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.