Community Paramedicine and Mobile Health, Exclusives

Incorporating Pharmacists Into Mobile Integrated Health Teams: A Cost-Benefit Analysis

Provided photo

This study evaluates the economic impact of a mobile integrated health community paramedicine (MIH-CP) program with a consultant pharmacist partnership established in Manatee County, Florida. The purpose of this retrospective cost-benefit analysis was to determine if this pharmacist-paramedic model resulted in cost benefits from a payer perspective. Costs to payers were quantified through evaluation of ambulance transports, emergency department visits and hospitalizations avoided as a direct result of interventions of the program. Over three years, the net cost savings to payers resulting from interventions provided by the Manatee County Community Paramedicine Program ranged from $4,358,570.93-$7,390,358.51.

The average cost-benefit ratio was determined to be 1:4.02 (1:3.24-4.80). This indicates that for every $1 spent on program implementation, $4.02 was saved by payers. The results of this analysis do not include cost savings from medication-related interventions for which there is limited historical cost data from a payer perspective. Further potential savings to payers were identified as $824,704-$10,544,165 from medication interventions alone. As compared to a system not featuring a MIH-CP Program consisting of a pharmacist-paramedic partnership, there is a positive economic benefit to the payer. This data supports implementation of similarly structured pharmacist-paramedic MIH-CP programs as an approach to reduce overall costs to payers.

Related

Introduction

In 13 months, patient RG had 46 medication changes made by different physicians on his healthcare team. During this timeframe, he suffered an abdominal aortic aneurysm and pneumonia, and battled daily to get his chronic obstructive pulmonary disease (COPD), heart failure, atrial fibrillation, hypertension and gastroesophageal reflux disease under control. Patient RG’s struggle mirrors that of many battling chronic disease and complicated medication regiments.

From 2008 to 2015, Manatee County, Florida, experienced high utilization of emergency services for patients who had poorly managed chronic diseases, coinciding with a 37% surge in 911 calls.1 In 2015, 69% of 911 calls were for non-emergencies and many of these cases involved patients in need of chronic disease management. The increasing call volume resulted in limited access to resources, emergency department (ED) overcrowding and ED wait times exceeding four hours.In addition, 44% of Manatee County households live below poverty level or earn less than the basic cost of living in Florida.2 These households have difficulty navigating health insurance options, accessing primary care, and are more likely to visit the emergency department for non-emergency care.3

Communities experiencing similar health-system burdens have explored implementing MIH-CP teams as a novel solution to improving health equity among the medically vulnerable and reducing healthcare costs. MIH-CP is a provision of healthcare that delivers patient-centered care directly to patients’ homes through the utilization of mobile resources, consisting primarily of community paramedics.4 MIH-CP often includes additional practitioners of various fields and specialties that are integrated with emergency medical services (EMS). However, this evaluation is the first economic review of a fully implemented MIH-CP program with a pharmacist on the team. 

The Manatee County Community Paramedicine Program was established in response to local gaps in access to healthcare and implemented in a similar in-home patient-centered model. The goals of the program include increasing access to primary and preventative care, reducing use of unnecessary emergency medical services and improving patient outcomes among the medically underserved.

Specifically, Manatee County Community Paramedicine integrates community paramedics with a consultant pharmacist to provide a unique combination of skills. Paramedics bring field experience assessing and treating patients in the home, triaging emergency situations and managing acute disease exacerbation. Pharmacists provide expertise in medication reconciliation, medication therapy management, addressing nonadherence and identifying medication adverse effects.5,6The program was designed to address the highest areas of need in Manatee County in the following categories: mental health or substance use disorders, diabetes mellitus, chronic cardiovascular or respiratory disease, frequent falls, and high system stilizers. Patients may be referred by the active 911 system, primary care providers, health systems, case managers and the public.

This research serves to evaluate the economic impact of a MIH-CP program consisting of community paramedics and a consultant pharmacist through cost benefit analysis and to illustrate the effectiveness of the model through program data and case reports. This evaluation may impact policy development for leaders of health systems, Centers for Medicare and Medicaid Services (CMS) and insurance companies in considering payment for innovative mobile healthcare models. Economic evaluation through this research may also assist county governments and other EMS agencies in the decision-making process as they develop MIH-CP teams in their communities. Additionally, this research may be useful for health systems in determining whether interprofessional mobile health teams consisting of community paramedics and consultant pharmacists are a reasonable strategy for optimizing transition of care efforts and discharge planning to reduce hospital readmission rates.

Material and Methods

This cost-benefit analysis was performed from a payer perspective. The overall costs incurred by county government (EMS) were collected and compared to costs prevented through program interventions. Costs to payers were estimated based on average actual payments distributed from CMS to local hospitals for these events. Costs analyzed include those associated with program implementation, ambulance transports prevented, ED visits prevented, hospital admissions prevented, medication nonadherence corrected and adverse drug events (ADE) avoided. Costs of services and estimates for CMS payments were calculated from county and federal records. Estimations of medication intervention costs were derived from the literature available at the time of this analysis.

Costs Utilized

In this analysis, actual costs incurred or costs prevented through intervention which occurred within the 2017-2019 timeframe were considered current, and were not adjusted for inflation. Costs estimated from prior to 2017 data were adjusted for inflation to current value.

The operating costs included in this analysis account for the program’s average annual budget. This includes the community paramedic salaries and benefits, pharmacist salary, emergency response vehicles, medical equipment and overhead costs. The consultant pharmacist associated with Manatee County Community Paramedicine is provided by a higher education institution at no cost to the program. However, for this analysis the cost of adding a pharmacist to a community paramedicine team is estimated to be $151,355 annually.7 This estimate is based on the current national median pharmacist salary, plus cost of benefits.

The minimum cost for any ambulance transport in Manatee County is $622.16.8Per a 2012 report by the U.S. Government Accountability Office, the cost paid by Medicare for ambulance transport in 2010 ranges from $224-$2,204 per transport for Medicare beneficiaries.9Upon adjusting for inflation in 2019, this equates to $262.63-$2,584.06.10 These values were utilized in this cost analysis to estimate savings in ambulance transport diversions.

The average cost of a visit to the emergency department in Manatee County is $7,331 per patient visit.3 Payer costs associated with hospitalization were also included in this analysis, as interventions provided which would reduce ED visits could also be assumed to reduce resulting hospitalizations. The Centers for Disease Control and Prevention (CDC) reports on ED visits that result in hospital admission, stratified by age group. Based on this data, coupled with demographic data of the program’s patient population, an adjusted hospital admission rate was calculated at 17.93%.11 A hospital admission in Manatee County results in an average length of stay of 4.5 days and average cost charged to CMS of $85,677 per patient per stay.3 In 2018, local facilities received $22,442 in reimbursement from CMS per hospitalization.12

Costs associated with medication nonadherence are variable. A meta-analysis by Cutler et al. in 2018 reviewed 79 studies assessing the economic impact of medication nonadherence.13 Of the 79 studies reviewed, 83% reported total healthcare costs, though some studies evaluated a collection of pharmacy costs, inpatient costs, outpatient costs, emergency department visit costs and/or hospitalization costs.

Cutler et al. found the overall annual cost of medication nonadherence per patient to be $21,257 (range $5,271 – $52,341).13 In addition, the authors evaluated disease-adjusted nonadherence impact in over 14 disease areas. Correlating this data to the patient categories relevant to the Manatee County Community Paramedicine program, the annual cost of medication nonadherence per patient would total: mental health $11,052, addiction $53,504, diabetes mellitus $6,310, cardiovascular disease $9,204 and respiratory disease $6,505. Costs of nonadherence for fall patients were not analyzed in the Cutler study.

Although medication-adverse event costs have been previously reported for hospitalized patients, conclusive data on these costs within the outpatient setting is lacking. It is proposed by Classen et al. that hospitalized patients who suffer a medication adverse effect have an increased cost of $2,262.14 A systematic review done by Formica et al. evaluated the economic burden of preventable adverse drug reactions in the United States and Europe and found costs to society ranged from $193 – $9,440. [15] This range was utilized to determine the additional economic impact associated with medication interventions.

Outcomes Measured

Based on the clinical expertise of the team’s medical director, interventions provided by the community paramedic and/or the consultant pharmacist that directly prevented 911 use or ED visit were classified as an ambulance/ED diversion, and costs associated with ambulance transport, ED visits, and an assumed hospitalization rate of 17.93% were included in this evaluation. 

Based on the clinical expertise of the team’s consultant pharmacist, interventions provided by the community paramedic and/or the consultant pharmacist that directly resulted in medication adherence (adherence >80%) or prevented an adverse drug event were classified as a medication intervention. Costs associated with the corresponding interventions were included in this evaluation. Data for adverse drug events prevented had not been previously documented in aggregate, therefore a random sampling of patient case data was employed to determine a study population average. Thirty-three patients from a sample of 313 were randomly selected utilizing an online random number generator and evaluated to identify and classify adverse drug event(s) avoided.

Results

This economic analysis reports on the costs and cost benefits of the Manatee County Community Paramedicine Program over three consecutive years. The costs of operation totaled $604,867 in year one, $645,368 in year two, and $693,749 in year three. The Manatee County Community Paramedicine operation, including the costs of employing a full-time pharmacist, cost a total $1,943,984 over three years.

Manatee County Community Paramedicine diverted 389 ambulances in Year One, 489 ambulances in Year Two, and 428 ambulances in Year Three. As noted, a typical CMS reimbursement for ambulance transport ranges from $262.63-$2,584.06; therefore, the program saved payers an estimated $342,994.78-$3,374,782.36 in ambulance transports prevented.

In addition to avoiding ambulance transports, the program also prevented emergency room visits and hospitalizations. Based on available data, CMS reimburses approximately 26% of the costs billed for every hospitalization. Assuming a similar reimbursement rate of 26% for emergency department visits, the costs saved by payers is described here. The program avoided 309 ED visits in Year One, 396 in Year Two, and 300 in Year Three. Manatee County charges an average $7,331 per patient per ED visit.3 Assuming CMS reimburses 26% of the costs, the CP program saved the payer $1,915,590.30 from avoided ED visits.

For each hospitalization, health systems in Manatee County charge an average of $85,677 per patient per hospital stay.3 Per CMS data, CMS paid Manatee County hospitals an average of $22,442 per hospitalization. Based on the hospitalization rate of 17.93%, interventions made by the program over three years resulted in an estimated 180 hospitalizations prevented and $4,043,969.85 saved by the payer.

Figure 1 demonstrates program costs compared to savings achievable by payers, specific to ambulance diversions, ED visits avoided, and hospitalizations prevented.

Figure 1: The Cost of a Pharmacist-CP MIH Program vs Savings to Payers per Year
This graph demonstrates the cost of the Manatee County Community Paramedicine Program compared to the estimated savings to payers based on ambulance diversions, ED visits avoided and hospitalizations prevented per year of operation.

Payer costs for adverse drug events and nonadherence are poorly described in the literature. However, total health system costs have been successfully estimated, with payers undoubtedly absorbing a significant portion of these costs. Pharmacist interventions tracked through this program were classified as an ADE avoided or medication nonadherence identified and resolved. Current studies estimate the benefit of every ADE prevented to be $193-$9,440 saved, and medication nonadherence corrected to be an average of $21,257 (range $5,271-$52,341) per patient per year. Applying these costs to the Manatee County MIH-CP model, costs saved over three years of program implementation range $60,409-$2,954,720 in ADEs prevented and $3,082,265 (range $764,295-$7,589,445) in medication nonadherence corrected. (See Figure 2.)

Figure 2: Pharmacist-CP MIH Program Costs Prevented over a 3-year period
This figure provides average savings estimated from a payer perspective and demonstrates additional healthcare savings from adverse drug events and nonadherence events that have been successfully managed through the Pharmacist-CP Program. Payers undoubtedly absorb a significant percentage of these costs, which are poorly described in the literature.

Figure 2 provides average savings estimated from a payer perspective and demonstrates additional healthcare savings from adverse drug events and nonadherence events that have been successfully managed through the pharmacist-CP program. Payers undoubtedly absorb a significant percentage of these costs, which are poorly described in the literature. The total number of medication interventions over three years exceeds 700, with 64% of interventions focused in correcting nonadherence and preventing adverse drug events (See Table 1).

Table 1: Summary of Pharmacist Interventions Performed over 3 years
This table demonstrates the total number of medication-related interventions resulting from consultant pharmacist involvement. Additional interventions not quantified in this cost benefit analysis include, but are not limited to, identifying untreated indications, incorrect use of medicines and dosage adjustments.

The economic impact of Manatee County Community Paramedicine can be illustrated through the example of a patient case. Patient RG was selected due to a past medical history of COPD, heart failure, and pneumonia,three conditions tracked by CMS for hospital readmissions and related reimbursement models.16 The clinical course of this patient highlights the collaboration between the community paramedics and consultant pharmacist leading to his graduation from the program. While this case demonstrates the various cost-benefits discussed in this study, RG’s system utilization and interventions can be categorized as “above average” compared to most patients within the program.

The cost of enrolling RG into the community paramedicine program was calculated by extrapolating total costs of the program divided by the total number of CP appointments made to date. Based on the data, a single appointment can range from $234.92-$307.68 depending on the service requirements of the patient. Community paramedics met with RG for a total of 56 appointments over a course of 13 months. Additionally, the pharmacist provided 20 hours of medication therapy consultation, totaling $1,456. In total, the cost of RG’s enrollment in the Manatee County Community Paramedicine program was $14,610.72.

In the case of RG, six ambulance transports were diverted resulting in a CMS cost savings estimate of $1,575.78-$15,504.36, and six ED visits were prevented resulting in further savings for CMS of $11,436.36. Continuing with the assumption that 17.93% of ED visits result in hospitalizations, it can be estimated that without the community paramedicine program intervention, RG would have been hospitalized at least once. This results in an additional $22,442 in savings for CMS. In total, approximately $35,454.14-$49,382.72 was saved by payers as a direct result of interventions provided by this program. Figure 3 demonstrates RG costs versus savings by payer.

Figure 3: Costs of Enrollment of Patient Case RG vs Estimated Savings to Payer
Caption: This figure demonstrates the enrollment costs of highlighted patient RG, compared to the estimated savings to payer based on calculations of ambulance diversions, ED visits avoided and hospitalizations prevented.

Additionally, this patient received pharmacotherapeutic interventions that resulted in the avoidance of 11 medication adverse events. This included ADE’s from multiple medication errors, drug toxicities, incorrect use of medications and two different episodes of angioedema. The initial episode of angioedema was attributed to lisinopril and pregabalin. The second episode occurred when lisinopril was reinitiated by a new physician previously unaware of the patient’s medical history and allergy profile. Both times, the reaction was identified by the pharmacist on the community paramedicine team, and the reaction was successfully treated on an outpatient basis and did not require hospitalization.

The costs saved to society by the prevention of 11 ADEs totaled $2,123-$103,840. The pharmacist also corrected multiple nonadherence concerns relating to RG’s cardiovascular health and respiratory disease, resulting in an additional $15,709 saved by society. Pharmacy interventions added $17,832-$119,549 cost savings to society, much of which would be absorbed by payers (See Figure 4).

Figure 4: Cost savings associated with patient RG over 13-month enrollment
This figure illustrates a breakdown of the total cost savings estimates from a payer perspective, as well as nonadherence events and adverse drug events managed through the program, as calculated from a societal perspective. Payers undoubtedly absorb a percentage of these costs that are unspecified in the literature.

Overall, throughout three years of operations and including the annual cost of a full-time pharmacist, the net benefit of the Manatee County Community Paramedicine Program ranges between $4,358,570.93-$7,390,358.51. The calculated cost-benefit ratio for the program is 1:4.02 (1:3.24-4.80). Beyond this ratio, pharmacist interventions with nonadherence and adverse drug events contribute an additional cost benefit to society of $824,704-$10,544,165, much of which is expected to be realized as savings by payers.

Conclusions

Following the evaluation of the economic impact of the Manatee County Community Paramedicine Program, this analysis finds a substantial financial benefit to establishing paramedic-pharmacist partnerships within mobile integrated health teams. Secondary to the CP-pharmacist collaboration and pharmacist’s expertise in medication reconciliation and medication therapy management, the program has shown significant impact in avoidance of ambulance transports, ED visits and hospitalizations in the targeted patient populations. By utilizing payer-perspective data on the attributable costs of these services, the program shows a net-benefit ranging between $4,358,570.93-$7,390,358.51, as well as an average cost-benefit ratio of 1:4.02.

These cost benefits are further augmented by the pharmacist regarding nonadherence and adverse drug event interventions. It was determined that a pharmacist resolving nonadherence and identifying ADE’s adds additional cost savings to society of at least $824,704, but according to literature available, savings up to $10,544,165 could be realized over a span of three years.

This study does not attempt to quantify nonadherence and ADE savings from a payer-perspective. Examples of pharmacist and medication-related benefits not included in this analysis are benefits associated with improved health status, transitioning patients off disability, reduction in mortality rate and quality of life improvements. Additionally, some interventions proved difficult to evaluate from an economic perspective, including the identification of medication errors and undertreated health conditions, and were therefore not included in the composite benefit calculations of the program. More studies are needed to fully determine the cost saving benefits of pharmacist-paramedic collaborative services to third party payers.

As previously mentioned, the current program has utilized a pharmacist whose time is donated by a higher education institution. The pharmacist performs medication reconciliations, medication therapy evaluations, and facilitates communication with physicians regarding critical medication issues and uncontrolled chronic diseases. These actions contribute significantly to the cost-savings realizable within this model. MIH-CP programs with small caseloads may also find it possible to optimize EMS operations with the addition of pharmacist expertise; for example, pharmacists can ensure compliance with Drug Enforcement Agency controlled substance requirements, increase efficiency of medication storage and inventory management and evaluate prehospital drug administration protocols to maintain evidence-based practices.

Estimated savings by the program were also noted to correlate with the number of employed community paramedic personnel. For example, between Year Two and Year Three, one community paramedic left the program. This may have resulted in the lower potential costs savings seen in Year Three and may highlight a need for additional personnel to maintain or improve cost benefits to the payer.

The implementation of a pharmacist-paramedic mobile integrated health community paramedicine team is a cost-effective approach for payers in reducing ambulance transports, ED visits, and hospital readmissions, as well as for minimizing nonadherence, and preventing adverse drug events.

Declarations of Interest: There are no declarations of interest from any authors related to this research. Dr. Victoria Reinhartz has otherwise received compensation for expert healthcare consulting services related to mobile integrated health systems improvement, and for drug therapy lectures given to mobile integrated health and community paramedicine teams.

Funding Source: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

References

  1. Crutchfield J, Dicicco P. Manatee County Emergency Medical Services. Data Analysis presented at: Manatee County Healthcare Alliance Meeting; 2016; Bradenton, FL.
  2. ALICE: A study of financial hardship in Florida [Internet]. (NJ): United Way of Northern New Jersey; 2010-2016 [cited 2020 Feb 13]. Available from: https://www.uwof.org/sites/uwof.org/files/2018%20FL%20ALICE%20REPORT%20AND%20CO%20PAGES.pdf.
  3. Stone SS, Grosholz J. Program Evaluation of the Manatee County Community Paramedicine Program, Phase I. 2019.
  4. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey. Journal of Emergency Medical Services [Internet]. 2018 Apr 12 [cited 2020 Mar 10]. Available from: http://www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.pdf?Status=Temp&sfvrsn=a741cb92_2.
  5. Community Paramedicine [Internet]. Manatee County (FL): Manatee County [cited 2020 Feb 13]. Available from: https://www.mymanatee.org/departments/public_safety/community_paramedicine.
  6. Evashkevich M, Fitzgerald M. A framework for implementing community paramedic programs in British Columbia [Internet]. Richmond, BC: Ambulance Paramedics of British Columbia; 2014 May [cited 2020 May 19]. 74 p. Available from: https://www.researchgate.net/publication/305817026_A_framework_for_implementing_community_paramedic_programs_in_British_Columbia.
  7. Occupational Outlook Handbook, Pharmacists [Internet]. Washington (DC): U.S. Bureau of Labor Statistics. U.S. Department of Labor; 2019 [updated 2020 Apr 10; cited 2020 May 19]. Available from: https://www.bls.gov/ooh/healthcare/pharmacists.htm.
  8. Ambulance Medical Billing. Manatee County EMS. Financial Summary 10/01/17-9/30/19.
  9. Cosgrove JC. Ambulance providers: costs and Medicare margins varied widely; transports of beneficiaries have increased [Internet]. Washington (DC): U.S. Govt. Accountability Office; 2012 Oct [cited 2020 May 16]. 46 p. Available from: https://www.gao.gov/assets/650/649018.pdf.
  10. CPI Inflation Calculator [Internet]. Washington (DC): U.S. Bureau of Labor Statistics [cited 2020 Feb 10]. Available from: https://www.bls.gov/data/inflation_calculator.htm.
  11. FastStats – Emergency Department Visits [Internet]. Centers for Disease Control and Prevention. [updated 2017 Jan 19; cited 2020 Mar 10]. Available from: https://www.cdc.gov/nchs/fastats/emergency-department.htm.
  12. Payment measures [Internet]. Medicare.gov Hospital Compare; [cited 2020 Feb 10]. Available from: https://www.medicare.gov/hospitalcompare/Data/Payment-measures.html.
  13. Cutler RL, Fernandez-Llimos F, et al. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open [Internet]. 2018 Jan 21 [cited 2020 Apr 14];8(e016982):1-13. doi: 10.1136/bmjopen-2017-016982. Available from: https://bmjopen.bmj.com/content/bmjopen/8/1/e016982.full.pdf.
  14. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: Excess length of stay, extra costs, and attributable mortality. The Journal of the American Medical Association [Internet]. 1997 Jan 22 [cited 2020 Apr 14];277(4):301-6. doi:10.1001/jama.1997.03540280039031. Available from: https://jamanetwork.com/journals/jama/article-abstract/413536.
  15. Formica D, Sultana J, Cutroneo P, Lucchesi S, Angelica R, Crisafulli S, et al. The economic burden of preventable adverse drug reactions: a systematic review of observational studies. Expert Opinion on Drug Safety [Internet]. 2018 Jul 3 [cited 14 Apr 2020];17(7):681-95. doi: 10.1080/14740338.2018.1491547. Available from: https://www.tandfonline.com/doi/abs/10.1080/14740338.2018.1491547?journalCode=ieds20.
  16. Hospital Readmissions Reduction Program (HRRP) [Internet]. Baltimore (MD): CMS [updated 2020 Jan 6; cited 2020 Feb 10]. Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program.