Part 1 of this discussion is available here.
The healthcare system is undergoing arguably the most transformative shift in economic models in recent history, transitioning away from fee-for-service (FFS) models that financially reward providers based on the volume of services provided, to value-based models that financially reward providers based on the value of the services they provide. EMS is not immune to these changes. We need to be prepared for some tough questions and interesting economic proposals that are beginning to be introduced in some EMS systems.
At the Pinnacle EMS Conference in San Antonio, Texas, leaders from the EMS, hospital, payer and physician community gathered to present a half-day power seminar designed specifically to prepare EMS leaders for the reimbursement revolution. Here are some pearls of wisdom from these leaders.
Data Integration and Exchange
Greg Mears, MD, ZOLL Medical Corporation and Todd Stout, FirstWatch
There is a sea change occurring in healthcare—specifically the movement toward pay-for-performance to achieve improved patient experience, improved population health and reduced cost of care. CMS has publicly stated its goal of having 90% of payment tied to some measure of quality by 2018.
A health information exchange (HIE) allows doctors, nurses, pharmacists, other healthcare providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care. There is an HIE adoption timeline articulated in the healthcare meaningful use guidelines consisting of enhancing:
- Local HIE capability between 2011 and 2019
- Regional HIE capability between 2014 and 2019
- National HIE capability starting in 2016 and running through 2024
There needs to be a scalable solution for EMS, meaning, connecting EMS to regional data hubs as opposed to each EMS agency connecting to each hospital independently, and here’s why: There are currently 19,437 EMS agencies and 5,686 hospitals. If an independent connection was needed for each hospital and EMS agency, there would be 110,518,782 separate connections—certainly a challenging number!
When engaging in a discussion about using EMS data to prove value, you first need to recognize that if we want to prove value to our payers, we really need to speak their language—in outcome domains using statistical run charts. There are generally four outcome domains the payers and our other healthcare partners focus on: quality and safety, experience, utilization and cost. Each of these domains can have the following specific outcome metrics for EMS providers:
Quality and Safety
- Protocol compliance
- Repatriation rate
- Adverse outcomes
- Patient satisfaction survey
- Patient “quality of life” survey
- Reduce ambulance transports
- Reduce ED visits
- Reduce admission/readmission rates
- Savings due to reduced utilization
Finally, there are a few keys to success in using EMS data for improvement and value. Start by doing the hard, messy work. Focus on using data for internal process improvement. Construct a run chart of a meaningful measure, such as compliance with a clinical bundle for STEMI patients. Find out how compliant you are at time “X,” then initiate a process improvement strategy and, here’s the most important part, re-measure the compliance rate of the STEMI clinical bundle at time “Y” to see if your process improvement made a difference in the compliance rate. Be transparent and accountable. Give your partners access to your performance information in near real time—no surprises. Share your successes and failures. Invite them into your improvement processes and welcome their feedback and ideas for improvement.
Doug Hooten and Matt Zavadsky, MedStar Mobile Healthcare; Brenda Staffan, Regional EMS Authority
If you have been successful in applying the concepts discussed so far in this series, there are now opportunities for you to engage in negotiations for value-enhanced service lines. Start the negotiation knowing that EMS is uniquely positioned and owns a very specific space for value in the healthcare arena. In virtually every community in America, after calling a three-digit number, you can have a trained medical professional in your living room in less than 30 minutes with high reliability. No other healthcare provider can do that—it is something we need to carve out and make our own in contracting for services.
Now, when someone asks, “How much does EMS cost?” many EMS leaders will rattle off cost per unit hour, cost per call or cost per transport. But, in terms of healthcare payers, we cost a lot more than that. We transport about 22 million people a year to EDs; 61% of those patients are treated and released. Calculating the cost to the healthcare system, the average payment for an ambulance transport is $419 and the average facility payment for an ED visit is $969.
$419 + $969, times 22 million visits equals almost $21 billion annually in healthcare system costs attributable to potentially preventable ambulance trips to the ED.
If EMS was able to make patient-centered navigation decisions for our patients, and even perhaps refer 15% of our patients to alternate care locations other than the ED, we could save the healthcare system almost $2 billion annually in ED expenditures!
Consider using alternative payment models (APMs as the payer community likes to call it) for your service delivery. Some options to consider could be:
- Payment for providing medical care vs. supplying transportation
o Allows for making patient-centered recommendations for care, not requiring transport just to get paid
- Capitated rates
o Population-based payments, typically on a per member/per month fee, regardless of ambulance response
o Aligns incentives to prevent the call and save the resulting downstream expenditure
- Shared savings
o Allows the EMS provider to share in the cost saving associated with reducing ED and ambulance expenditures by making patient-centered navigation decisions
Clinical and Service Metrics that Matter
Neal Richmond, M.D., MedStar Mobile Healthcare
We’ve been chasing the holy grail of reporting metrics that matter almost as long as we have been trying to actually prove that response times make a difference in patient outcomes. Policy makers seem to understand response times, likely because a) they are relatively easy to measure and report, and b) it’s what we’ve been primarily suggesting for years as the measure that should be used to evaluate performance (see reason a). In 2008, Prehospital Emergency Care published a position paper that de-emphasized using response times as the measure of system effectiveness, but rather, use clinical metrics that matter.1
There are several reasons EMS systems have difficulty measuring and reporting meaningful performance measures:
- System delivery models vary
- Each system usually has more than one component (dispatch, first response, transport)
- There are few universally accepted definitions of data points (data points typically reside in multiple sources and aggregating the longitude of the information is complex)
- There is little evidence base for the clinical things we do
- Most EMS system leaders have been promoted through the ranks and may lack the skill set necessary to design quality improvement data
In 2003, the National EMS Information System (NEMSIS) created a data dictionary of more than 400 data points that can be used to help measure EMS system performance. However, the way the data is entered into NEMSIS, as well as the ability to query the data, makes the system relatively hard to use for generating outcome measures. The recent EMS Compass project has renewed the interest in standardized quality metrics, and the steering committee is hopeful that the release of these measures will allow EMS agencies, and the industry in general, evaluate measures that matter.
The unfortunate reality is that most EMS systems do a reasonable job of measuring operational performance (unit hour utilization, response times, cost per unit hour and task times), but painfully few actually track and report clinical measures such as CPR flow time, capnography use or compliance with clinical bundles for things like STEMI, stroke, hypoglycemia or serious trauma.
But measure our effectiveness and quality we must. Policy makers and payer are starting to ask the tough questions like, “Do we really need all those paramedics?”, “Is ALS better than BLS?”, “Does the fact that a patient calls 9-1-1 for a STEMI improve their outcome?”, or “What is the reason that although our ROSC rate in the field has increased by 40%, our survival to discharge rate has not appreciably changed?”
To get into the mindset of measuring what matters, start small. Pick a few measures you can track and track them. Things like CPR flow rates or compliance with clinical bundles are a good place to start. Learn what you don’t know and lean how to then find it out. Once you start looking—really looking—at the quality of the care going on in the field, you will most likely have a career’s worth of quality improvement work ahead of you!
1. Myers B, Slovis C, Eckstein M, et. al. Evidence-based performance measure for emergency medical services systems: a model for expanded EMS benchmarking. Prehospital Emergency Care. 2008;12(2):141–151.