Passing legislation that meets both Medicaid & private insurance requirements
During the 2011 session of the Minnesota Legislature, my lobbying partner and fellow paramedic Buck McAlpin, recognized the incredible possibilities for community paramedics (CP) in the evolving EMS delivery system. An innovative idea gains traction and secures credibility in the healthcare delivery system when it’s clearly structured, able to demonstrate a clear benefit to enhancing patient care, shows promise of saving the system money and is clearly legitimized by being recognized by state law.
For more than a decade, Buck and I had been monitoring the various CP pilot projects around the country and determined that this concept could play a significant role in the evolution of EMS in Minnesota. However, understanding the way that healthcare works here we recognized that community paramedics would never take root without having clearly identified training, certification, regulatory oversight, statewide consistency and a means of reimbursement.
The various pilot projects, such as Fort Worth-based MedStar’s efforts with “frequent flyers” to the all-encompassing Eagle County, Colo., CP program, had yielded data that demonstrated the value of community paramedics. It was clear to us that establishing another pilot project would be redundant. Consequently, we decided we would rely on the hard work of others to build a case for establishing community paramedics as a clearly defined member of the healthcare delivery team in state law.
As described in an article in the February 2012 issue of the EMS Insider, (See “How to Pass Community Paramedic Legislation,” p. 2), we drafted legislation, amended it 19 times and successfully lobbied it through the Minnesota Legislature. When the bill was signed into law by Gov. Mark Dayton, Minnesota became the first state in the country to have community paramedics clearly identified in law as a distinct provider.
Buck and I realized early in the process that, we needed a legitimizing agent that would reimburse CP’s services to be taken seriously by the majority of third-party payers. Thus, we proceeded with a two-year strategy. First, we were to secure passage of the initial legislation defining a CP, describing operating parameters, education, regulation and certification, and mandating that it be a reimbursable care provider under Minnesota’s Medicaid program. Second, we needed to establish payment criteria and a fee schedule.
We succeeded in accomplishing the first goal in 2011. Then, in the recently completed 2012 legislative session, we secured passage of the Medicaid reimbursement piece.
Medicaid legislation
The specific language we needed for the Medicaid payment portion of our plan was somewhat elusive. The 2011 law mandated that CP’s services be paid, but not until the state’s Department of Human Services (DHS) had established the specifics of the reimbursement mechanism. As the legislative committee deadlines came and went, the specific language required failed to manifest.
Several meetings were called by our Senate author, Julie Rosen. Senator Rosen, McAlpin, I and an ever-growing cadre of DHS staff members met repeatedly to identify language for the legislation. We pushed a proposal that would reimburse CPs at 90% of what a physician’s assistant is paid as a placeholder. Although we didn’t expect that this would necessarily be the final wording of our bill, it provided a means of keeping our initiative “alive” as the legislative session was winding down and agency staff continued to mull over acceptable language.
Finally, during what proved to be our last meeting with DHS staff, Senator Rosen rose slightly from behind her desk, looked at the assembled DHS employees and told them to “pull the trigger.” Several days later, we had our agreed-upon wording. It was offered as a delete-all amendment on the floor of both houses of the legislature and passed.
What that means is that CP services are reimbursable for any Medicaid recipient who has received hospital emergency department services three or more times in a period of four consecutive months in the past 12 monthsor an individual who has been identified by the patient’s primary care provider as receiving CP services would likely prevent readmission to a hospital or nursing home.
Although the law took effect on August 1 of this year, we are waiting for federal approval on our state’s Medicaid plan, which requires an amendment for CP coverage before the money starts flowing for reimbursement. Although we don’t anticipate a problem, we want to receive approval before formally taking action.
Medicaid patients represent a relatively modest percentage of the population in Minnesota. Private insurers capture the vast majority of insured individuals in the state. However, by placing the imprimatur of the state on Community Paramedic services, it legitimizes the concept to the entire health-care provider community. Had we not secured legislation that assured clear consistency in training, experience, certification and skill set, the private insurers would not necessarily considered us a legitimate provider. Now, they can look in the statutes, see what we are all about, and know that Minnesota considers CPs a reimbursable entity.
We’re currently meeting with various private, third-party payers to determine the specifics for coverage under their benefit packages. In the meantime we’re endeavoring to train and certify enough community paramedics to meet the anticipated demand.
There is no right or wrong way to implement CPs in your state. However, in our experience, securing legislation which clearly identifies what a CP is, how they are trained and their operational parameters, is the fastest way to assure the long-term sustainability of CPs because it will help assure consistent and reliable revenue sources.
As we all bear witness to shrinking reimbursements and revenue in the healthcare system, it’s imperative that CP services be reimbursed. As the late American journalist and essayist, H.L. Mencken was fond of saying, “when they say it’s not about the money, it’s about the money.”
