Administration and Leadership, Mobile Integrated Healthcare, News

Is EMS Next to Transition to Medicare’s Value-Based Payment Model?

Issue 9 and Volume 39.

In Merriam-Webster’s Collegiate Dictionary, “value” is defined as “the amount of money that something is worth,” or “usefulness or importance.”

America’s healthcare industry is all abuzz with value-based purchasing (VBP) and moving rapidly toward paying for things proven to make a difference in the patient’s outcome.

The U.S. health-care system is the most expensive in the world. According to the National Center for Health Statistics, we spend $8,700 per capita on healthcare,1 nearly double the average expenditures for most other economically developed countries.2

And, for that investment, we have some of the worst health outcomes. Compared to the 15 most economically developed countries, 28.6% of our population is classified as obese (highest), life expectancy is 78.7 years (eighth lowest) and all-cause death rate is 505 per 100,000 (highest).3

The Affordable Care Act is an attempt to change this equation, requiring the Centers for Medicare and Medicaid Services (CMS) to set a laser focus on value by adopting an economic model for hospitals and other providers based on performance metrics that have been proven to make a difference in patient outcomes.

The hospital VBP (HVBP) program pays hospitals bonuses or charges penalties based on defined outcome measures the hospitals are required to track and report. The VBP metrics are phased in over three years. (See Table 1.)

Hospital value-based purchasing metrics

Hospitals have been under this model for a portion of their Medicare payments since 2013. Individual hospital performance on these metrics is also published on the CMS Hospital Compare website at www.medicare.gov/hospitalcompare.

The Patient Experience
The weighting of the patient experience metric doesn’t change over time—it always remains 30% of the VBP measure. As additional metrics are added, everything but the patient experience metric is reduced.

The patient experience metric is required by CMS to be measured using an external agency. The agency (e.g., Press Ganey, Gallup, etc.) receives patient data from the hospitals, contacts the patients to conduct the survey and reports the results to the hospital and CMS.

How many EMS agencies can say they’re taking a similar approach to measuring patient experience? For more insight into the importance of the patient experience measure, read the article “The Patient Experience: The Affordable Care Act’s emphasis on patient-centered care will transform our industry” in the February issue of JEMS.

Latest from Medicare
On June 24, CMS announced physician groups will fall under the same VBP model starting in 2015, stating:

“The Physician Feedback/Value-Based Payment Modifier Program provides comparative performance information to physicians and medical practice groups, as part of Medicare’s efforts to improve the quality and efficiency of medical care. By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume. This program supports the transformation of Medicare from a passive payer to an active purchaser of higher-quality, more efficient healthcare through the value-based purchasing (VBP) initiative.”

CMS now also has a companion to the Hospital Compare website called Physician Compare (www.medicare.gov/physiciancompare), designed to help patients make informed choices about the healthcare they receive through Medicare.

Similar to how CMS rolled this out to hospitals, physician groups currently receive an incentive bonus for reporting quality of care information to the new website. Like hospital data, reporting will soon be mandatory, with penalties for physician groups that don’t report.

Impact on EMS
The recent CMS Office of Inspector General report indicated ambulance service is the fastest growing Medicare Part B expenditure, placing EMS squarely on the radar.4

The time is rapidly approaching, whether we like it or not, when EMS will be required to report outcome-based, quality metrics based on demonstrated clinical practices that make a difference in patient outcomes in order to be eligible for payments.

The challenge for us is that there’s a dearth of peer-reviewed, clinical performance metrics that demonstrate anything we do makes a difference in the patient’s outcome—a difference that would make a payer want to pay us for the care we provide in the out-of-hospital setting because it saved them money in the long run. In fact, there’s some published data that demonstrates things like going to the hospital by police car or other means results in better patient outcomes for certain trauma cases.5

If CMS knocked on your director’s door today and asked, “What metrics do you have that demonstrate to us you’re delivering outcome-based, quality clinical care?” How would you answer?

Response times? Many studies have proven response times make little difference in patient outcomes.6–8 Even in cardiac arrest, any response time greater than five minutes makes no difference in survival rate.9

Cardiac arrest survival? Yes, there’ve been minimal improvement in cardiac arrest survival rates, but most health insurance payers will tell you that a revived cardiac arrest in the field doesn’t typically equate to an economic savings to them. Perhaps that’s why Medicare decided a decade ago to allow payment for not transporting a cardiac arrest victim to the hospital, but rather, pronouncing them dead on scene.

In most agencies, this is where the conversation ends. It’s way past time for us to begin measuring and reporting clinical quality measures proven to make a difference in patient outcome in the same way hospitals have had to report their VBP metrics.

EMS Medicare Metrics?
What would an EMS Compare website look like? We might report measures such as:

  • Percentage of ST elevation myocardial infarction (STEMI) patients who received pre-arrival dispatch instructions for aspirin administration;
  • Percentage of STEMI patients who had an ECG acquisition and transmission to the receiving facility within three minutes of patient contact;
  • Percentage of STEMI patients where on-scene time < 10 minutes;
  • Percentage of stroke patients last seen normal > six hours ago and who were transported to a comprehensive stroke center; or
  • Percentage of patients surveyed who’d recommend us to another patient.

The National Health Service (NHS) in the United Kingdom has invested considerable time developing metrics that make a difference in patient outcomes for their ambulance service trusts. NHS also ties financial incentives for the ambulance trusts for demonstrated compliance with these clinical bundles. The STEMI clinical bundle in Table 2 identifies the clinical treatments that have scientifically been proven to improve patient outcomes. Note how the compliance with virtually all the metrics has gradually improved during the cycle reporting periods.

NHS ambulance trust cycle reporting measures

In addition to STEMI, there are clinical bundles for stroke, hypoglycemia, asthma and cardiac arrest. To help assure compliance with the clinical bundles, each NHS ambulance service trust tracks compliance by individual provider. This helps reinforce the importance of patient outcomes, identifies educational opportunities to help improve performance, and then loops back with additional performance measures to see if there’s been any improvement.

Conclusion
EMS agencies need to have a pair of binoculars in one hand to continuously look to the horizon for changes occurring in other facets of healthcare, anticipating those coming our way. In the other hand, agencies need to have a microscope to closely examine how we’re performing to meet quality clinical metrics to prove our worth.

References

1. FastStats: Health expenditures. (May 14, 2014.) Centers for Disease Control and Prevention. Retrieved July 12, 2014, from www.cdc.gov/nchs/fastats/health-expenditures.htm.
2. Snapshots: Health care spending in the United States & selected OECD countries. (April 12, 2001.) Kaiser Family Foundation. Retrieved July 12, 2014, from www.kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states-selected-oecd-countries.
3. Allen AC. (July 7, 2014.) Countries spending the most on health care. USA Today. Retrieved July 12, 2014 from www.usatoday.com/story/money/business/2014/07/07/countries-spending-most-health-care/12282577.
4. Office of Inspector General. (Sept. 24, 2013.) Utilization of medicare ambulance transports, 2002–2011. U.S. Department of Health and Human Services. Retrieved July 12, 2014, from https://oig.hhs.gov/oei/reports/oei-09-12-00350.asp.
5. Band RA, Salhi RA, Holena DN, et al. Severity-adjusted mortality in trauma patients transported by police. Ann Emerg Med. 2014;63(5):608–614.e3.
6. De Maio VJ, Stiell IG, Wells GA, et al. Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates. Ann Emerg Med. 2003;42(2):242–250.
7. Blackwell TH, Kline JA, Willis JJ, et al. Lack of association between prehospital response times and patient outcomes. Prehosp Emerg Care. 2009;13(4):444–450.
8. Pons PT, Haukoos JS, Bludworth W, et al. Paramedic response time: does it affect patient survival? Acad Emerg Med. 2005;12(7):594–600.
9. Blackwell TH, Kaufman JS. Response time effectiveness: Comparison of response time and survival in an urban emergency medical services system. Acad Emerg Med. 2002;9(4), 288–295.