News & Updates

An excellent insight into one of the primary drivers of ED delays and boarders in the ED.

At the recent American College of Emergency Physicians (ACEP) Summit on ED Boarding, the inability to discharge inpatients was a major driver highlighted. This is exacerbated by the paltry economic model for post-discharge providers, including ambulance service.

As an example of how economics and payment reform drive this process, I recently received a phone call from the Executive Director of one of the largest Medicaid MCOs in the DFW metroplex. He said he had 5 inpatients waiting for ambulance trips in Dallas (not MedStar’s service area), and he could not get any agency to transfer the patients out. He went on to explain that the cost of the inpatient facility care was significantly higher than if the patients were to be transferred to the post-discharge facilities. We discussed the low Medicaid reimbursement, and EMS shortages due to the staffing and economic crisis as the likely reason he could not find a provider and suggested that it may be in his economic interest to offer a higher reimbursement for the services to facilitate the ambulance transfers – which he said he could and would do.

Not also the opinion that payment reform could help patients get the right care, in the right setting, avoiding preventable hospital visits. The EMS profession has been promoting that change for years, since currently, we are ONLY reimbursed for services by Medicare and most commercial insurers who follow the Medicare rules, if we transport a 911 patient to the ED. A perfect example of how payment policy drives clinical practice.

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Opinion: Discharge delays are another sign of a broken healthcare system

Chris Van Gorder

October 04, 2023

https://www.modernhealthcare.com/opinion/scripps-health-ceo-chris-van-gorder-discharge-delays-broken-healthcare-system

August marked a milestone for Scripps Health and one of our patients. After two years and three months at Scripps Mercy Hospital San Diego, the patient was finally able to leave. The patient didn’t need to be in an acute-care hospital for that long; there was just nowhere else for him to go. With a severe behavioral health diagnosis and a county mental health conservatorship, he required transfer to a specific, locked level of care. But there was no space available. So he stayed.

His situation is not unique. Another patient has been at one of our hospitals for more than a year and a half waiting for a county bed. During that time, he has exhibited disruptive behavior, including multiple episodes of hitting and throwing objects at staff members.

We have a number of patients who have been in our hospitals for more than 500 days. Our longest-term patient has been here for 2 1/2 years. He is on a five-year wait list for a state psychiatric hospital, but open beds for transfers are extremely rare, with priority given to state criminal patients over those being boarded at hospitals.

If we cannot move patients out of beds when they are ready to leave, we cannot take in more patients. It’s as simple as that. So we face bottlenecks—acute-care beds occupied with patients we cannot discharge even though they are ready to leave, which backs up patients in the emergency department. That, in turn, backs up ambulances waiting to offload patients.

This problem exists at hospitals across the country. A survey conducted over a three-month period last year by the Healthcare Association of New York State found that the 52 responding hospitals accrued 60,000 avoidable bed days at an estimated cost of $169 million. A report by the University of California Davis Medical Center said it racked up more than 7,800 ABDs in 2019 at a total cost of $20.4 million. According to an Advisory Board 2019 report, 71% of hospitals have at least 500 avoidable bed days per 1,000 cases.

At Scripps Health, we record more than 33,000 avoidable beds days annually. That’s up from about 11,000 three years ago. Our daily average jumped from 30 in 2019 to 91 in 2023. Over that period, the annual costs we absorb have skyrocketed, from $16.7 million to $59 million.

This is a state and national policy failure—one of many involving regulations and unfunded mandates focused on hospitals. The real problems that need to be addressed are chronic and intentional underfunding and a focus on fixing parts of the system rather than the broader issues threatening hospitals. Piecemeal legislation and policymaking won’t get the job done.

At the urging of the American Hospital Association and hospitals across the country, Congress considered proposals in December 2022 to compensate hospitals for some of their avoidable bed day costs through a temporary Medicare payment adjustment, but to date, none of those proposals have advanced.

Several reasons account for why these patients have nowhere to go. In San Diego, we have just over 800 inpatient behavioral health beds, but we need more than 1,600. Many step-down healthcare providers might have beds, but are struggling with staffing shortages. And many facilities won’t take patients with Medi-Cal (Medicaid in California) or Medicare if there are better-paying patients, or they will only designate some beds for them.

California hospitals have not received an increase in Medi-Cal base rate reimbursements in 10 years. But while facilities downstream from hospitals can pick and choose which patients they take because the Emergency Medical Treatment and Labor Act does not apply to them, hospital emergency departments don’t have a choice. So the patients stay.

Increasing government reimbursement to cover the cost of care at hospitals, as well as at other providers such as home health, skilled-nursing and behavioral health organizations, would give patients a better chance of being accepted elsewhere when they no longer need to be in an acute-care hospital. Or maybe they would receive the proper level of care in the first place, keeping them out of hospitals altogether.

Avoidable bed days are another sign of a broken healthcare system. Hospitals should not be stand-ins for nursing homes or specialized residential treatment facilities. Hospitals are the most expensive setting for these patients. And they’re not the right medical setting.

This is an untenable problem that must be fixed, but that won’t happen until more people are focused on solving it at all levels: local, state and national.

Outstanding program that many communities/agencies are implementing, or at least investigating…  Kudos to the ATCEMS Team for this initiative!

MedStar just entered into an agreement with a commercial payer that reimburses us for this type of alternate response, without sending an ambulance, including patient navigation through our 911 center… It uses CPT codes vs. typical HCPCS ambulance codes, for the alternate response reimbursements.

Key quotes from the news report –

• ‘Selena Xie, president of the union that represents EMS workers in Austin, says 90% of 911 EMS calls are not medical emergencies, but are resource needs. So this program gets people the help they need, while freeing up ambulances for the higher needs calls, like heart attacks and other life-threatening situations.’
• ‘Over the summer, Council Member Alison Alter pushed to have more money for paramedics included in the budget so the program can run 24/7. “This is really important if we want to grow as a city,” Alter said. The city can respond to calls for help "without having to add a million [fire and EMS] stations as we grow.”’
• ‘When someone calls 911 and they don't necessarily need an ambulance or to go to the emergency room — they have an infected wound or a minor injury requiring stitches, for instance — this team of paramedics responds with alternative solutions. The goal is usually to keep the person at home.’

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A 911 call for help doesn't always require an ambulance. But these paramedics respond.

KUT 90.5 | By Luz Moreno-Lozano

October 2, 2023

https://www.kut.org/austin/2023-10-02/a-911-call-for-help-doesnt-always-require-an-ambulance-but-these-paramedics-respond

Capt. Doug Schulz looks just like any other paramedic in Austin. He wears a navy blue uniform with his name pressed on the right corner of his chest. He carries a medical bag with equipment and sky blue gloves.

But his job is different — and it's not just that he responds to calls for help in an SUV instead of an ambulance. It's that he has the ability to meet people where they are.

Schulz is part of a team of paramedics referred to as the Collaborative Care Communication Center, or C4, a program that began with the COVID-19 pandemic.

The team aims to respond to calls for help that do not require an ambulance or trip to the emergency room, reducing the strain on hospitals and the health care system.

“Back in March [2020], I got a call from one of our chiefs,” Schulz said. “He said, 'You are going to screen COVID calls that come in on 911, and we are going to try to deal with them without overloading the system or the ambulances.'”

But that was just for COVID-related calls. As the pandemic dwindled, Schulz said the team realized they were really good at this, responding to calls that weren't necessarily emergencies.

“We eventually thought: Why don't we do it for these other low-acuity calls,” he said, referring to calls for help that wouldn't be considered emergencies. “That is what birthed the [program].”

What is C4?

The Collaborative Care Communication Center is sort of like a telehealth line, Gabe Webber, a commander with C4, said.

“Maybe that is an oversimplification,” he said. “But it is our way of trying to find alternative dispositions for low-acuity health care needs.”

When someone calls 911 and they don't necessarily need an ambulance or to go to the emergency room — they have an infected wound or a minor injury requiring stitches, for instance — this team of paramedics responds with alternative solutions. The goal is usually to keep the person at home.

The program often caters to people who are either low-income or vulnerable and have no other resources. Many are dealing with chronic health issues.

Michael Minasi

The goal of the C4 team is to treat a person where they are and not bring them to the emergency room.

“Usually they don't have a relationship with a primary care provider,” Webber said. “They have no place else to turn, so disproportionately they’ll access 911.”

That creates a cycle, he said. They get into an ambulance, are seen by a doctor at the hospital, and told to follow up, but they don’t because they don’t have the ability to do so. That's where C4 comes in.

“We try to break that endless cycle,” Webber said, “and try to connect them with an appropriate resource.”

That then not only creates a better outcome for the patient, but is also a cost savings. Operating an ambulance and going to the hospital are expensive, Webber said.

Selena Xie, president of the union that represents EMS workers in Austin, says 90% of 911 EMS calls are not medical emergencies, but are resource needs. For example, she said, if someone calls 911 who has trouble getting around, a paramedic can respond to help and also provide a referral for services. So this program gets people the help they need, while freeing up ambulances for the higher needs calls, like heart attacks and other life-threatening situations.

“It is a keystone of what we are trying to do,” Xie said. “We do have limited ambulance resources, and we are covering the entire county and city.”

Using best judgment

Schulz said the team is given a rough set of guidelines when responding to calls. “'Make good decisions' was basically the direction we were given,” he said. “Like, 'Use your best judgment.'”

Schulz said the paramedics try to keep people home or where they're most comfortable rather than taking them in an ambulance to the hospital. But that's not always possible.

Earlier this month, Schulz responded to a call from a 56-year-old man with a spinal disease. The man had been discharged from the hospital just two days before and had promised to give himself medicine through an IV. But all of the sudden, he couldn’t get out of bed and was unable to get this medicine from the refrigerator.

Living alone with his cat, he called 911 for help.

Schulz did his best to try to keep the man home, but because he had missed several doses of medicine and was unable to move, a trip to the hospital was really the best option.

“He even agreed,” Schulz said. “He was right there. If he called 24 hours ago that would’ve been way different because we would’ve gotten a dose in. … We tried.”

Expanding the program

Schulz and his fellow team of paramedics respond to many calls for help. But they can only answer a call within the hours they are available — usually from 9 a.m. to 9 p.m. The overnight hours are left unfilled, when paramedics say lots of calls happen, especially mental health calls.

Over the summer, Council Member Alison Alter pushed to have more money for paramedics included in the budget so the program can run 24/7.

“This is really important if we want to grow as a city,” Alter said. The city can respond to calls for help "without having to add a million [fire and EMS] stations as we grow.”

Webber said expansion is important for consistency.

“People do call 24 hours a day … the system never sleeps,” he said. “But during the day, certain calls are diverted [to C4].

During the nighttime, those kinds of calls have to be handled in the traditional manner, and that creates confusion for paramedics in the field.”

While consistency is important, Webber said, fewer resources are available at night, like walk-in clinics and other social services.

“But we could potentially verify the stability of the caller and provide medical advice or maybe a temporary solution overnight, and then set up followup the next day,” Webber said. "Again, potentially keeping from sending that ambulance to that call."

The goal is to have the program 24/7 by late next year. But Xie said there is more to be done.

“It’s a good start,” she said. “And it's good to celebrate it, but we shouldn't feel like we’ve made it to the end zone yet.”

Yet another challenge that continues to pile on to the “EMS Misery Index”….

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Scripps News Investigates: The deadly toll of a US ambulance shortage

Aging and damaged ambulances are making it tough for emergency departments around the country to provide reliable service.

By Chris Conte and Daniel Lathrop

Sep 20, 2023

https://scrippsnews.com/stories/scripps-news-investigates-the-deadly-toll-of-a-us-ambulance-shortage/

Jennifer Cowan didn’t used to worry about breaking down. 

When she became an EMT in Clay County, Tennessee nearly 20 years ago, she knew she could depend on the ambulance she drove to make it to any emergency call that came in.  

But now, a nationwide shortage of ambulance chassis is leaving Cowan and other EMTs constantly worried about breaking down on the way to an emergency — or with a patient in back, when seconds often can mean the difference between life or death. 

“I’ve broken down running an emergency with a patient in the back before. [You’re] worried about not being able to get someone’s child or grandma to the hospital because you don’t have an ambulance to get them there,” Cowan said. 

She’s not alone. 

Scripps News Investigates found local emergency medical services departments across the country that have been waiting years for replacements and repairs of aging and damaged ambulances.  

“It’s always in the shop for something. We’ve been ready to buy a new ambulance for years,” Cowan said of her ambulance as she navigated the country roads in the rural part of the state. 

How we got here

The paint is peeling on some of Clay County’s ambulances. Maintenance and repair bills are piling up. 

Nationally, the problem began in 2020 when the COVID-19 pandemic ground global trade to a halt, preventing automakers from getting enough of the microchips that are critical to making modern cars, trucks — and ambulances.

Ambulances are made by a small number of specialized companies, which build them on top of bare chassis — the engine and frame of a truck — purchased from companies like Ford Motor Company and General Motors. 

Vehicles using the components of those chassis continued rolling off the assembly lines during the pandemic, but in lower numbers than usual. 

As the backlog grew, EMTs said they had more and more trouble with their aging vehicles. 

In fact, in 2021 there were a reported 13,540 mechanical failures that prevented ambulances from responding, and in 2022 that figure climbed to 14,905, according to U.S. Department of Transportation data. That’s a 10% increase. 

And, critics charge, automakers simply did not prioritize chassis for them over passenger trucks and other products analysts say are more lucrative than bare chassis. 

“Our customers are in dire demand for ambulances. The fact that we know a lot of our customers are running ambulances way past their life expectancy, the reliability of products on the road is very concerning,” said Randy Smith, president of Iowa-based Life Line Emergency Vehicles. 

Among the critics is American Ambulance Association president Randy Strozyk, who represents public and private ambulance service providers. 

He’s frustrated that automakers and public officials haven’t heeded emergency responders’ repeated warnings.  

“You would think we wouldn’t have had to jump up and down. This should have been an easy decision to make,” Stroyzk said. 

Clay County’s aging fleet

Clay County ordered a new ambulance in March 2022. But it still hasn’t arrived, and EMS director Andy Hall’s not optimistic. 

“We are looking at our next ambulances five years down the road,” Hall explained. 

Hall’s agency has four ambulances to cover a county that encompasses an area of 259 square miles.  

The newest is a 2019 model, purchased and delivered before the pandemic. 

The oldest is a 2010 with more than 235,000 miles on it — so many miles Hall had to get special permission from the state of Tennessee to keep using it. 

And in Clay County, the situation is compounded by a larger issue in rural health care. Back in 2018, the county’s only hospital shut down, leaving this county of 7,555 people without an emergency room.  “We are their hospital, we’re their ER until we can get them to a facility,” Cowan said 

In fact, the closest ER is now 20 miles away.  A typical round-trip call for EMTs lasts around 90 minutes. 

That increases the chance that the oldest vehicles in the fleet will be put into use — and increases the chance that the newer, more reliable units will be tied up when a call comes in. 

The new normal

Meanwhile, in 2022 representatives of the nation’s ambulance operators, fire chief, EMTs and firefighters sent a joint letter to Secretary of Transportation Pete Buttigieg that called the situation a “crisis” and asked that DOT push ambulance makers to prioritize them now and in the future. 

But a spokesman for Buttigieg said DOT lacks jurisdiction — and that its role enforcing safety and environmental regulations actually prevents the agency from pushing for changes in “production decisions.” 

At Buttigieg’s urging, a White House task force on supply chain issues did examine the chassis shortage.  

Automakers told officials that the supply chain issues preventing chassis manufacture have been resolved, said U.S. Department of Commerce spokesman Charlie Andrews. 

A representative of Ford, the leading provider of chassis to ambulance makers, echoed that. 

“From our vantage point, Ford is not the current constraint in the ambulatory supply chain,” spokeswoman Catherine Hargett said. “Beginning last year, we allocated more chassis to ambulance converters to address a vehicle backlog created by pandemic-driven supply chain issues and demand.”  

But ambulance makers, EMS workers and fire departments interviewed by Scripps News said they still are unable to place orders for chassis in the volume needed to reach pre-pandemic needs — much less account for a two-year backlog. 

Before the pandemic, Life Line made about 250 vehicles per year. The company should reach 220 this year, Smith said.

But that’s nowhere near what’s needed by those using ambulances day in and day out. 

“I’m not saying I want a year’s worth of chassis in two weeks but they have the ability to do that,” Smith told Scripps News.  

Meanwhile, the people who put their lives on the line said their concern is not just the current backlog — but what will happen when another pandemic or disaster disrupts global supply chains. 

“We want priority. We should’ve been able to raise our hand once and this was recognized,” said Stroyzk, the head of the ambulance association. 

Other EMS officials say they see long delays as a new normal that agencies need to simply plan for. 

“They are coming through, it just takes some time,” said assistant EMS chief Dave Edgar of West Des Moines, Iowa. 

But back in Clay County, Cowan and Hall said they’re just hoping their time comes soon. 

“Our hands are tied, there’s nothing we can do,” Cowan said. “We can’t help people if we can’t get to people.” 

Interesting bi-partisan, bi-cameral happening in DC!  With support from the regulator, physician, EMS, and hospital community in WV.

A coalition consisting of NAEMT, IAFF, IAFC and AAA are lobbying diligently to get TIP/TAD legislation introduced in Congress.  This effort may add some additional support for the legislation.

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MANCHIN, CAPITO, MILLER, MOONEY URGE CMS TO ADOPT TREAT-IN-PLACE MODEL IN WEST VIRGINIA

New Model Would Improve Use Of Healthcare Resources, Reduce Costs For Patients, Insurers And Hospitals

SEPTEMBER 18, 2023

https://www.manchin.senate.gov/newsroom/press-releases/manchin-capito-miller-mooney-urge-cms-to-adopt-treat-in-place-model-in-west-virginia

 

Washington, DC – Today, U.S. Senators Joe Manchin (D-WV) and Shelley Moore Capito (R-WV) and U.S. Representatives Carol Miller (R-WV) and Alex Mooney (R-WV) called on the Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure to consider a “treat-in-place” model to address the workforce challenges faced by West Virginia hospitals and Emergency Medical Services (EMS) providers.

“This would be a major step forward in advancing an improved model that better utilizes limited EMS and hospital staff while ensuring quality patient care and saving approximately $3 million in unnecessary emergency room visits.

Furthermore, this model could be replicated nationwide, especially in rural communities with limited health resources,” the lawmakers wrote in part.

The West Virginia Office of Emergency Medical Services (OEMS) and the West Virginia Hospital Association (WVHA), along with a small coalition of emergency medicine physicians, EMS providers, and payers sent a proposal to CMS urging them to support a new “treat-in-place” model to reduce unnecessary emergency room trips by establishing medical triage lines for low-acuity 911 calls.

“The availability and effective functioning of the emergency medical services system and hospital emergency departments are of vital importance to all West Virginians,” said Jim Kaufman, President and CEO of the West Virginia Hospital Association. “This demonstration will provide the flexibility necessary for our first responders to care for West Virginians in the appropriate setting and it aligns with the goals of better utilizing EMS and hospital staff while ensuring quality patient care and reducing unnecessary emergency room visits. Emergency medical services systems, hospitals, and their emergency departments, are fundamental components of West Virginia’s health care delivery network.

Together they provide the state’s safety net and CMS’s approval of this project will go a long way to ensure access to care, especially in our most rural communities.”

The full letter is available below or here:

Dear Administrator Brooks-LaSure,

We write to you to ask you to review the proposal submitted by the West Virginia Office of Emergency Medical Services (OEMS) and the West Virginia Hospital Association (WVHA) along with a small coalition of emergency medicine physicians, EMS providers, and payers to explore a statewide, multi-payer demonstration to address the workforce challenges faced by West Virginia hospitals and Emergency Medical Services (EMS) providers. The Center for Medicare and Medicaid Innovation (CMMI), or “Innovation Center,” was authorized under the Affordable Care Act (ACA) and tasked with designing, implementing, and testing new health care payment models to address growing concerns about rising costs, quality of care, and inefficient spending. We feel that the proposal submitted by the coalition of providers in West Virginia warrants a closer review by the Centers for Medicare & Medicaid Services (CMS) and CMMI.

During the Public Health Emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) provided greater flexibility allowing EMS to treat certain conditions at the scene or transport patients to an alternative site of care.

However, this flexibility appeared to have limited impact in West Virginia due to several factors such as in rural communities where there are no alternatives sites of care while in urban areas the alternatives sites were not prepared for an ambulance presenting at their facility.

Beyond the CMS flexibilities, the Center for Medicare and Medicaid Innovation (CMMI) launched the Emergency Triage, Treat, and Transport (ET3) voluntary, five-year payment model to provide greater flexibility for Medicare Fee-for-Service (FFS) beneficiaries following a 911 call. West Virginia chose not to participate in the ET3 demonstration, and one barrier noted was the requirement to transport patients to an alternative site of care. However, Kanawha County West Virginia EMS did participate in the community paramedicine model allowing EMS to provide basic services in the community.

The treat-in-place option that the coalition is exploring is built upon an effort in western Pennsylvania that focused on three conditions that can be treated in place following a 911 call and following narrow protocols developed by EMS. The effort in Pennsylvania was unsuccessful because only one payer participated, so EMS had to have different processes for patient’s based on their insurance status. As a result, the coalition has focused on one model for EMS with a goal of securing most payers agreeing to participate in the treat-in-place option, so EMS has one statewide protocol and billing process.

Additionally, we are aware that CMS decided to end the ET3 Model on December 31, 2023, which is two years prior to the original agreement. We feel that a statewide model, such as the coalition is proposing, warrants review despite that lower than anticipated projected interventions from the ET3 Model. By utilizing a multi-payor state model, CMS would be best able to receive robust quantitative and qualitative date to review the models’ efficacy.

After receiving initial support for the treat-in-place option from the coalition and three statewide payers (Highmark, Public Employee Insurance Agency (PEIA), and Medicaid) OEMS has started drafting protocols for three conditions:

• Diabetes – Hypoglycemia Evaluation
• Asthma/COPD Evaluation
• Seizure Evaluation

Based on preliminary data for these three conditions, about 15,000 patients sought care in West Virginia hospitals’ emergency departments but were not admitted as inpatients in 2022.

Furthermore, EMS 2022 data shows that symptoms of these conditions prompted 64,777 calls of which 49,061 were transported for additional care, while 4,136 were treated at the scene or released for other transportation. It is important to note that the planned EMS services for the treat-in-place option is within the current scope of practice of EMS. In addition to the services provided by EMS, part of the protocol will be to advise the patient to follow-up with their primary care provider to ensure continuity of care.

If Medicare would participate in this demonstration, West Virginia would be able to advance a statewide demonstration that all EMS providers could participate in while having the payers for approximately 75 percent of the patients that EMS treats included in the demonstration. This would be a major step forward in advancing an improved model that better utilizes limited EMS and hospital staff while ensuring quality patient care and saving approximately $3 million in unnecessary emergency room visits. Furthermore, this model could be replicated nationwide, especially in rural communities with limited health resources.

We appreciate your review of this matter, and look forward to hearing from you regarding your consideration of the coalition’s proposal.

EMS-based MIH programs designed to reduce preventable readmissions may gain traction because of this finding. At MedStar, we’ve seen a significant increase in referrals from our partner hospitals as they derive economic value from reducing readmissions.                                                                                    

Note the reference to staffing issues in in post-acute care settings as a driver of readmissions.

EMS agencies could be a valuable partner for hospitals struggling with readmission rates.

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More hospitals to be charged readmissions penalties: CMS

MARI DEVEREAUX

September 15, 2023

https://www.modernhealthcare.com/safety-quality/hospital-readmissions-penalties-increasing-2024-cms

More hospitals will face readmissions penalties in 2024, a departure from the lower rates of reimbursement cuts providers saw last year, according to preliminary data released Thursday.

While the Centers for Medicare and Medicaid Services has resumed use of its pneumonia readmissions measure, which was excluded last year from its Hospital Readmissions Reduction Program, payment adjustments have not returned to pre-pandemic levels.

The hospital readmissions performance period for fiscal year 2024 still excludes data from the first half of 2020, pulling claims from July 2019 to December 2019 and from July 2020 to June 2022. The penalties also exclude data from hospitals with approved extraordinary circumstance exceptions.

“It's probably going to be a messy couple of years,” said Akin Demehin, senior director for quality and patient safety policy at the American Hospital Association. “The ways in which COVID-19 interacts with quality performance on things like readmissions will take time to settle out completely.”

Higher rates of penalties for hospitals likely reflect their hardships during peak months of the pandemic in 2021 and 2022, Demehin said.

For the upcoming year, 70.1% of hospitals will be charged penalties of less than 1% on their readmissions. That compares with 67.1% of hospitals in fiscal 2023.

Meanwhile, 7.5% of hospitals will be charged penalties of 1% or more in fiscal 2024, a percentage virtually unchanged from last year. Another 22.4%of hospitals will not be assessed penalties.

The average penalty for hospitals with the highest proportion of Medicare-Medicaid dual-eligible patients—peer group five—is 0.29%. For hospitals with the lowest number of dual-eligible patients—peer group one—the average penalty is 0.34%. During fiscal year 2023, groups five and one were penalized 0.23% and 0.37%, respectively, on their readmissions.

Before 2020, penalties were on the rise following an increase in measures that are part of the readmissions program.

It is hard to compare readmission rates between periods of the pandemic due to factors like spiking variants affecting hospitals in separate locations at various points in time, said Rick Kes, senior healthcare analyst at RSM.

“You had employment issues in different geographic markets and a pretty substantial increase in traveling nurses, which changed how care was being delivered to patients,” Kes said.

While hospitals have increased their focus on quality and length of patient stay during the past few years, and the acute nature of the pandemic has begun to subside, there are likely still areas of improvement for hospitals to work on, he said.

Understaffing in post-acute care facilities and home health agencies, as well as hospitals’ lack of ability to discharge patients are also problems that contribute to poor readmission rates, Kes said.

Interesting data in the FAIR Health report, but notably lacking is the reasons for out-of-network status of ambulance claims. Likely reasons cited by ambulance agencies have included:

• Lack of interest by insurers to contract with ambulance agencies, citing < 1% of the payer’s spend is on ambulance services and they are focused on providers that represent larger % of their spend.
• Low in-network reimbursement rates offered by insurers, well below the cost-of-service provision.
• The basic in-network model (lower fees in return for higher volume (i.e.: more efficiency) does not work for primarily 911 providers (911 calls represent most out-of-network claims))
• Many public EMS agencies lack the desire to become in-network providers.

You can download the FAIR Health report at the link below – Notable findings are highlighted below.

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Most ambulance rides still out of network

By Maya Goldman and Tina Reed

Sep 13, 2023

https://www.axios.com/newsletters/axios-vitals-4fcd9efd-e475-4636-9f48-149d4b989270.html

Illustration: Sarah Grillo/Axios

Nearly 60% of ground ambulance rides were out of network in 2022, according to an analysis provided first to Axios by FAIR Health.

Why it matters: Patients can't really shop around for an ambulance ride, but they're getting smacked with major medical bills because their emergency transportation is outside of their insurers' network, Tina writes.

• Using its collection of 42 billion private health claims records, FAIR Health found most ground ambulance claims were out of network between 2018 and 2022.
• There was a small decline in out-of-network ambulance rides during that time, from 63.7% in 2018 to 59.4% in 2022.

Our thought bubble: The data indicates that ground ambulances likely remain a large source of surprise bills after Congress dropped them from surprise billing legislation.

What we're watching: A congressional advisory committee last month examined the ground ambulance issue, and it plans to make recommendations in November, per PBS Newshour.

What we're also watching: The internet's favorite physician-comedian Dr. Glaucomflecken's recent take on ambulance bills.

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Notable excerpts from the FAIR Health report:

• “In addition to being used for transport, ground ambulances can provide on-site treatment, without transporting the patient from the original location to a hospital. Such treatment increased from 2018 to 2020, rising from 1.4 percent to 2.0 percent of all ground ambulance claim lines, but decreased slightly in the following years, dropping to 1.9 percent by 2022.”

• “From 2018 to 2022, response and treatment without transport accounted for a higher percentage of ground ambulance claim lines among individuals aged 19 to 35 than any other age group: between 2.2 and 3.1 percent. By comparison, the age cohort 65 years and older had the lowest percentage.”

More agencies may be finally billing for Treatment in Place (TIP), but the CMS COVID waivers may have impacted this statistic.

Also notable, the data does not include Medicare FFS claims.

Other notable findings in the report:

The average allowable fees in these states are below the national average COST of providing service, according to cost report data from the Public Consulting Group.

We may need to do a better job of documenting clinical impressions to reduce the number of “General Illness” claims.

Only about 30% of the patients under 65 transported to the ED by ambulance were admitted to the hospital. Can we do something other than transport to the ED with the other 70% of the patients?

Another example of the major challenges facing communities across the country, and their EMS agencies.

The latest media tracker has identified 1,087 of the 1,177 (92.4%) local and national news stories about EMS highlight staffing and funding challenges, with 65 agency closures since 2021.

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Why Pennsylvania paramedics say ‘EMS is dying’

The state budget includes a $20.7 million increase to ambulance reimbursement rates, but EMS agencies say much more is needed.

by Gillian McGoldrick

Aug. 30, 2023

https://www.inquirer.com/politics/pennsylvania/ems-philly-lansdale-reimbursement-ambulances-20230830.html

HARRISBURG — Emergency medical services are the only first responders that most Pennsylvanians don’t pay toward until they call 911.

And EMS agencies are warning that they might not be there when they’re needed if they don’t see substantial funding increases.

For years, EMS agencies have been generating less revenue than they need to operate each year. Unlike other first responders, they rely entirely on ambulance reimbursements, philanthropy, and other creative ways to raise money.

“EMS is dying,” said Heather Sharar, the executive director of the Ambulance Association of Pennsylvania, which represents 220 EMS agencies. “How long can you exist if no one is paying you the cost for your service?”

The funding shortfall has led a number of EMS agencies to close, with three in Pennsylvania closing in the last three months — leaving a ripple effect that will require other agencies in the region to pick up the need.

“We take for granted that there’s always going to be an ambulance to respond if we dial 911,” said Shane Wheeler, the CEO of VMSC Emergency Medical Services, which provides emergency care to the greater North Penn area of Montgomery County. “Increasingly, we’re finding that that might not be the case.”

The state Senate is expected to unveil Wednesday a plan to implement a $20.7 million increase to ambulance reimbursement rates. These funds — and a number of other new initiatives — were included in the $45.5 billion state budget signed earlier this month, but require further legislative action for the state to actually spend the money.

Eight municipal governments, including Philadelphia, pay toward their emergency medical services through their fire department. Last year, the Philadelphia Fire Department responded to 251,501 EMS incidents, according to a 2022 city report.

However, Philadelphia also relies on some independent EMS agencies to respond to emergency calls. These agencies don’t receive funding from the city and mostly rely on ambulance billing, Sharar said.

Both Wheeler and Sharar said they appreciated the state’s expected funding increase this year, but much more is needed. For Wheeler’s EMS agency, a statewide $20.7 million funding would only increase its annual revenue by nearly $45,000.

“It’s going to take a lot of $20 million initiatives to get EMS on a good, stable platform,” Wheeler added.

Any delay to these funds hurts EMS agencies, Sharar said. The increased ambulance reimbursement rates won’t get disbursed until both the Senate and House approve them. The state House isn’t scheduled to return to session until the end of September, following a special election for a safe Democratic seat that is all but sure to return House Democrats to their numeric majority of 102-101. Until then, the chamber is tied 101-101, and House lawmakers are unlikely to return until after that election.

VMSC Emergency Medical Services has turned to each of the seven municipalities in Montgomery County, including Hatfield Township and Lansdale, to request they each pay toward their usage of EMS services. Their annual request totals approximately $1 million, calculated on the number of calls in that area that they responded to.

Wheeler said the North Penn region is better off than some Pennsylvania communities. With only about 10% of its population on Medicaid, most people have private health insurance.

”And we still have a 14% gap between revenue and expenses,” Wheeler said.

Ambulance services don’t receive increased payment for providing higher-quality care either, Wheeler noted. For example, his agency has tried to add ultrasound technology to their emergency vehicles in an effort to determine a person’s condition before they reach the hospital. There is no way for them to charge extra for the clinical enhancement, which could improve a patient’s outcome.

Ambulance rides are more than “just a ride,” Sharar said.

“You are receiving a mobile [emergency room],” she said. “It’s not just the gas for the ride to the hospital. It is care. It is medical monitoring, treatment, and observation. It is a lifesaving resource that unfortunately, nobody wants to pay for.”

This report raises more questions than it answers –

• Was the initial underpayment by UnitedHealthcare the results of a high-deductible health plan?
• What was the “Usual and Customary” fee for a critical care transfer in that area of California?
• • Doubtful that it is $1,000.
• When UnitedHealthcare determined that the infant was covered by mom’s insurance, not dads, why could they not subrogate between United and BCBS as opposed to taking the underpayment back?
• Why is BCBS denying payment?  Is ambulance service a covered benefit in the family’s BCBS plan?

This report illustrates the way insurers put patients in the middle of coverage disputes because of surprise underpayments, as opposed doing the right, and expected thing, for what is clearly a medically necessary, critical care transfer.

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Ambulance rides can be costly — and consumers aren't protected from surprise bills

CBS-mornings

BY ANNA WERNER

AUGUST 29, 2023

https://www.cbsnews.com/news/ambulance-rides-costs-consumers-arent-protected-surprise-bills/

Americans are protected from most surprise medical bills by the No Surprises Act that took effect last year. But there's one key item the legislation left out: ambulance rides.

A recent report found more than half of ambulance rides by insured patients result in a surprise bill. Those rides cost patients roughly $130 million a year, according to the U.S. Public Interest Research Group, or PIRG.

David Feng and Christy Shum are currently fighting their bill, which totals more than $7,000. The bill is for an ambulance ride their 1-year-old son, Theo, took from home as a newborn, a week after he was born prematurely. 

"He was breathing, but very heavily," Feng said. "So he wasn't getting all the oxygen he needed."

Doctors told the couple the baby would need to be transferred by ambulance to a children's hospital with a special team and life support. At no point during that process did the cost of the ride cross their mind.

Yet a few weeks later, with Theo still hospitalized with what specialists determined were two holes in his heart, the couple got a bill for the ambulance transfer. It totaled over $7,000.

Christy's insurance company, UnitedHealthcare, paid nearly $1,000 of that, leaving them owing the rest – more than $6,000, because UnitedHealthcare said the service was an "out-of-network provider or facility."

"It's totally shocking when you see the bill and to me, it's really unfair," Feng said.

Many surprise medical bills like the one they received were eliminated by the No Surprises Act, legislation passed by Congress in 2020 that protects consumers against most surprise bills for emergency services, including life-saving helicopter flights.

But what it didn't get rid of were surprise bills from regular ground ambulances.

Patricia Kelmar with PIRG said Congress "dodged" the issue, and "decided to acknowledge the problem by creating a federal committee to look at the problem more deeply." Kelmar is on that committee.

"There are fixed costs when it comes to ambulance treatment," she said. "We should set a price that is tied to costs, and that will help make our insurance companies pay those costs, at a true price, and will protect people from these really high out-of-network bills."

But there's no firm timeline for developing a new system, leaving some families struggling.

Shum appealed their $6,000 ambulance bill, but got a letter from UnitedHealthcare saying: "Payment for this service is denied." The insurance company also took back the $1,000 it did pay – saying Feng's insurance company, Blue Cross Blue Shield of California, should have paid all the expenses for the baby's first month.

Over a year later, the ambulance bill – over $7,000 in total – remains unpaid despite hours spent on the phone with both companies, trying to get answers.

"It's frustrating," Shum said. "The fact that it's taking so much of our time and it's still not resolved and we still don't know anything."

The company that provided the ambulance told CBS News the bill had been submitted several times but had gotten "stuck" in the system. It also said specialized critical care transport is expensive to operate around the clock, and it relies on insurance companies to reimburse timely and at a fair rate.

Blue Cross Blue Shield of California told CBS News it couldn't answer questions about issues with the couple's bill due to federal privacy laws.

The family says Blue Cross Blue Shield called and promised it is working to resolve the issue, but the family says there's been no resolution yet.

UnitedHealthcare, Shum's insurer, said primary coverage for Theo was under his father's insurer, not UnitedHealthcare, but they have now "contacted both the ambulance company and (Blue Cross Blue Shield of California) to help get this bill resolved."

Still, Feng and Shum say the stress from the bills couldn't put a damper on a magical moment — the day Theo finally came home from the hospital after two and a half months. He is now healthy.

The Academy of International Mobile Healthcare Integration (AIMHI)  AIMHI Excellence in Integration Awards celebrate and promote high-performance, high-value EMS, its partners, and leaders.

Nominations for the 2023 Awards are due by December 31, 2023.

Winners will be recognized at the AIMHI Board Meeting at the American Ambulance Association Conference & Trade Show April 22-24, 2024. They will also receive recognition on the AIMHI website and social media platforms.

Please see www.aimhi.mobi/awards for criteria for each specific award category.

Nominations are due by December 31, 2023.

Yet another state government report sounding the alarm on collapsing EMS systems. These issues are not limited to rural areas, but also in urban and suburban areas as well.

According to Rob Lawrence’s most recent media tracker has identified 68 EMS agency closures since 2021.

The referenced Colorado report does not appear to be out yet, but once it is, we’ll try and get it out to you all.

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Colorado ambulance services are on the verge of collapse, government report finds

August 27, 2023

By Lucas Brady Woods, KUNC

https://yellowscene.com/2023/08/27/colorado-ambulance-services-are-on-the-verge-of-collapse-government-report-finds/

Snow was still on the ground last year one afternoon in late March when Hinsdale County’s only full-time paramedic, Buffy Witt, got what she thought would be a routine call about a car accident on Highway 149.

She realized she was wrong as soon as she arrived at the scene. The car pinned against a tree next to the road belonged to her 20-year-old son, Logan. He was trapped inside with a shattered femur, six broken ribs, a fractured vertebrae and a collapsed lung.

Witt immediately went into first-responder mode and focused on saving her son’s life.

“I told myself, put on your sheet of armor and just do it,” she said. “My son told me that he was getting right with dying because he knew he couldn’t get out of the car.”

Logan Witt survived after being flown to the nearest trauma center equipped to treat him, which was almost 150 miles away in Grand Junction. The experience was so traumatic that Witt stopped going on calls altogether. But there weren’t any other paramedics in Hinsdale County at the time to take her place, so less than two months later, Witt responded to the scene of another car accident. That time, the driver, a longtime friend of hers, died.

“That feeling of responsibility in a rural community, where you know the people that you respond to – it’s just such a heavy weight,” Witt said. “The burnout rate is magnified here because of the staffing issues, the personal connection and the responsibility to the community.”

On top of being a paramedic, Witt is also Hinsdale County’s director of emergency medical services. She manages the department and goes on calls for a salary of less than $60,000 per year. Like in many rural areas, any other first responders that back her up are volunteers. In fact, more than one in 10 ambulance agencies in Colorado have all-volunteer staff.

For Witt, the job is worth the challenges because she serves the community where she was born and raised. But ambulance services across Colorado, especially those in rural areas, are facing the same existential problems: a lack of funding, workforce shortages and declining volunteerism. A draft report sent to Gov. Jared Polis last week from the state’s EMS Sustainability Task Force found that many of the state’s emergency medical services are unsustainable, with some at risk of disappearing altogether.

The 20-member task force was launched last year to address the problems over a five-year period and is made up of state lawmakers and EMS professionals. Many first responders, however, including some serving on the task force, say more urgent action has to be taken.

“We can’t wait,” Lisa Ward, a professional EMT on the task force, told KUNC. “We’re already losing EMS services in Colorado. It’s not sustainable to have a volunteer and all-volunteer base when you can’t pay them, you can’t offer them health benefits, the mental and physical exhaustion that it takes to do the job wears on people.”

Fewer and fewer people are willing and able to dedicate time to volunteering as a first responder. Those that do often have to juggle other jobs to pay the bills, which means they’re only able to volunteer periodically and are at higher risk of burnout. At the same time, many small agencies don’t have the budgets to pay for full-time ambulance staff.

The problems partially stem from inconsistencies between state and local oversight of ambulance services. For example, first responders like paramedics and EMTs are currently licensed by the state while their emergency vehicles and the agencies that manage them are licensed on the county level. Colorado is the only state in the U.S. without centralized oversight of its EMS system. The state also has no uniform system in place for communicating or sharing data and information between local agencies.

“One county does one thing and another county does another thing. If you want to transfer a patient from one county to another county, you have to figure out what that looks like, how that’s done and who responds,” Ward said. “Right now it’s kind of a patchwork of county to county regulation.”

The patchwork system has resulted in varying access to emergency medical services across the state. Even the requirements for life-saving equipment on an ambulance can change from county to county because there are no statewide standards. Lawmakers passed legislation last year, Senate Bill 225, which will consolidate ambulance licensing at the state level starting in January.

Colorado ambulance services are funded in a variety of ways as well. Some are private businesses, nonprofits or function through hospital systems. Others are funded by property tax revenue alongside other local services like schools, libraries and water districts. That means local residents have to agree to higher taxes to increase funding for their emergency medical services.

Many local ambulance agencies also rely on grants from the Colorado Department of Public Health and Environment, but the lack of statewide standards blocks access to other funding sources like federal grants.

“When you have consistency and you have standards, you make a case for reimbursement models and funding models to say, ‘Hey, look, there’s no difference in any of these agencies. It’s not a rural agency versus an urban agency.’ It creates consistency in licensing standards, education standards and equipment standards,” Ward said.

Ward also noted that ambulances in Colorado are only reimbursed if they transport a patient to a hospital. They do not get paid for calls where they only treat a person on the scene. Under state law, ambulances are considered transportation services, not medical services.

“When any one of us individuals has an emergency, we just pick up the phone in the 21st century in America and dial 911, and we anticipate that the expert on the other end of the phone is going to realize and figure out which type of emergency service to send to us within minutes,” EMS Sustainability Task Force Chairman and State Sen. Mark Baisley said. “It works pretty well for a fire because fire is considered an essential service, which is a term that has a meaning to it: that the local municipality shall provide fire response. Not so with emergency management services.”

Baisley added that there needs to be more public awareness of the issue and how Colorado EMS systems function. But he also agrees with Lisa Ward that funding needs to be the first priority, and he’s working with the task force on legislation that he plans to introduce during next year’s legislative session. He believes tourists need to cover some of those EMS costs.

“I intend to rethink the entire manner of how this is funded,” Baisley said. “Obviously, it’s always going to be through taxation. But since our tourism industry creates a lot of the cost and demands a lot of our responsiveness and appropriate care, then we will look at that.”

The population of many rural mountain communities balloons in the summer months due to tourism. Those tourists often have to use local emergency medical services, which adds even more strain to those systems.

In Hinsdale County, the population increases from about 800 people year-round to about 6,000 people over the summer months when tourists descend on the area to hike, climb, fish and hunt among the peaks of the San Juan Mountains. Buffy Witt is doing what she can on the local level to keep emergency medical services available there while holding on to hope that the state can get its EMS oversight on the right track.

“I’m just trying to keep the wheels rolling and keep the duct tape and the fingers plugged in the holes,” Witt said. “There is hope that change is on the horizon, and this personally gives me motivation to be a part of that change.”

She’s launching a local training course in partnership with neighboring counties so that volunteers don’t have to travel to become first responders. She’s also put in place a stipend program to provide some compensation to volunteers, which is funded by the San Juan Solstice 50 Mile Run, an annual Hinsdale County marathon that typically attracts about 300 runners.