It’s final! In June 2011, the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act (PPACA), commonly known as Obamacare. This past November, President Barack Obama won reelection and Democrats maintained a majority control of the Senate. Any hopes Republicans had of repealing the law went away with those two opportunities. By the end of Obama’s second term, many of the PPACA’s core components will have been in effect for three years or more. There’s really no turning back; healthcare as we know it is going to change.
The healthcare bill was 2,733 pages long and EMS is only referenced a few times in the document. But the effect on EMS will be dramatic. I suspect that many EMS systems will look totally different in 10 years.
I know; you’ve heard this rhetoric before. About 15 years ago, we heard that managed care organizations would be the “gatekeepers” that would keep people from unnecessarily calling 9-1-1 to go to an emergency department (ED). We heard that call centers for insurance providers would properly evaluate the caller and route them to the appropriate level of care instead of calling 9-1-1. Those changes largely failed to materialize.
Changes to Managed Care
The problem with managed care is that it was mainly an effort by some insurance providers to control costs and profits, and it was voluntary. The PPACA will be legally required. Besides the 2,733 pages of the bill itself, more than 14,000 pages of federal regulations have already been written.
In addition, the PPACA is partially funded through tax reforms (e.g., a 2.3% tax on medical devices costing more than $100). Expect those manufacturers to pass that cost on to you when you purchase devices costing more than $100.
Although nobody truly knows how these changes will affect healthcare, there’s one thing we can be sure of: People are still going to get shot, have heart attacks at the ball game and get into auto accidents going home from work. Our 9-1-1-based EMS systems will still be needed to address such medical emergencies.
What’s most likely to change for EMS is how we deal with chronically ill patients who call 9-1-1 because they have waited too long to address their medical problem or because they lack health insurance and use the ED as an entry into the healthcare system to address their problem. For Medicare patients, these needs will most likely be met through accountable care organizations (ACOs), which are just starting to form.
The main function of an ACO is to monitor and control reimbursements for healthcare providers while also monitoring the quality of the care being provided. The PPACA allowed for the establishment of a Medicare Shared Savings Program (MSSP), which allows for ACOs to contract with Medicare. Under this type of scenario, the ACO would need to be totally responsible for the quality, cost, care and management of at least 5,000 Medicare recipients.
An ACO can deny or reduce payment if the provider isn’t meeting quality standards. For example, reimbursement can be denied when a patient is readmitted to a hospital within three days for the same problem. It’s therefore in that hospital’s interest to make sure the patient doesn’t get readmitted for the same problem.
How does this affect EMS? To avoid such readmittals and other quality of care issues, hospitals may partner with the local EMS system to perform a variety of services. These can include checking on the patient with home visits for the first three days, or if complications arise, transporting the patient to another level of care.
Start Preparing Now
EMS managers should prepare now for the changes that are coming. As patients with insurance are moved to management systems and existing Medicare patients are moved to ACOs, prepare for initial call load increases. This should be followed by a leveling-off period. Start meeting with your local hospital administrators to discuss partnerships that can come about with the implementation of the PPACA.
As the saying goes, “Chance favors the prepared mind.” EMS systems that start preparing for the long-term impacts of the PPACA will no doubt reap the benefits.
The main function of an Accountable Care Organization (ACO) is to monitor and control reimbursements for healthcare providers while also monitoring the quality of the care being provided. The PPACA allowed for the establishment of a Medicare Shared Savings Program (MSSP), which allows for ACOs to contract with Medicare. Under this type of scenario, the ACO would need to be totally responsible for the quality, cost, care and management of at least 5,000 Medicare recipients.