EMS World

NOV 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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10 NOVEMBER 2018 | EMSWORLD.com O ver the la st three columns we've discussed the costs of traditional EMS delivery, done a deep dive into revenue analysis, and explored the costs of innovative EMS delivery models. In our final column on EMS financial acumen, let's put it all together and look at alternative payment models for EMS. Economic Models 1.0 and 2.0 Since the inception of Medicare in 1965, ambulance transportation has been a cov- ered benefit for Medicare beneficiaries. 1 The key word in that sentence is transportation. If transportation is not supplied, Medicare coverage is not available (with one minor exception involving the cessation of CPR and presumption of death on scene by the ambulance crew). EMS is paid based on the transportation supplied, not the medical care provided. This is why Medicare gener- ally refers to ambulance services as suppli- ers, not providers. The current economic model for EMS is volume-based and simple: The more transports we do, generally, the more we get paid. Prior to 2002 each EMS agency billed according to its own pricing scheme, generally above their average cost (model 1.0). Following the introduction of the pro- spective payment schedule in 2002, EMS agencies billed according to a formula that involved the level of service and mileage but was still based on fee-for-service, with the service being transportation (model 2.0). As the healthcare system moves toward value-based and outcome-driven economic models, our model becomes antiquated and, frankly, incompatible with demon- strating value. Few studies empirically show patient outcomes are better because they arrived at the hospital by ambulance as opposed to private vehicle, police car, or ride-share. In fact, the opposite has been shown: BLS care in cardiac arrest has better outcomes than ALS care, and penetrating trauma victims transported by police car have better survival rates. 2,3 Alternative Economic Models (Model 3.0) Let's apply what we've learned in our previ- ous columns to some alternative economic models being piloted across the country. Ambulance response, treatment, and non- transport—Anthem announced in October 2017 it would reimburse ambulance services for response and treatment without trans- port in all 14 states in which it operates. 4 The Healthcare Common Procedure Cod- ing System (HCPCS) code for that service is A0998. Historically that HCPCS code has not been paid by Medicare and most insurers who follow the Medicare guidelines because Medicare does not consider A0998 a cov- ered benefit (because there was no trans- port). But Anthem desired to decouple pay- ment from transport as a way to remove the economic incentive for ambulance services to transport patients to EDs just to get paid. It is now paying medically necessary claims billed under the A0998 HCPCS code at 75% of the statewide average amount allowed for an ambulance transport. Let's run the numbers: If the statewide average ambulance transport payment allowable for Anthem were $800, a billed A0998 nontransport claim would be paid $600 (75% of $800). Recall that Anytown EMS' average commercial payer revenue per transport was $800, so the ability to collect $600 as opposed to $0 for the nontransport would help keep Anytown EMS relatively fis- cally whole for the response, even without transport. Payment for treat-and-refer—Some payers, most notably Arizona Medicaid (AHCCCS), have begun paying for EMS response and referral without ambulance transport. 5 Note the deliberate use of the terms EMS and ambulance. Under the AHCCCS pilot an EMS agency is eligible for the treat-and-refer payment even if it isn't an ambulance supplier. In the AHCCCS pro- gram a first-response agency can respond to a 9-1-1 call, assess, treat, and refer the patient, then bill Arizona Medicaid for the service, even though they are not a licensed ambulance provider. The AHCCCS payment for this service is $203.80. Recall that Anytown's first-response cost per call was $50 ($50,000 annual cost to operate ÷ 1,000 responses). Receiv- ing $203.80 for the response, if there is no transport, more than covers its cost. PROMOTING INNOVATION IN EMS Examining alternative payment models for EMS By Matt Zavadsky, MS-HSA, EMT, and Kevin G. Munjal, MD, MPH Business Acumen Part 4— Putting It All Together Over 2018 EMS World, in conjunction with the National Association of EMTs, will provide detailed implementation strategies for key recommendations of the Promoting Innovation in EMS (PIE) project. The PIE project utilized broad stakeholder involvement over four years to identify and develop guidance to overcome common barriers to innovation at the local and state levels and foster development of new, innovative models of healthcare delivery within EMS. Each month we will focus on one recommendation and highlight the document's actionable strategies to continue the EMS transformation.

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