Health-Care Reform Means Payment Reform

In Washington, there’s been no topic more hotly debated in recent history than health-care reform. But, it’s not a new topic. In fact, Theodore Roosevelt campaigned for president in 1912 on a platform promising national health insurance. Similar health-care reform discussions have been brought to the national stage by presidents Harry Truman, Richard Nixon, Jimmy Carter and Bill Clinton.

The current health-care reform is momentous because, other than the implementation of Medicare and Medicaid in 1965 under President Lyndon Johnson, few legislative changes that affect the entire health-care system have been signed into law. Even so, this discussion’s end is nowhere in sight. As is normal for major legislative initiatives, implementation will stretch out for years to come. By design, sections of this legislation will not even take effect until 2018.

Many decisions will still need to be made at the administrative level, making the final effect on health-care organizations ambiguous right now. It’s such a complex, ever-changing process that there are individuals who dedicate entire careers to determining a bill’s final impact. So it’s important for EMS to recognize that we’re at the beginning of a long process, and no crystal ball can show us the final impact of the legislation. That’s why JEMS has decided to publish this column–to keep you up to date on the process, and its impact on EMS, as it occurs.

Discussion will also affect elections in November and the future, which may impact EMS and your agency. No matter which side prevails in any election, there will be fine tuning of the bill, with the final outcome landing somewhere in the middle. What we do know about the health-care reform legislation is that it’s ultimately going to result in payment reform with the goal of insuring more Americans and making health care more accessible, affordable and higher quality across the board.

Removing Disparities
In EMS and safety net hospitals, we’re well aware there are “haves” and “have nots” when it comes to health care. The goal of this legislation is to narrow the gap between them by ensuring that 32 million more Americans will have access to health-care coverage. The legislation increases access to affordable coverage and mandates that Americans purchase this insurance coverage.

Of course, many potential issues accompany this plan. Will people purchase the coverage? Is the incentive for purchasing coverage greater than the negative impact of not buying it? Will there be individuals who currently have coverage who won’t have access to coverage in the future–even if they want to purchase it? These are all legitimate, unanswered questions, each of which will impact EMS.

Another issue is coverage for undocumented residents living in the U.S. The bill claims to cover 98% of American citizens. However, 4% of people living here are undocumented residents who won’t be covered under the new legislation. As such, states and EMS agencies that have a large undocumented population will be substantially impacted. The magnitude of that impact remains to be seen. But hopefully, this legislation will result in a smaller, more homogeneous uninsured population, making it easier to provide appropriate and timely health-care solutions for those who remain or become “have nots.”

Health-care reform = Payment Reform
The current reimbursement system is based on quantity of care provided with less emphasis on quality and none on coordination. Payment reform will begin to change the reimbursement system, rewarding clinical providers for coordinating care and for ensuring that patients receive needed care at the appropriate level. This new model will force the disparate parts of the health-care system–from EMS to hospitals to physicians to rehabilitation–to work closer together and place a greater emphasis on care outcomes and quality instead of quantity. You can sense the impact this will have on EMS, from electronic recordkeeping to data system linkage.

The legislation should also help distribute the cost of health care more evenly and level the playing field for payment and utilization across the U.S. Currently, there are huge disparities between what health-care organizations get paid in different areas of the country for performing the same “care” for a patient with the same needs.

The legislation also addresses the cost-shifting that’s occurring today. We’re paying for health-care delivery in one way or another through our own medical bills, insurance premiums and taxes. This legislation should give us a clearer understanding of what we’re paying for and what we’re getting for our money.

On the Fast Track
Many of the changes addressed in this reform legislation have already been occurring on some level because, regardless of the legislative actions, the health-care landscape is constantly evolving and changing. Hospital and physician alignments have been strengthening. Investments in information technology and connectivity have been occurring. Increased emphasis has been placed on delivering quality care that produces good outcomes. Some states have already taken steps to insure their population, and hospitals have already been working to address capacity issues and emergency department (ED) throughput.

However, this legislation will intensify some of the problems that were already present in the system, such as lack of access to primary care, information systems that don’t communicate with each other and health-care workforce shortages. These will continue to be hot-button issues for the foreseeable future, because changes will take significant time and resources.

Additionally, even with a growing number of insured patients, the shortage of primary care providers will continue to contribute to patients using EMS and EDs as a “front door” to the health-care system.

The new legislation provides the framework to put many of these initiatives on the fast track, helping health-care organizations work smarter. I believe innovative EMS organizations and hospitals that get out in front early with solutions will be rewarded. In fact, the bill includes some incentives for pilot projects allowed under the early phases of the formal reform process to develop and expand creative approaches to improve access, reduce cost and improve quality. Ultimately, these organizations will be more successful in a reform environment.

EMS Flying Under the Radar
EMS-related components were mentioned just four times in the final bill–only in areas that reference 9-1-1 communication and coordination, first responders and interfacility transport. So EMS and related services aren’t on the minds of health-care planners. However, anything evoking major changes to the overall system will ultimately have a far-reaching impact on EMS, primarily due to changes in the organizations EMS interacts with daily.

The omission of EMS from the final health-care bill provides challenges and opportunities. The challenge will be to help legislators and decision-makers understand that anything impacting the greater health-care system also directly impacts EMS.

This column is intended to help you influence interpretation and application of the final legislation. I will highlight important elements of the legislation and share major trends and modifications being discussed in Washington. I’ll also discuss the impact of payment reform, outcomes measurement, information systems, workforce development, health-care provider consolidation and increased coordination.

If we work together, we’ll have a unified voice in Washington and significant opportunities to identify and fix elements that haven’t worked in the past. Pay close attention to this column and the progress of this legislation so you understand their impact. Become a part of the process that implements its key features and regulations, and ultimately be part of the process for the benefit of the patient. JEMS

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