High-Value EMS: The Key to Our Future

This is the second in a yearlong series of articles developed by the Academy of International Mobile Healthcare Integration (AIMHI) to help educate EMS agencies on the hallmarks and attributes of high-performance/high-value EMS system design and operations. Find January’s opening installment at www.emsworld.com/12285703.

In our last column we explained the system design elements for high-performance EMS (HPEMS) as a service delivery model, primarily as a lead-in to the concept of turning HPEMS into high-value EMS (HVEMS).

The concept of value is a main driver today, especially in healthcare delivery. The Centers for Medicare & Medicaid Services (CMS) has articulated its desire to move healthcare away from a fee-for-service, volume-based economic model to a value-based model, with a goal of 50% of Medicare payments through alternative payment models (APMs) and 90% of Medicare payments linked to quality by 2018.¹ Second only to taxpayers, Medicare is the largest payer for EMS services, accounting for $5.3 billion of expenditures in 2011.²

Why Value Matters

Why does EMS really need to focus on the value proposition for the service we provide?

Changing stakeholder expectations—The expectations of our stakeholders are changing. As the rest of the healthcare system moves from volume to value, the old “you call, we haul” model of EMS delivery is being challenged. If a hospital is transitioning into APMs that may include shared-savings agreements such as accountable care programs and bundled payments based on episodes of care, its leaders may be more interested in the potential of improved outcomes and expenditure savings by avoiding unnecessary ED visits and admissions than the potential revenue generated from that utilization.

Similarly there is growing financial pressure in local governments for traditional public safety services such as police, fire and EMS. Savvy taxpayers, city/county managers and elected officials are beginning to ask tough questions about the return on investment for EMS services. The pension funding issue also tops the priority list for many large cities strapped with millions of dollars in unfunded pension liabilities.

Questions about the clinical value of EMS—The actual clinical value of traditional EMS has been questioned in research publications such as the Journal of the American Medical Association, as well media outlets such as the New York Times, Philadelphia Inquirer and Washington Post. Although the methodologies of some recent studies are questionable, the headline shock value cannot be overstated:^3–5

“Police Transport a Good Bet for Shooting Victims, Study Finds”

“Need an Ambulance? Why You May Not Want the More Sophisticated Version”

“More Advanced Emergency Care May Be Worse for Cardiac Arrest Victims: Study”

Fraud and abuse in the ambulance industry—Walk the halls of Congress or state legislatures and ask about changing payment models for EMS. The response from elected officials is often something like, “What are you going to do about the fraudulent billing issues we already have?”

While the incidence of fraudulent billing in the ambulance world generally amounts to a few unscrupulous providers billing for nonemergency services, headlines like these do not help demonstrate the value EMS provides America:^6–8

“Ambulance Company Operators Face Health Care Fraud Charges”

“Millions Lost Yearly to Ambulance Companies Acting Like a ‘Taxi Service’” (“Every year,” this story reported, “$350 million in ambulance services is lost to or ripped off by companies…”)

“Think the E.R. Is Expensive? Look at How Much It Costs to Get There”

How to Demonstrate It

Our success as an industry depends on our ability to prove we bring value in new ways—the ways our healthcare stakeholders and funders perceive value. That specifically includes patient safety and quality, outcomes, utilization and cost of care, and experience of care.

CMS and the Agency for Healthcare Research and Quality (AHRQ) have outlined their National Quality Strategy, which features three broad aims for healthcare quality:⁹

• Better care—Improve overall quality by making healthcare more patient-centered, reliable, accessible and safe; 
• Healthy people/healthy communities—Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher-quality care; 
• Affordable care—Reduce the cost of quality healthcare for individuals, families, employers and government.

In implementing its value-based purchasing strategy, CMS has laid the foundation for what healthcare providers such as EMS will be held accountable for (see Table 1).¹⁰ So far these measures have been applied to hospitals, physicians, home health agencies and skilled nursing homes. It’s logical to presume they will eventually be applied to EMS, especially as our cost to CMS continues to grow and we seek to implement APMs that reward the successful navigation of patients through the healthcare system, as opposed to just transport from Point A to Point B.

Note, by the way, that the weighting of the process domain—which means clinical process of care—has diminished over the past five years as the weights for spending efficiency and safety have grown in significance.

Who Should See It

Let’s explore the major stakeholders to whom we need to prove value and the most effective ways to do so.

Employees and family members—Our employee team members are some of the best ambassadors of our profession. As they feel valued through initiatives such as empowered work teams, just culture, thank you letters, employee appreciation events and participatory engagement, they will value their organization and profession.

Healthcare partners—As mentioned previously, their world is dramatically changing. Communicate and engage with them. Ask about their needs and ways you can bring value to them that may be new and different. You may hear they want help with patient experience scores and might want to see yours. They may want assistance with APMs they’re part of and to know how you can partner with them to reduce unnecessary healthcare utilization. Be prepared to include them in internal decisions that may impact them. MedStar recently engaged several healthcare stakeholders as part of an interview panel for a key position within the organization.

Elected and appointed officials—Most important for this stakeholder group is a happy constituency. Do things to limit complaints about things like response times and ambulance fees. Find ways to include them in community benefit initiatives and support their projects. Keep them informed of major incidents and preparations for large events.

Medical directors—Bring your medical directors value by ensuring your clinicians provide excellent medical care and know not only how to apply a protocol, but when and why. Provide access to data that demonstrates a commitment to quality improvement initiatives and research. Keep medical directors informed about major incidents and include them in major decisions.

Coresponders—Most of all be nice to your coresponders. Give them respect on every scene. Recognize their exceptional service as often as possible. Everyone on a medical call should be involved in patient care and scene safety decisions. Include coresponse agencies in operational decisions and training initiatives that may affect them.

The media—They play a very important educational role in the community. Keep them informed about major incidents and initiatives you undertake. Realize that a news story will happen with or without you, and use opportunities to partner with the press by providing HIPAA-compliant information about incidents they’re interested in reporting.

Value and Quality Reporting

EMS providers would do well to read the roadmap laid before us through other healthcare providers and develop dashboards of value-based measures we could and should publicly report. Doing so would begin to demonstrate how we perform with metrics that have been applied to other healthcare provider entities. If we find things to improve along the way, at least we have a basis upon which to measure the changes we’ve made over time.

Knowing this information will also help the EMS industry measure the effectiveness of new service delivery models and APMs we may pilot to demonstrate more value for our stakeholders. For example, if we have data showing that 61% of the patients we bring to the ED are treated and released and the costs associated with that service delivery model, what if we did something different? What impact does that have on patient outcomes? On patient satisfaction? On the cost of care?

We need to be prepared for new value models in the way we deliver care. Following the concepts outlined here, we can not only be ready for the conversation but perhaps even guide it.

References

1. Centers for Medicare & Medicaid Services. Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume, www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html.

2. U.S. Department of Health and Human Services. Report to Congress: Evaluations of Hospitals’ Ambulance Data on Medicare Cost Reports and Feasibility of Obtaining Cost Data from All Ambulance Providers and Suppliers, www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/Report-To-Congress-September-2015.pdf.

3. Avril T. Police transport a good bet for shooting victims, study finds. Philadelphia Inquirer, 2014 Jan 8.

4. Sun LH. Need an ambulance? Why you may not want the more sophisticated version. Washington Post, 2015 Oct 12, www.washingtonpost.com/news/to-your-health/wp/2015/10/12/need-an-ambulance-why-you-may-not-want-the-more-sophisticated-version.

5. Reinberg S. More Advanced Emergency Care May Be Worse for Cardiac Arrest Victims: Study. U.S. News & World Report, 2014 Nov 24, https://health.usnews.com/health-news/articles/2014/11/24/more-advanced-emergency-care-may-be-worse-for-cardiac-arrest-victims-study.

6. Abrams M. Ambulance Company Operators Face Health Care Fraud Charges. CBS Philly, 2013 Sep 25, https://philadelphia.cbslocal.com/2013/09/25/ambulance-company-operators-charged-with-medicare-fraud/.

7. Kerley D. Millions Lost Yearly to Ambulance Companies Acting Like a ‘Taxi Service’. ABC News, 2015 Jan 16, https://abcnews.go.com/blogs/politics/2015/01/millions-lost-yearly-to-ambulance-companies-acting-like-a-taxi-service.

8. Rosenthal E. Think the E.R. Is Expensive? Look at How Much It Costs to Get There. New York Times, 2013 Dec 4, www.nytimes.com/2013/12/05/health/think-the-er-was-expensive-look-at-the-ambulance-bill.html?hp&_r=1&.

9. Agency for Healthcare Research and Quality. About the National Quality Strategy (NQS), www.ahrq.gov/workingforquality/about.htm.

10. Fontana E. Adjustments ahead: Your value-based purchasing forecast. Advisory Board, www.advisory.com/research/financial-leadership-council/at-the-margins/2015/07/adjustments-ahead.

Matt Zavadsky, MS-HSA, EMT, is the chief strategic integration officer at MedStar Mobile Healthcare, the exclusive emergency and nonemergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas and the recipient of the EMS World/NAEMT 2013 Paid EMS System of the Year.