Hospice care is one of the fastest growing components of our healthcare delivery system due to the recognition that palliative care is a very appropriate and humane part of healthcare delivery. It also has a significant impact on healthcare system expenditures.

Thirty percent of all Medicare expenditures are attributed to the 5% of beneficiaries who die each year, with a third of that cost occurring in the last month of life, often with little or no impact on the patient’s outcome.¹ A recent study published in the Journal of Clinical Oncology found that average Medicare expenditure for a patient in hospice is $6,537, while the Medicare expenditures for a patient who disenrolls from hospice is $30,848.²

Historically, patients and families have not chosen palliative care as an end-of-life option. This may be due to a lack of understanding of the role effective palliative care can have on the patient’s quality of life. Further, our fee-for-service driven healthcare system has historically incentivized care providers to provide as much care as possible in order to generate more revenue.

As an example, on a recent flight I had the pleasure of sitting next to a very nice physician’s assistant traveling from Fort Worth, Texas, to Minneapolis to unwind a healthcare situation developing with her parents. Her father was 89 years old and his cardiologist had convinced her mom and dad to go forward with a heart transplant to help alleviate is heart failure. Her father had chronic obstructive pulmonary disease (COPD) and colon cancer. The PA knew a heart transplant was an unreasonable course of treatment and was determined to convince her parents that palliative care was the much better option for her father.

The Institute for Healthcare Improvement’s Conversation Project is a demonstration of the healthcare industry’s push toward more effective and appropriate ways of handling end-of-life issues.³ In fact, a 2012 report to Congress from the Medicare Payment Advisory Commission (MedPAC) recommended that Medicare increase the payment rate for hospice care as an incentive to enroll more patients into hospice programs.⁴

We have illustrated several times in this series how the Affordable Care Act (ACA) transformed the financing of the healthcare system and does so, in large part, through the alignment of incentives for improving patient outcomes. End-of-life and palliative care is another example of this incentive alignment. There was much discussion during the early development of the ACA about “death panels.” In the final version, the ACA did not specifically address payment reform for end-of-life care, but it did raise the awareness that the healthcare system does need to handle this issue in a more proactive way.

Hospice Economics

Hospice agencies have an interesting economic model. When a patient is enrolled in hospice, the hospice fee (typically a per-diem payment based on the setting of the care and patient diagnosis) is designed to cover all hospice-related care for the patient. If the patient’s cost for delivering services in the hospice plan of care exceeds the revenue generated from the hospice payment, the hospice agency loses money. The clinical, emotional and economic incentive for home hospice is to help the patient transition to their next care setting peacefully at home (we often refer to this as “getting onto the escalator”). Consequently, ambulance trips to high-cost care settings such an emergency department, or an in-patient hospital stay for a hospice-related episode of care, is not in the best interests of the hospice agency, the patient or the family.

As many of us in EMS know, there are times (typically at or near the end of life) that the patient’s family wants everything done to save the patient’s life, or they are simply scared in the final moments and activate the 9-1-1 system. Often, that means much confusion on the scene of the call and all too often results in an expensive ambulance trip and an even more expensive hospital stay. The patient or patient’s family may then also voluntarily dis-enroll the patient from hospice once in the hospital. This means that the hospice agency has expended dollars for the patient’s care and then loses the per-diem revenue for the rest of the patient’s potential hospice enrollment. This is not an effective economic model for the hospice agency.

Further, if the patient and/or the patient’s family is noncompliant with the hospice plan of care by insisting everything be clinically done for the patient or by routinely calling 9-1-1, the hospice agency may have an incentive to disenroll the patient from hospice status. If the patient disenrolls, the cost of caring for that patient reverts to traditional payer models, typically Medicare. Sometimes, once the high-cost care episode is over, the hospice agency may wish to re-enroll the patient to hospice service. CMS discourages hospice agencies from churning patients in and out of hospice status.

The EMS/MIH Solution

To help avoid these potential pitfalls, hospice agencies are beginning to look to EMS for a mobile integrated healthcare (MIH) strategy to help safely transition the patient from home hospice to another setting (either in-patient hospice status or beyond) and are willing to pay for those services. In the case of my agency, MedStar in Fort Worth, VITAS Innovative Hospice is funding a program to help patients successfully make this transition.

VITAS assesses patients and families they enroll into hospice and uses a special tool to determine the potential risk for a voluntary disenrollment. Green means low risk, yellow is moderate risk and red is high risk for voluntary disenrollment or revocation. Patients categorized as red or yellow are referred for enrollment into the VITAS/MedStar hospice revocation avoidance program.

Once identified, a MedStar mobile healthcare practitioner (MHP), all of whom have been specially trained by VITAS to help with end-of-life care issues, and a VITAS hospice nurse conduct a joint home visit with the patient and patient’s family. The program is explained to the family and patient and they are reminded that the primary contact for any hospice-related medical issues is the VITAS hospice nurse. They are provided a 10-digit number to access MedStar’s 24-hour call center if for some reason they are unable to reach the hospice nurse right away. This provides an additional level of reassurance for the patient and family. Once enrolled, important documents such as the patient’s do-not-resuscitate (DNR) orders are scanned and entered into MedStar’s electronic medical record system for ease of access in the likely event they cannot be found at the emergency scene.

MedStar also registers the patient into our computer-aided dispatch (CAD) system with an address flag that contains the information that the patient at this address is enrolled in the hospice revocation avoidance program and the contact phone number for the on-call VITAS hospice nurse. If the family calls 9-1-1, the call goes through the usual emergency medical dispatch (EMD) process, with an additional question added to the end of the case entry and key question process:

“With the information you have provided about the patient’s complaints, we would normally send an ambulance to your residence. Would you like for us to start one that way, or would you prefer we send just [the specially trained paramedic] to evaluate and help you with your concerns/questions?”

If the caller opts for only the MHP to respond, we do that, and call the hospice nurse to let them know we are on the way and to please join us. If a regular EMS system response is requested, we send it, with an MHP added to the response along with notification to the hospice nurse that we are responding.

Once on scene, if the response is for something not within the hospice plan of care, such as a fall or other injury, the patient is treated and transported as with any other patient since this is not part of the care plan, and we cancel the hospice nurse to the scene. However, if the medical issue is within the hospice plan of care, the patient and family are reassured and provided with any needed clinical or emotional support while the hospice nurse is on the way to the residence to assume care of the patient and family. Through a special medical control arrangement between the MedStar medical director and the hospice agency medical director, our MHPs are authorized to access the patient’s “comfort pack,” which often includes medications to alleviate pain and suffering, and administer that medication to the patient.

In some cases, the on-scene MHP and the hospice nurse may decide it is in the best interest of the patient and the family for the patient to be transferred from an out-patient hospice setting to an in-patient hospice setting. In these cases, the patient may be transported from the home setting to an in-patient hospice setting, preventing a disenrollment while providing additional support for the patient and family.

Fee Structure

There are a number of economic models that can be used by an EMS-based MIH solution for hospice patients.

• Fee for enrollment: The hospice agency pays a fee to have the patient enrolled in the program.

• Outcome-based payment: The EMS agency is paid a fee when the patient successfully gets onto the escalator at home without a hospice revocation.

• Capitated payment: The hospice agency pays a monthly fee for each patient enrolled in the program.

Summary

The healthcare system is moving quickly to more effectively dealing with end-of-life care for patients. Hospice patients have historically been a unique challenge for EMS agencies. Scenes are often chaotic and difficult to manage, not necessarily from a clinical perspective, but from an emotional and legal perspective. Working collaboratively with hospice agencies to effectively navigate their patients through the last moments of the end-of-life process improves the patient’s and the family’s experience of care, improves patient outcome (in a nontraditional way—death in these cases is the better outcome) and reduces costs to the healthcare system. This is probably why the IHI has adopted the Conversation Project and why EMS-based MIH should adopt new ways of helping this growing population of patients.

REFERENCES

1. Barnato A, McClellan M, Kagay C, et al. Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Services Research. 2004;39(2):363–376.

2. Carlson M, Herrin J, Du Q, et al. Impact of hospice disenrollment on healthcare use and Medicare expenditures for patients with cancer. Journal of Clinical Oncology. 2010;28(28):4371–4375.

3. IHI (n.d.) The Conversation Project. Retrieved on June 11, 2014, from www.ihi.org/Engage/Initiatives/ConversationProject/Pages/default.aspx.

4. MedPAC. (March 2012) Hospice Services. Retrieved on June 11, 2014, from www.medpac.gov/chapters/Mar12_Ch11.pdf.

The post Mobile Integrated Healthcare-Payer Perspective appeared first on EMS Insider.

In discussions on Mobile Integrated Healthcare (MIH) program sustainability, we often say, “follow the money,” to find the stakeholder at risk for writing the check for healthcare service delivery. That trail often leads to commercial health insurance companies such as Aetna, Blue Cross/Blue Shield, Humana, United-Healthcare or others.

Commercial insurers have a very genuine interest in MIH and Community Paramedicine (CP) services as a mechanism to improve patient outcomes and reduce costs. As such, MIH/CP programs can be a natural fit for commercial insurers. The EmedHealth community para-medicine program was initiated a decade ago as part of the University of Pittsburgh Medical Center (UPMC) health plan as a way to meet those two goals. They started by delivering mobile healthcare services such as health screenings, immunizations, disease management services and other preventive services to health plan employees.

Dan Swayze, the leader of the program, identified one of the early interventions delivered by community paramedics: “drive-by shootings” as a method to curb the difficulty UPMC had in vaccinating its nursing employees against influenza. The health system had previously offered flu vaccines in the hospital’s cafeteria during meal breaks. Needless to say, that delivery model did not work as effectively as they wanted. The reason?

If the nursing staff got a break for a meal, the last thing they wanted to do was stand in line waiting for a flu shot. So Swayze came up with a different solution: Use community paramedics in the hospital to go to the nursing units and give vaccines at the nurses’ station while they were working. It was a huge success!

From that beginning, Swayze’s program has grown to providing MIH/CP services to 17 communities in western Pennsylvania, funded by a unique partnership between UPMC and the Allegheny Health Network, two entities that fiercely compete at every level, except when it comes to jointly funding the MIH/CP program through EmedHealth. The reason these two competitive entities collaborate on the CONNECT Community Paramedicine program is that they have a shared interest: Keep patients healthy to prevent unnecessary ED visits and reduce hospitalizations.

Insurer hurdles

EMS has two interesting hurdles to overcome when it comes to commercial insurers. First, what provider type are we? That question has been asked by more than one commercial insurer we’ve met with. If we are an ambulance provider, they know how to process that claim—transportation, just like always. However, if we are proactively working to prevent an ambulance call by providing services such as in-home educational visits, disease management, navigation to appropriate alternative clinical destinations or 9-1-1 nurse triage, how do they code us in their claims processing system? They could figure it out if we were a licensed home health agency, but in most cases, we are not necessarily licensed as home health providers either.

Second, many of the payers are moving away from typical fee-for-service arrangements to shared risk economic models with providers such as hospitals, large physician practices, Integrated Delivery Systems (IDS) or the growing number of Accountable Care Organizations (ACOs). This means that you may be referred to those entities for payment, since they are at risk for the financial loss or benefit from improved patient outcomes and reduced costs. This circles us back to the hospital as a payer, discussed in last month’s issue of EMS Insider . Some large physician Independent Practice Associations (IPAs) may be motivated to work with you under these arrangements for the same reasons the hospitals are. In Fort Worth, for example, North Texas Specialty Physicians (NTSP) has entered into a shared risk arrangement with UnitedHealthcare for about 20,000 Medicare Advantage patients. Under the shared risk arrangement, NTSP has a higher incentive to meet the Institute for Healthcare Improvement (IHI) Triple Aim, and our programs are actually billed to NTSP for payment. NTSP is the entity in the arrangement that achieves the greater economic gain for reducing the cost of care for shared risk patients.

MedStar has been approached recently by a large IDS that has an insurance, hospital and physician practice component. They are seeking an agency to provide healthcare call center services and potentially consolidate some of their current seven call centers into one, which would be located in our secondary 9-1-1 public safety answering point (PSAP). In addition to the obvious benefit of consolidation, the IDS sees value-added services such as the ability to provide episodic nurse triage services and send mobile healthcare practitioners to callers to assess, communicate and refer patients to the most appropriate resource for their medical needs.

Medicare & Medicaid as payers

Thankfully, Medicare is showing more interest in MIH services, as demonstrated by the Centers for Medicare & Medicaid (CMS) Healthcare Innovation Awards (HCIA) being granted to three EMS agencies—most notably, the Regional Emergency Medical Services Authority (REMSA) in Reno, Nev. Brenda Staffan, the HCIA Project Director for REMSA’s program, and her team have done an amazing job implementing a grant-funded MIH program that has been closely watched by CMS. The early results have been stellar and the program has the potential to demonstrate to CMS that shifting the economic model from traditional fee-for-service EMS based on transportation benefits to an MIH model based on patient outcomes provides an incentive for Medicare to meet the Triple Aim.

In a recent meeting with the Chief Medical Office of CMS, we were reminded that Medicare payment policy is largely statutory, so we as an industry need to get behind initiatives such as the EMS Field Bill (H.R. 809) to change the statutory authority of CMS to be able to move EMS to the value-based purchasing arrangement becoming so prevalent in other healthcare delivery models such as hospital and physician services. Interestingly, Medicare is also looking forward to more providers being part of risk-sharing arrangements, either through the models referenced earlier, or a push to managed Medicare programs under the Medicare Part D program. So EMS may need to be prepared to be part of a larger provider group through ACOs or others as part of that future change, and work with commercial payers.

Medicaid is an interesting scenario. States have more flexibility in how they allocate Medicaid dollars for services and may be able to move more quickly than Medicare to providing payment for MIH services. Gary Wingrove, Buck McAlpin and their team at the Minnesota Ambulance Association were the first to convince state legislators that Medicaid investment in MIH/CP services not only improves patient outcomes, but reduces the cost of care. As a result, Minnesota has legislation enabling Medicaid to pay fee-for-service for MIH/CP services. Kevin McGinnis’ team at North East Mobile Health Services in Maine and Mark Babson’s team at the Idaho Department of Health and Welfare have also found success in moving Medicaid to pay for MIH/CP services. In Oregon, the Oregon Health Shares program is essentially a Medicaid ACO and they have shown a keen interest in MIH/CP service delivery models to their enrollees.

However, chasing fee-for-service reimbursement from Medicaid may have diminishing returns as, much like Medicare, Medicaid is quickly moving to managed care arrangements with commercial insurers to reduce the cost of care. In general, patients enrolled in managed care tend to have better outcomes and reduced cost due to intensive case management for complex patients and assertive utilization review processes. It is for this reason that many states are encouraging enrollment of patients into managed Medicaid programs. Consequently, this circles us back around to the commercial insurance payer issues explained previously.

Summary

Commercial insurers, including IDS with an insurance component, are logical payers for services that help them meet the IHI Triple Aim for their enrolled patients. MIH/CP programs ideally fit into that model, either directly or through innovative shared risk arrangements. We have a lot of education to do with this payer group to help demonstrate how we fit into this space with them.

The post Mobile Integrated Healthcare Payer Perspective appeared first on EMS Insider.

Thankfully, innovative economic models are flourishing. This comes as a result of healthcare financing changes within the Affordable Care Act (ACA) that seek to align incentives to help make the entire healthcare delivery system more financially sustainable. We are also seeing implementation of some long-standing, but stagnant finance reforms.

Some of the more recognized finance changes—such as bundled payments, risk-sharing arrangements, enhanced managed Medicare and Medicaid programs and, of course, Accountable Care Organizations (ACO)—are ways the ACA is transforming our healthcare delivery models. However, programs such as 1115 Medicaid waivers, managed Medicare and Medicaid, and traditional fee-for-service models are rapidly recognizing MIH provides a valuable service in which they should be investing.

This is the first of four columns that will focus on the financing and economic models for MIH services that hospitals, Medicare and Medicaid, commercial insurers, integrated delivery systems, ACOs, hospice agencies and even home health agencies are funding and, more importantly, why they are funding them.

The question for this first article: What is motivating hospitals today to work with other agencies to actually reduce the inappropriate use of their in-patient facilities?

Value-based purchasing

One of the efforts to improve quality and reduce healthcare costs in the ACA is an initiative called value-based purchasing (VBP). Under VBP, hospitals are eligible for bonuses or penalties of up to 1.25% of their total Medicare payment based on quality metrics in 2014. That percentage will increase over the next three years to 2%. It’s worth emphasizing that this bonus or penalty is applied to all Medicare payments a hospital receives, not just payment for admissions on which they did not score well. By way of example, for a hospital with annual Medicare payments of $500 million, a 0.5% VBP penalty can amount to $2.5 million. VBP process metrics and clinical guidelines include considerations such as:

• Percent of heart attack patients given medication to avert blood clots within 30 minutes of arrival at the hospital

• Percent of heart attack patients given percutaneous coronary interventions within 90 minutes of arrival

• Percent of heart failure patients given instructions upon discharge about how to take care of themselves

The second domain of evaluation is the much talked about patient satisfaction measures.¹ These are measures such as:

• How well nurses communicated with patients

• How well doctors communicated with patients

• How clean and quiet the hospital room and hall were

The patient’s experience of care comprises 30% of the total VBP calculation. Consequently, hospitals pay very close attention to the patient’s perception of the hospital both during inpatient care and post-discharge (see article in February JEMS² ). This has increased the hospital’s focus on the patient’s transition from the hospital to the home environment, not only to help reduce preventable readmissions, but to enhance the patient’s perception of the hospital’s concern about the patient post-discharge.

The third area evaluated for VBP is mortality rates among Medicare patients admitted for heart attack, heart failure or pneumonia.

Hospitals could also be interested in programs that reduce ED visits for low-acuity patients. These patients often have long wait times in the ED, resulting in an unfavorable experience of care. When those patients receive patient satisfaction surveys, there is potential that the rating will be low, thereby impacting the 30% patient experience score. Further, decongesting the ED may have a positive impact on the experience for other ED patients through potentially reduced wait times, thereby possibly improving satisfaction scores. In the MedStar system, all four hospital systems are jointly funding the 9-1-1 nurse triage system to help navigate low-acuity callers to safe alternative care sources for exactly that reason.

EMS-MIH Opportunity: Hospitals may be willing to invest in EMS-based safe transition programs to enhance patient perceptions about the transition.

Readmissions

Another quality measure being applied to hospitals is the 30-day readmission rate for three specific diagnosis-related groups (DRGs): congestive heart failure, myocardial infarction and pneumonia. The reason these three were selected is the cost to Medicare for these conditions, as well as the tendency for these DRGs to have high readmission rates. In October 2014, COPD and hip and knee replacements will be added to the list of DRGs. Hospitals are eligible for bonuses or penalties up to 2% of their total Medicare payments based on their 30-day readmission rate. The readmission criteria is currently an “all cause readmission,” meaning that if a CHF patient who is discharged from the hospital readmits for a fall two weeks later, that counts as a readmission.

Two-thirds of the nation’s hospitals are being assessed a readmission penalty.³ For some, the fnancial incentive to reduce high readmission penalties may outweigh the actual payments they receive for the admission. A recent article in Modern Healthcare reported that Michigan-based Henry Ford Health System’s system-wide fnancial penalty for preventable readmissions was estimated at $2.2 million in 2013, and $4.3 million in 2014.⁴ The financial incentives for hospitals to reduce readmission penalties may lead them to be receptive to EMS-based MIH programs to reduce potentially preventable readmissions. This is likely the reason that the Henry Ford Health System is actively working with, and paying for, its ambulance provider Medstar Ambulance’s program to reduce preventable readmissions.

EMS-MIH Opportunity: Hospitals may be willing to invest in EMS-based CHF readmission prevention programs. Examples of such funded programs are MedEx Ambulance and the University of Chicago Medical Center; Christian Hospital EMS in St. Louis and the Christian Hospital System; Green Bay Fire Department and the Bellin Health System; and East Baton Rouge EMS and Lane Regional Health System.

Public reporting

In addition to the fnancial incentives, hospital readmission rates and patient experience ratings are now published by Centers for Medicare & Medicaid Services (CMS) on their Hospital Compare website (www.medicare.gov/hospitalcompare). Hospital administrators working with MedStar have indicated the public reporting of patient satisfaction and subsequent perception of poor clinical care due to high readmission rates is even more of an incentive to improve satisfaction ratings and reduce readmissions than the current financial incentives.

Medicare spending per beneficiary

Looming on the horizon for hospitals in 2015 is a new measure to which CMS will hold hospitals accountable: Medicare spending per beneficiary. ⁵ This measure will be part of the VBP bonus or penalty and will be based on the amount of money Medicare spends for a patient’s care—preadmission, during admission and post-discharge. This may change the economic incentive for hospitals to discharge patients to high-cost services such as long-term acute care (LTAC), skilled nursing facilities (SNF) or even home health. It may also lead them to look to EMS for programs to reduce length of stay for inpatient care.

EMS-MIH Opportunity: Hospitals are looking for more cost-effective post-acute care, not only to reduce readmissions, but also to reduce the overall Medicare spending per beneficiary in the post-acute setting.

Shared risk

More hospitals are becoming part of risk-sharing arrangements with payers. The most talked about model is an ACO. In an ACO, the hospital shares in the potential savings in caring for a defined population of patients. In other words, they gain an economic advantage if the cost of caring for the patients in the defined population is less than anticipated. As such, it’s possible that the hospitalization of a patient in this type of program could actually cost them money.

Perhaps it’s for this reason that the Presbyterian Health System, an innovative integrated delivery system in Albuquerque, N.M., launched its “hospital in the home” project. In this program, patients are “admitted” to the hospital, but the care is provided in the patient’s home. Hospital beds, IV pumps, cardiac monitors and all equipment and supplies needed to care for the patient are brought to the home. Doctors and nurses “round” on the patient several times a day, or are continuously at the bedside. Their experience was that the patients had shorter length of stays and higher satisfaction scores with this arrangement. And, the cost of providing the care was reduced.

Another example of a funded program to reduce unnecessary ED visits is the program Mesa Fire Department and Mountain Vista Medical Center are conducting in Mesa, Ariz. Mountain Vista provides a nurse practitioner and Mesa Fire provides a paramedic captain in a transitional response vehicle. This unit responds to low-acuity calls in the system to assess, treat and navigate patients

UNLAWFUL TO COPY WITHOUT THE EXPRESS PERMISSION OF THE to the most appropriate care setting, thereby preventing an unnecessary ED visit. And, as an added bonus, since services provided by a nurse practitioner are a health benefit under Medicare and most commercial insurance programs, Mountain Vista bills for the services provided by their nurse practitioner.

EMS MIH Opportunity: Hospitals are looking for clinically safe, cost-efficient systems to navigate patients to the most appropriate care. This is a perfect fit for an integrated healthcare delivery model that navigates patients to the most appropriate setting for their care or, even better, prevents the need for acute care services.

Summary

There are numerous reasons why hospitals across the U.S. are funding MIH services. The key to success is in an effective relationship built upon collaboration to meet a defined need for the community and the patient, while simultaneously enhancing the economic model for the hospital as a payer.

Become part of the solution!

REFERENCES

1. Rau J. (Nov. 14, 2013) Methodology: how value based purchasing payments are calculated. Kaiser Health News. Retrieved on April 2, 2014, from www.kaiserhealthnews.org/stories/2013/november/14/value-based-purchasingmedicare-methodology.aspx.

2. Hooten D, Zavadsky M. Patient experience revolution. JEMS. 2014;39(2):54–59.

3. Rau J. (August 2, 2013) Armed with bigger fines, Medicare to punish 2,225 hospitals for excess readmissions. Kaiser Health News. Retrieved on April 2, 2014, from www.kaiserhealthnews.org/Stories/2013/August/02/readmission-penalties-medicare-hospitalsyear-two.aspx.

4. Greene J. (Dec. 10, 2012) Hospitals face reimbursement penalties over readmission rates. Modern Healthcare. Retrieved on April 2, 2014, from www.modern-healthcare.com/article/20121210/INFO/312109979.

5. QualityNet (n.d.) Medicare spending per beneficiary measure overview. Retrieved on April 2, 2014, from www.qualitynet.org/dcs/ContentServer?c= Page&pagename=QnetPublic%2FPag e%2FQnetTier3&cid=1228772053996.

The post Mobile Integrated Healthcare: The Payer’s Perspective appeared first on EMS Insider.

Under the Value-Based Purchasing (VBP) formula, hospitals receive performance-based bonuses or penalties based, in part, on the patient experience of care domain. Up to 30% of a hospital’s total performance score (one of the measures for the VBP calculation) is based on customer satisfaction. A survey conducted by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is the basis of the patient experience of care domain.

The HCAHPS is a national standard process designed to measure the patient’s perceptions of their hospital experience. The HCAHPS survey is mandatory (except for specific Critical Access Hospitals that can choose to voluntarily participate) and is published for public view through Centers for Medicare & Medicaid Services (CMS) Hospital Compare registry. This means that the entire world can see how a hospital’s patient experience ratings compare to other regional hospitals, as well as state and national averages (www.medicare.gov/hospitalcompare).

Patient satisfaction and experience of care is impacting virtually every aspect of hospital operations. Recently, a group of hospital emergency department directors formed a task force to address the rising incidence of prescription drug overdoses. One of the strategies proposed to try to reduce these occurrences was to have all hospitals pledge to refer patients in the emergency department (ED) with chronic pain management issues to specialists instead of prescribing narcotic pain relievers. One ED physician director commented that strategy would be a hard sell to ED doctors unless patients seeking pain medications could be classified as “no info” patients, negating the possibility that the patient would receive a HCAHPS survey. The concern was that a portion of hospital income is derived from the patient satisfaction scores. If patients don’t get their pain prescription, they could rate the experience negatively and negatively impact the satisfaction score and the hospital’s income.

As a result of this focus on the patient experience of care, many hospital systems are adding a new C-suite member to their team. They have always had positions such as chief executive officer, chief operating officer, chief medical officer and chief nursing officer. But now, many are adding the chief experience officer (CXO). Cleveland Clinic was the first major academic medical center to make patient experience a strategic goal and to appoint a CXO, and one of the first to establish an Office of Patient Experience.¹ CXOs do not typically come from the healthcare industry, but rather from organizations that do customer service well, such as the Marriott Corp.

Why patient experience should matter to EMS

EMS providers need to pay particular attention to this growing focus on patient satisfaction and experience of care for several reasons.

1. Our patients care. We typically get zero points for the clinical care we provide. Patients assume that since we arrived at their medical emergency in mobile intensive care units when they called 9-1-1, we have clinical expertise. We get bonus points from the patient’s perspective when we are nice to them—when we communicate well and explain everything we are doing, when we ensure their pain is controlled, when we worry about their pets after we take their master to the hospital, or as was recently demonstrated, when the fire crew stays on scene and finishes laying the sod the homeowner could not finish due to chest pain he experienced after laying only three pallets.

2. Our payers care. Our largest healthcare payer is providing bonuses or penalties based on satisfaction scores. It won’t be long before other payers follow suit. In fact, CMS has accelerated using quality and outcome-based metrics program for physicians. These bonuses and penalties were scheduled to start in 2017, but CMS moved this implementation date up to 2016, due in large part to the improvements in patient-centered care and outcomes fostered through the assessment of bonuses or penalties to hospitals based on HCAHPS scores. EMS benefits are paid through Part B of Medicare, the same part from which physicians are paid. CMS has notified the EMS industry that we will be undergoing a review of the ambulance fee schedule this year. On Sept. 24, the Office of Inspector General released its report on the growth in Medicare payments to the ambulance industry from 2002 and 2011.² The report places us in an interesting position as we move into those discussions with Medicare. If you have not read the report, we strongly urge you to do so.³ See also the related story in this issue.

3. Our healthcare stakeholders care. Ask any hospital administrator what their top-box HCAHPS scores are for their facility, and they will know. The top-box is the most positive response to HCAHPS survey questions. The top-box response is “always” for five HCAHPS composites (communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, and communication about medicines) and two individual items (cleanliness of hospital environment and quietness of hospital environment); “yes” for the sixth composite (discharge information), “9” or “10” (high) for the overall hospital rating, and “would definitely recommend” for the recommend hospital item.

EMS has an impact on the hospital’s HCAHPS scores. If we aggravate the patient on the way to the hospital, it may affect the score that patient gives the entire hospital. Similarly, if we are the last people to interface with the patient as they are leaving the hospital (discharge home, for example) and we leave a less-than-favorable impression, it may impact the hospital’s score when the patient receives an HCAHPS survey in the mail three days later.

4. It may be one of the only quality metrics we have. EMS has had a difficult time proving value to the customer. Few peer-reviewed studies prove that because the patient with a fractured ankle, or abdominal pain, or dislocated shoulder, etc. went to the hospital by ambulance, the patient’s outcome was different than it would have been otherwise. In today’s new healthcare world, we need metrics that we can use to prove value to the payer. It’s probable that externally conducted and verified patient experience scores may help as part of an overall set of clinical metrics that we can use to demonstrate value.

5. We need to bend the perception curve. EMS is not viewed by our payers or other financial stakeholders as providers of medical care. We are viewed as transportation. That is why we are not paid if we do not transport. Perhaps if we begin to think of ourselves as healthcare providers, and measure the same factors as healthcare providers (clinical outcomes, patient satisfaction) instead of response times, people will think of us and pay us as healthcare providers.

The challenge for EMS

Historically, we have not done a great job measuring the patient’s experience with our services. While many agencies send out customer opinion surveys, the surveys are not typically conducted by an outside agency and they most often are response cards mailed to patients that come back to the agency. In-house surveys are better than nothing, but they bring suspicion of bias, as opposed to third-party surveys conducted by an external agency—similar to the way CMS requires the HCAHPS surveys be conducted. It would be much better to have an external agency do the survey, provide us a summary and then even benchmark our performance to other agencies.

We also invest little time training our field providers, call center personnel and business office staff on how to deliver exceptional customer service. How much time is invested in teaching customer service compared to how much time we spend teaching how to resuscitate a cardiac arrest victim or how to apply a traction splint? Why is it we spend so much time teaching our people how to do things to our customers, and virtually no time how to do things for our customers? They may apply a traction splint once in their career, but they interact with patients on every call.

Thankfully, the National Association of Emergency Medical Technicians (NAEMT) developed a course on the Principles of Ethics and Personal Leadership (PEPL) which teaches EMS personnel how to make sound ethical decisions, prevent conflict and how to be EMS ambassadors.⁴

The time is now

We are arguably at the most pivotal time in our young profession. The ACA has provided EMS an unprecedented opportunity to become part of the healthcare system, a move that many of us have dreamed of for decades. We need to pay attention to the changing dynamics of the environment in which we operate. The factors that currently impact hospitals, doctors and other healthcare providers will also impact us sooner than we think. Take the time to help shape our future, and how we participate in this new healthcare system.

It’s time to really focus on the patient and the patient’s experience with our service.

RESOURCES

1. Cleveland Clinic Office of Patient Experience, http://my.clevelandclinic.org/patients-visitors/patient-experience/ default.aspx.

2. McCallion T. (Oct. 11, 2013) OIG Report: Utilization of Medicare Ambulance Transports, 2002-2011. EMS Insider . Retrieved on Oct. 28, 2013, from http://www.emsinsider.com/ems-articles/oigreport-utilization-of-medicare-ambulance-transports-2002-2011/.

3. Department of Health and Human Services Office of Inspector General, http://oig.hhs.gov/oei/reports/oei-09-12-00350.pdf

4. NAEMT Principles of Ethics and Personal Leadership, http://www.naemt.org/education/pepl/pepl.aspx 

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