Promoting Innovation in EMS: PIE Project Priorities—Decoupling Payment From Transport

Over 2018 EMS World, in conjunction with the National Association of EMTs, will provide detailed implementation strategies for key recommendations of the Promoting Innovation in EMS (PIE) project. The PIE project utilized broad stakeholder involvement over four years to identify and develop guidance to overcome common barriers to innovation at the local and state levels and foster development of new, innovative models of healthcare delivery within EMS. Each month we will focus on one recommendation and highlight the document’s actionable strategies to continue the EMS transformation. 

The NAEMT’s EMS 3.0 Committee continues to work on creating strategies for implementing the top recommendations of the Promoting Innovation in EMS (PIE) project. As a reminder, the PIE project was a collaborative initiative led by Drs. Kevin Munjal and James Dunford. The project included numerous stakeholders internal to EMS but also, just as important, from outside the EMS profession, such as hospitals, payers, home health, and hospice agencies.

The project was funded by NHTSA, HHS’ Office of the Assistant Secretary for Preparedness and Response (ASPR), and the Department of Homeland Security (DHS). It sought to identify barriers to innovation in EMS and provided more than 250 recommendations.

So far in this column we have offered potential strategies for national EMS associations relating to innovations for quality metrics, data and data integration, and financial sustainability. This month we outline strategies for another recommendation, this one contained in the Strategies for Overcoming Financial Barriers to Innovation section of the PIE report:

“National EMS associations should continue to advocate in a unified way for the decoupling of reimbursement from transportation across all public and private payers.”

Many EMS innovators have illustrated the misalignment of incentives that results from payers reimbursing ambulance agencies based solely on the transportation supplied, as opposed to medical care. A recent study published in Health Affairs identified:¹

“12.9%–16.2% of Medicare-covered 9-1-1 EMS transports involved conditions that were probably nonemergent or primary care-treatable. Among beneficiaries not admitted to the hospital, about 34.5% had a low-acuity diagnosis that might have been managed outside the ED… If Medicare had the flexibility to reimburse EMS for managing selected 9-1-1 calls in ways other than transport to an ED, we estimate the federal government could save $283–$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.” 

Thankfully there has been significant movement as payers begin to recognize the value of decoupling payment from transport:

• In October 2017 Anthem announced it would begin paying the A0998 HCPCS code (for ambulance response and treatment with no transport) at 75% of its normal rate for ambulance transport.² 
• Arizona Medicaid currently pays EMS agencies for treat-and-refer services at a rate of $203.80.³ 
• At MedStar, a large commercial payer has begun paying a capitated payment (fixed amount per member/per month) for ambulance and MIH services. Under this arrangement there is no fee-for-service payment for ambulance transports, since it is prepaid each month.

And Medicare reimburses ambulance providers for the response and nontransport of cardiac arrest victims pronounced in the field. According to Medicare rules, if the patient is declared dead “by an individual authorized by the state to make such pronouncements” after dispatch but before the beneficiary is loaded onto the ambulance, Medicare pays the base BLS emergency rate, even if an EMS crew provides no treatment.⁴

Strategies for Success

Although these pockets of success are encouraging, there is still much work to be done toward the widespread adoption of payments to EMS agencies for response, assessment, treatment, and referral to appropriate medical care. What strategies can national EMS associations undertake?

Get together—Note a key phrase in the PIE recommendation: “should continue to advocate in a unified way.” Those of us who have the opportunity to meet with elected officials often hear the EMS community is fragmented when it comes to matters of legislation. The PIE authors recognized this and deliberately included a statement about unification. The major associations that influence payment policy, such as the American Ambulance Association (AAA), NAEMT, International Association of Fire Fighters (IAFF), and International Association of Fire Chiefs (IAFC), should agree on key tenets of decoupling payment from transport and all push in the same direction, perhaps even publishing a statement on the components they agree on. 

Enhance education, medical direction, quality improvement, and the economic model—Most EMS providers may lack the education and training to safely navigate 9-1-1 callers from the scene of a call to an alternative destination. If we as a profession are serious about decoupling payment from transport, we need to prepare providers to do it safely and effectively. This will require new education, protocols, and quality improvement processes. The National Association of EMS Physicians (NAEMSP) and American College of Emergency Physicians (ACEP) should work with the National Association of EMS Educators (NAEMSE) and NAEMT to develop education and training standards that prepare EMTs and paramedics for alternative delivery models that provide patient navigation. 

As part of this model change, if EMS providers are going to have the opportunity to refer patients to alternative destinations, national EMS associations should reach out to peer associations to build QA feedback structures. For example, urgent care centers should be encouraged to provide patient outcome data to any EMS agency that refers patients to urgent care instead of an ED. The same would be true for primary care clinics and even primary care physicians. The Urgent Care Association of America might be a logical group to collaborate with to promote this new EMS service-delivery model.⁵  

Many EMS agencies have billed for treatment without transport for years, but typically at a nominal fee because in most cases the patients are the ones paying. As more third-party payers cover services as a way to save downstream expenditures, EMS agencies may need assistance developing an economic model and legal framework. Forward-thinking national EMS associations may find it valuable to provide templates and education to their members on how to build the economic model and contracts for this service delivery.

Start small—The associations above have invested an impressive amount of time, energy, and resources to influence federal payment policy that decouples payment from transport. Changing such policy is hard, and to date these efforts have not resulted in any significant movement. For example, the concept of reclassifying ambulance services from a “supplier” of transportation to a “provider” of medical care has been both a regulatory and statutory challenge. 

However, states such as Arizona have implemented Medicaid policy changes that facilitate payment for nontransport. Similarly, commercial insurers have changed policy to decouple payment from transport. In addition to Anthem, Blue Cross Blue Shield of Georgia just announced it will begin paying the A0998 HCPCS codes for commercially insured members and add Medicare and Medicaid members as states and the federal government approve this payment model.⁶ Perhaps the message here is that more effort should be directed by national EMS associations to help facilitate this change at the state and local levels by working with state legislators, regulators, and payers. Medicare is a large payer for EMS services, but for many agencies Medicaid and commercial insurers combined represent a larger payer mix than Medicare.

Build coalitions—Just as important as the national EMS associations getting together will be building coalitions to decouple payment from transport. There are many external stakeholders who would likely be willing to join us to influence this change. 

Commercial and managed Medicare/Medicaid payers such as Blue Cross Blue Shield, Kaiser Permanente, Humana, Aetna, Cigna, and UnitedHealth have all been working with local EMS agencies to change payment policies. Their national trade association, America’s Health Insurance Plans, may also be willing to form a closer coalition with some national EMS associations.⁷ 

The Catalyst for Payment Reform is an active advocacy group for large employers such as AT&T, Boeing, Google, Walmart, and others that is pushing for changes in healthcare payment policy.⁸ The National Governors Association has been promoting Medicaid policy changes and has worked with agencies such as MedStar, REMSA, and others to promote payment for new models of EMS service delivery.⁹ The National Association of ACOs (part of the Patient-Centered Primary Care Collaborative) would also be a logical partner.¹⁰ ACOs have recently shown a keen interest in alternative destination/treat-and-no-transport EMS models and may be another logical partner to help decouple payment from transport.

Is the Horse Out of the Barn?

Decoupling payment from transport is a logical EMS evolution that’s already started in some areas. If national EMS associations are willing to get involved, decoupling payment from transport could be scaled in a much more coordinated fashion, employing the use of best practices from payers and agencies that are already doing it. Now is the time for these associations to realize it’s already happening and help provide the framework for expansion. 

References

1. Alpert A, Morganti KG, Margolis GS, et al. Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings. Health Aff (Millwood), 2013 Dec; 32(12): 2,142–8.

2. Erich J. ‘The Moment We’ve Been Waiting For’: Anthem to Compensate EMS Care Without Transport. EMS World, https://www.emsworld.com/news/218925.

3. Arizona Health Care Cost Containment System. Treat and Refer Recognition Program, https://www.azahcccs.gov/PlansProviders/NewProviders/treatandrefer.html.

4. J Emerg Med Serv. Do You Bill for Deceased Patients? 2008 Jul 31.

5. Urgent Care Association of America, https://www.ucaoa.org.

6. BlueCross BlueShield of Georgia. New Reimbursement Policy—Scope of License (Professional), https://www11.bcbsga.com/networkupdate/articles/archive/dec2017_ambRes.html.

7. America’s Health Insurance Plans, https://www.ahip.org.

8. Catalyst for Payment Reform, https://www.catalyze.org.

9. National Governors Association. Health Division, https://www.nga.org/cms/center/health.

10. Patient-Centered Primary Care Collaborative. National Association of ACOs, https://www.pcpcc.org/executive/national-association-acos.

Matt Zavadsky, MS-HSA, NREMT, is 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. He is a member of the EMS World editorial advisory board.