Reimbursement Issues Block Paramedics from Expanded Role

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Paramedics are primed to play a larger role in the health care system, which they’re sure will help lower costs and benefit patients. Yet they’re running into regulatory roadblocks that they say state and federal officials have to move.

Despite the track record of initiatives in places like Nevada and Texas, where paramedics are providing in-home care, coordinating patient services and saving millions in the process, Medicare, Medicaid and most private insurance plans still won’t reimburse for such work. The program successes to date are only beginning to change that.

“States don’t know what to do with us,” said Gary Wingrove, a former Minnesota EMS director who’s now director of strategic affairs for Mayo Clinic Medical Transport. “These are ambulance guys, but they’re not doing an ambulance function.”

Many of the programs — often referred to as community paramedicine — take aim at “super user” patients who consume a disproportionate amount of care. These individuals rely on ambulances and emergency services even in more routine medical situations, often because they don’t know who else to call or can’t afford appointments that require up-front payment. Some call 911 hundreds of times a year.

Local officials have tackled the problem in different ways. Some emergency call centers now have nurses determine whether an ambulance is really necessary — or whether helping an individual schedule a clinic appointment or less expensive travel to get care would suffice. Other communities send paramedics in vans to treat patients with non-urgent needs in their own homes. In rural areas, where doctors are scarce, paramedics often represent a critical primary care alternative.

Over three years, a Reno, Nevada pilot that utilized paramedics for in-home care saved an estimated $10.5 million in public health care expenditures. Since 2012, Fort Worth, Texas has saved over $1.2 million in ambulance and emergency department costs by allowing paramedics to coordinate care for super users.

And citing the potential care and cost benefits, the CMS Center for Medicare & Medicaid Innovation funded three programs in Connecticut, New York and Arizona for nearly $30 million in its last round of multiyear awards.

Nationwide, the impact from reducing ambulance calls and demands on ERs while freeing up doctors could be huge. A 2013 study in Health Affairs estimated that more flexible reimbursement for paramedicine approaches could save Medicare $283 million to $560 million annually and similar sums for private insurers.

“We can do more for our patients than just schlepping them all to the emergency room,” said Matt Zavadsky, the director of public affairs at Fort Worth’s MedStar, which launched its program in 2009. “It’s dramatically saved the health care system tons of money, and it’s also changed the patient’s experience in ways that we never imagined.”

Only Minnesota has passed legislation to reimburse paramedics for non-traditional services, however. A handful of other states have similar bills pending. Maine has several self-funded pilot programs, which lawmakers authorized in 2012.

At the federal level, there’s no movement to restructure reimbursement schedules. Yet advocates say recent legislative proposals could diminish some of the hurdles that community paramedicine faces.

The Field EMS bill, introduced last year by Rep. Larry Bucshon (R-Ind.) and Sens. Dick Crapo (R-Idaho) and Michael Bennet (D-Colo.), would require the first federal evaluation of these programs. It would also consolidate EMS oversight within HHS — rather than there, the Department of Transportation and other agencies — which advocates say would greatly improve the programs’ visibility.

Paramedics “are a critical part of the health care delivery system but unfortunately face challenges that undermine their ability to care for patients,” said Bucshon, who next week plans to reintroduce a new version of his bill. If passed, it would be the first major EMS legislation since the 1960s. “A commonsense first step to help solve this problem is to recognize EMS professionals as health care providers and leverage their capability to fill gaps in the health care system,” he said.

Most EMS departments aren’t holding their collective breath while waiting for lawmakers to act. Many have self-funded initiatives, hoping that proving their efficacy will draw future backing. Others have sought grant support, from private donors or agencies like CMMI. Still others are individually asking private insurers to reimburse their services, with mixed response.

Patient-centered medical homes and ACOs also offer a funding avenue. Within their new managed-care payment structures, a community paramedic can be considered a reimbursable provider.

Zadefsky, whose program was one of the country’s first, says hospitals and other providers in shared-risk contracts have come around because of the savings they’ve seen. Hospitals, for example, pay MedStar to have its paramedics coordinate care because that keeps their readmission rates down, he said.

“The private-sector folks that are closer to the patient can see the economic benefit of these arrangements and can decide in a board meeting to change policy, ” Zadefsky said.

In fact, he added, the greatest progress may ultimately be made that way. “An economic model that makes sense, but doesn’t require federal policy changes? That’s the future.”

Erin Mershon is a health care reporter for POLITICO Pro. Before she joined the team, she covered technology policy for POLITICO and for Communications Daily. She's covered nearly every aspect of Congress, from its Eagle Scout members to its wonkiest procedural maneuverings, for National Journal, Roll Call, The Huffington Post and PolitiFact. She's a graduate of Kenyon College, where she studied political science and ran the college newspaper.