Community Paramedic programs won’t work in private EMS

Money. That’s why.

There simply isn’t a financial incentive for a private EMS service to run a community paramedic program.

Hospital-based EMS services have a financial incentive to run a community paramedic program. If the hospital-based service can reduce ER visits, and therefore reduce hospital admissions, then there is a financial incentive for them to run a community paramedic program.

Fewer chronic visitors in the hospital = more ER beds = more available inpatient beds = more insurance payments for the hospital.

Plus, with new healthcare regulations stipulating that hospitals won’t be payed for re-admissions within 30 days for the same problem, hospitals really have an incentive to reduce visits by chronic users. Visit the patient in the home, keep them at home, and they won’t come to the hospital as often.

County-based EMS services likewise have a financial incentive to run a community paramedic program. Specifically, the county third services, not fire-based services, but I will get to them.

County-based EMS services have more leeway to deny or refuse transport to patients who meet certain criteria, or at least they do where I have worked. Having trouble urinating? We aren’t gonna take you to the hospital. Can’t sleep? Take a melatonin. We aren’t taking you to the hospital. But those chronic users learn how to work the system. Having trouble urinating turns into abdominal pain with difficulty breathing. Now we have to transport. Can’t sleep turns into headaches and dizziness, or general weakness, and now we have to transport.

These patients either aren’t insured, or won’t pay their bills. If, on the off chance they are insured, reimbursement from their insurer are low, and the copay won’t be covered. Transporting these patients becomes a net loss for the county service. Keep them at home, and more units are available to transport the patients for whom reimbursement rates are higher, or who actually need an ambulance to take them to a hospital.

It seems like ‘want’ and ‘need’ have become synonymous lately.

Fire-based services also have a financial incentive to implement a community paramedic program. If the fire-based service can send a community paramedic to a chronic EMS user’s house, and keep that user from activating 911 or requesting EMS, then those EMS units are available to run more calls that actually require EMS, and it keeps other fire units in service and available for fire calls. Or the EMS calls that fire services shouldn’t be running anyways.

But the private service that operates on a ‘you call, we haul’ basis has no incentive like the other three models. There is only an incentive for the private service to transport.

Transport – get paid. Don’t transport – don’t get paid. Pretty simple.

I have worked at various private EMS services for the past 10 years, and not once have I told a person that I was not going to transport them to the hospital. Every single time someone wants to go, we put them on the cot and take them to the hospital of their choice.

If the chronic EMS user does not have insurance, or doesn’t pay for their use of EMS, then the difference becomes a tax write-off, or is covered by a government subsidy of some sort. Private services aren’t concerned with readmission penalties at hospitals, and they aren’t concerned with overburdening an already busy ER.

More paramedics in ambulances = more paramedics to transport patients. Why would a private EMS owner or manager intentionally take a paramedic off of an ambulance, and put that paramedic into a vehicle to visit patients at their homes? That goes contrary to the very mission of the private service, which is to transport anyone and everyone who wants it.

More paramedics on ambulances = more paramedics to transport patients.

I wish it weren’t this way, and I wish that community paramedic programs could flourish in a private EMS service, but I don’t see it happening.

Maybe I’m cynical, but maybe not. I would be interested to see the private EMS service that has implemented community paramedic program with success.

Comments

  1. You make quite a few interesting points, but I have to say that I think you’re wrong.

    For that matter, I think the privates are uniquely positioned that can either make or break a Community Paramedic Program… or at least the privates who are taking into consideration all these changes and are being proactive about it with their hospital partners who are already focused on it.

    I’ll make the case for it in a forth coming blog post, but in the mean time I think you need to ask yourself this question: If the payment model for EMS Service, which is a fee for service, doesn’t change then how will Fire and County EMS programs fund themselves? Reduced demand will not reduce cost, but it can reduce revenue which will end up having to be covered somehow… or are you then reducing resources to match the reduced revenue and if you’re doing that, how long can you through resources at something that’s not funded? Even if you can then reduce resources, you will in fact be increasing cost because you’ll need less supplies/personnel/vehicles but you could potentially lose the volume discounts that some systems immensely enjoy.

    I’ll let you know when I compose my counter.

    • Dave; recognizing that we work in different areas, I may not understand the revenue model that you speak of for county- and fire-based services.

      I work for a private service, and we don’t collect what we don’t bill. My service only bills for transports we perform, and we itemize bills. From what I understand, an ALS1 ambulance ride is roughly $850 plus $9 per mile.

      But I don’t live in that same county. The county in which I live utilizes county fire ambulances to transport their patients. Since we (the residents/taxpayers) already pay for the service, we are billed at a different rate here. If I were to take an ambulance to Local Hospital, I would only be charged the mileage rate, and that would be billed to my insurance company. I would never see a bill, because I already paid my bill in advance.

      If I was 7 miles east, and my service transported me to the same hospital, I would see a (best guess) bill for $940.

      That’s where I see the complete difference in the billing model, and the incentive for the county service. County services are a “Budget looking for a mission” whereas the private service is a “Mission looking for a budget.”

  2. There appears to be some “seed” money in the form of grants floating around. Two private services in our area are reportedly working on pilot programs for community paramedics.

    Hospitals might have an incentive to use community paramedics, but the truth is they’d probably rather use RNs or even LPNs since what community paramedics are supposed to so is what nurses already DO.

    There is also the matter of how much additional training paramedics are going to need to do home based health care. The truth is that we are not all that good at knowing if someone needs to be in the hospital or not. Which of course brings me the topic of paramedic initiated refusals.

    Bad. Idea.

    Some of the more horrific stories that come out of EMS, as well as the attendant litigation, come from paramedics that tell patients “You don’t need to go to the hospital.” Services that have those policies in place tend to get sued a lot because their medics screw the pooch and leave really sick people at home to die.

    When a patient doesn’t fit in to the fairly narrow parameters to which we are trained, the response seems to be that the patient can’t be that sick. Some of the sickest patients I ever encountered were the ones that I could do little more than transport and then tell the hospital that they were pretty sick. I didn’t know what exactly was wrong with them, but I knew that they needed to be in the hospital.

    Unfortunately the norm seems to be to think the other way.

    This doesn’t mean that nurses are necessarily smarter than paramedics, it just means that they look at other things.

    The last obstacle that I see, at least for the purposes of this discussion, is finding medics to staff these programs. Either they are going to be pulled off of ambulances, on duty ambulance crews are going to be used, or the program will be staffed with medics that can’t or don’t want to work on ambulances.

    The latter are the most concerning because if it’s a paramedic on a light duty assignment because of illness or injury, what is going to happen when they inevitably find a patient that needs immediate treatment? If they can perform the skills that a paramedic can normally perform, why are they on light duty? If they can’t, how much good are they to the patient?

    If they are taken off of ambulances and reassigned to community paramedic programs, they will only exacerbate one of the problems they are supposed to solve.

    If on duty ambulance crews are used, then again you’ve worsened the ambulance shortage. Or at the least, you’ve put more work load on the paramedics.

    If you take a guy that is “burnt out” from working on an ambulance, is that going to be beneficial to the patient?

    I see a lot of problems and a lot of questions about these programs. What I haven’t seen is a lot of answers.

    • Yeah, the nurse/medic paradigm confuses me. It seems like smoke and mirrors to me, honestly.

      Why would a hospital pay an ambulance service (just throwing a number out there) half a million bucks a year to send paramedics to visit patients at their homes, when they could use the staff they already had for a much lower investment?

    • Flash Larry says:

      You raise here the interesting question that is quite a different issue than the financial one (see my comments on that below) and that is the competency of the people who are making transport decisions.

      We have already read some of the horror stories coming out of the UK government-run system where ambulance personnel are paid bonuses for not transporting patients and some of the decisions they have made have resulted in tragedy.

      The fact is that public safety, including the private EMS component, does not have a good history of appointing competent people into positions of authority. Private EMS often doesn’t care if lower management is any good as long as profits are maximized. Public agencies are rife with nepotism and favoritism and it’s the rare public agency where you can find an effective program for promotion of competent people. Having worked in a place like that for many years, I can see the difference between that and how things are done at every other place that I’ve worked. The difference is striking.

      So, yes. The questions are always, “Who is providing the care? Who is making the decisions?”

      It would be possible to put a system together, as I describe below, where hospital, EMS and home health care partner so that EMS summons an “urgent” response from a home health care nurse to look at a patient who is known to be under physician care at a particular hospital.

      Keep in mind, though. If a patient wants to go to the hospital in our current system (as opposed to the UK system), if one ambulance won’t transport them, they can always call another one that will transport for the money.

  3. So, here’s my thought on this. You have the privates that currently have no incentive really to do this due to the pay for transport model. I get that, I’ve experienced it, it doesn’t always lead to the best patient care, but in many places, this is what is and ultimately, let’s realize/remember what those private EMS services are. For profit business first, healthcare second.

    Go ahead, argue, I’ll wait.

    Back? Good. Here’s where I see an interesting change coming. When the readmission guidelines fall in to place, my understanding is they come back in less that 30 days for the same problem and are admitted, no one, not EMS, not the hospital, no one gets paid for the first or second time. Will that finally force EMS, regardless of delivery model, to give a rip about appropriate patient care and education of said patients? It pains me to say this, but maybe this change might wind up having some sort of upside to it.

    • I already made my case, so I’m glad you didn’t have to wait long.

      EMS won’t be punished for readmissions. They aren’t hospitals, and it isn’t the responsibility of the ambulance service to keep the patient out of the hospital. Actually, exactly the opposite is the case: the private ambulance service has more incentive to transport that patient to a different hospital every thirty days.

      I remember when “managed care” was supposed to change the way we did things, and when insurance call centers were supposed to refer patients to doctor’s offices instead of having them call 911. Neither one of those has happened, either.

      Don’t hold your breath, you might just pass out.

  4. I agree with theory and reality often being very divorced from one another. That being said, this would allow CMS(the government) to receive services without paying for them. A little different than an HMO really. My argument is this time there’s more chance of it happening.

    And the whole Medicare not paying anyone based on readmission is just what is coming down from on high. Haven’t yet sat down and read it for myself.

    • Speaking of CMS, here is the readmission penalty explained on their website:

      http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

      • Interesting reading. Strangely enough(and I haven’t waded through every single file available on that site and haven’t touched FY 2014 IPPS final rule propositions yet) I don’t see EMS specifically addressed one way or the other unless I’ve missed it. Guess it’s once again a game of wait and see.

        • Flash Larry says:

          It is difficult to put into a document that “EMS will not be paid if…” without a huge public outcry and without EMS providers saying to a patient, “We can’t take you back to the hospital unless you pay the bill here and now yourself because Medicare won’t pay it. Call your Congressman, Senator, and the President if you don’t like it because that’s the law.”

          They would have to find a way to implement it without putting it in writing. It is quite possible they will.

  5. Flash Larry says:

    Well, my friend, we agree about many things but I believe that here you have presented a generalization that may turn out to be true but may not as well. There are forces in play beyond the usual market forces that make things work or fail to work here.
    Can a private service operate a Community Paramedic program successfully? Of course it can. As with any private business, it simply depends on the financial incentive that would make it reasonably profitable.
    Right now the financial incentive is to transport the patient, and that’s true in almost all systems – private, public, fire, hospital, whatever. Transportation results in payment by the insurance entities – mostly. Mostly means that insurance companies/M&M have mechanisms in place to deny payment as often as possible but, in general, EMS services of all stripes depend on transports for their income. Some entities still operate on a taxation basis – the EMS service is supported by general taxation – but that will suffer and collapse in a poor economy, and where there is a large demand by increasing populations of people who use the EMS system as a taxi to their primary health care physician, otherwise known as the ER. We’ve seen the demand for EMS services outstrip the taxation support in two political subdivisions here, and as a result, we’ve seen the public hospital-based service resort to aggressive attempts to increase market share of insured patients.

    What has to happen is what is popularly (therefore usually not by me) called a paradigm shift. Assume that a hospital wants to decrease the patient returns to their facility as you describe. The only way that is possible is to partner with the EMS service. There is a hospital in my state that has acquired a home health care service and is going to use that company to follow up discharged patients to prevent readmissions. However, if the patient calls 911 for a medical complaint, unless the hospital has also partnered in some way with the ambulance service so that there is cross-exchange of patient information, the EMS system will do what it does – and the patient will be back in the ER. Therefore the EMS service has to be drawn into the plan, and to do that, it has to be compensated.

    Outside of the obvious connection between a hospital-based service and the receiving hospital – and it’s outside the scope of this discussion to consider how a hospital-based service can game the system in an urban multi-hospital setting but it should be obvious – county third services, private services and fire-based services have an incentive to participate in a plan IF they are adequately compensated.

    Private services make money.

    County third services and fire-based services want to reduce demand for tax support while at the same time continuing the same staffing levels, which justifies the employment of managerial and administrative support staff. They can do this not only through call volume with transports, but through a community paramedic program as well.

    Final note: the hospital that I mentioned above that has acquired a home health care system is trying to acquire managerial control or at least enter partnership with the local EMS services as well so there can be a unified approach to out-of-hospital responses. This may be a wave of the future.

    The legal issues have yet to be worked out. We’ll see how that goes.

  6. Hello –

    Actually, there’s little financial reason that this post needs to be true (except in fairly rare circumstances and certain rural stations), because the Shared Savings Model actually provides proactive financial incentives THAT ARE DESIGNED TO OFFSET THE REVENUE LOSSES ASSOCIATED WITH NON-TRANSPORT.

    But as usual – (though of you who know my company’s work have heard me say this before) – please do not take my word for it. Here is the quote from CMS: “The Shared Savings Program is designed to provide an incentive to Medicare-enrolled providers and suppliers that come together to form an ACO.” SOURCE: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/FAQ.html

    What you’ve pointed out here is the interesting – at least to the business folks in the room – wrinkle in the economic model for Community Paramedicine, which I also wrote about in my last “EMS Innovation Newsletter” (http://beyondlucid.com/mediview/ThoughtLeadership/APrimeronCommunityParamedicinePart2.aspx)

    That is to say that even though CP / Mobile Integrated Health proponents discuss cost savings and loss reductions, they frequently fail to mention revenue losses – without doing so, they skew the model so that “both sides of the ledger don’t match.” EMS agencies get paid to transport and they are NOT subject to readmission penalties, so if you provide bedside care but don’t transport the patient, you actually experience a net capital loss.

    HOWEVER, THIS DOES NOT HAVE TO BE THE CASE.

    In the case of MedStar, Matt Zavadsky often tells about how his agency got its regional hospitals to pay for EMS to provide bedside care instead of transporting. This ONLY makes economic sense if the loss (costs) associated with patient readmissions is higher than the amount the hospital would have to pay the medics to keep repeat patients out of the ED. However, not every organization will be able to get its partner hospital(s) to pay for such services – indeed, the economic model may not make sense unless there is a very large population of repeat transport patients (technically speaking, the aggregate penalty of all those patients must be HIGHER than the total cost of paying the EMS agency to offset the costs over time).

    BUT here’s hope: Many different communities can (and do) participate in ACO and ACO-like programs, and thereby enjoy the benefits of the Shared Savings model.

    Or here’s something else (and there is precedent in places like New York City): organizations can actually “build their own ACO” by restructuring their regional revenue model. If they don’t want to – or can’t – qualify as a federally recognized ACO with a prepackaged Shared Savings Model, they can still set up a community-based Shared Savings Model of sorts. The numbers aren’t particularly complex, and most private EMS agencies likely have the necessary costs modeled (or latent, at least) in their records due to having been paid for service over the previous three years.

    If this sounds like a daunting task – but it is of interest – let me know. My firm can help….we’ve developed a specialty in Community Paramedicine (who else would write this much about the economics of the model?), and with two MBAs running the company, we basically live and breathe numbers. We’ll be happy to help. Contacts below. Stay safe!

    Jonathon

    ========================
    Jonathon S. Feit, MBA, MA
    Jonathon.Feit@beyondlucid.com
    (650) 648-ePCR main

  7. Interesting historical perspective from a “fee for service” point of view. No only is the world of emergency services changing but so are the revenue mechanisms. MIH and CP are good buzz words that are trying to redefine what fire based EMS systems have been doing for years under the heading of EMS. Let’s call these services what they are… Non-Emergency Medical Services (NEMS). All EMS systems have handled these call types for years and these CP/MIH programs are models to handle them more efficiently. We have developed our own NEMS division that shifts revenue from “fee for service” to a number of broad based billing models and medical cost savings share plans. We believe there is a place for private EMS partnerships with fire based systems taking the lead. We are working to improve the services and the patient/pay ratio’s for private based transport companies that work with a fire departments delivery model. The “you call, we haul” model has never been an appropriate model, especially if you only haul to an ED. If you are a fire based EMS provider, let us help you improve your delivery model, add value to the community you serve, reduce costs across the broader healthcare sector, demonstrate continued high levels of patient health outcomes and satisfaction, all while offseting property based tax revenues with newer funding mechanisms being forced on all providers by PPACA. See FDCARES.com and feel free to contact us if you are interested in improving your fire based delivery model.

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