and vital MIH services fit into the broader healthcare spectrum is needed, an approach that breaks the status quo and jump-starts investments. This is how we will provide superior patient care to our communities. This is how we get more than just the sum of Mobile + Healthcare and, instead, evolve toward true Mobile Integrated Healthcare (in its many forms) as a critical healthcare service.
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