News & Updates

Meet Matt Zavadsky, Chair of the AIMHI Education Committee.

Congratulations to Sherry Willingham of Medstar Mobile Healthcare! Sherry was unanimously elected Chair of the AIMHI Reimbursement Committee on Friday. We thank her for her service!

Source Article | Comments courtesy of Matt Zavadsky

A very logical step being taken by the Pennsylvania legislature! 

And, one that is currently in place for payers such as Anthem and the Medicaid programs in Arizona and Georgia.  Additional payers are looking to implement similar programs.

Decoupling payment from transport helps enhance patient outcomes, improve the patient’s experience of care, and significantly reduce the down-stream cost of care. 

The misalignment of incentives of only reimbursing ambulance TRANSPORT to an ED is a significant cost driver.  In 2013, Health Affairs published a RAND study that determined that 12.9 – 16.2% of Medicare ambulance trips to the ED could have safely and effectively been managed in an alternate setting, and giving EMS flexibility to navigate patients could save the Medicare program up to $560 million annually.

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Barrar's bill to reimburse ambulance companies heads to governor

Digital First Media Oct 23, 2018

WEST CHESTER—Legislation drafted by state Rep. Steve Barrar, R-160, that would require ambulance companies to be reimbursed for providing medical treatment, even if the patient is not transported to a hospital, was successfully voted on concurrence by the House.

“The critical services provided by ambulance companies to Commonwealth citizens in their time of need will remain endangered, potentially to the point of extinction, if they aren’t reimbursed for their costs to render emergency care. My bill would entitle ambulance companies to payment when emergency medical responders treat and stabilize patients without a trip to the hospital,” Barrar said.

Under current practice, EMS agencies can only be reimbursed by insurance companies if they transport the patient, even though time is spent, supplies are used and services are provided regardless of whether a transport takes place. This is a significant contributor to the financial challenges facing ambulance companies, especially when many are facing the grim reality of pending closures.

House Bill 1013 would require reimbursement when transport to a facility does not take place as long as the following conditions are met: The Basic Life Support (BLS) or Advanced Life Support (ALS) unit must be dispatched by a county 911 center, and the EMS provider must have rendered emergency services even though the transport was declined.

Also, the House approved legislation to close a loophole that PennDOT has been using to deny free emergency vehicle license plates to volunteer fire companies that also have paid employees.

“Volunteer ambulance services all across the Commonwealth have been forced to pay for a plate that should have been given to them at no cost. It’s disappointing that PennDOT would take advantage of volunteer companies that save Pennsylvania so much money, but I’m pleased that I was able to influence the addition of an amendment on the bill to address this issue,” Barrar added.

Both bills now advance to Gov. Tom Wolf for consideration.

Health Affairs Source Article | Comments Courtesy of Matt Zavadsky

Interesting analysis of the various initiatives to address out of network medical billing. 

Recall that Health Affairs provided another analysis of legislative initiatives published by in September 2018.  Clearly this issue has the attention of federal and state lawmakers. 

Of note to our EMS family is that once again, Health Affairs calls on the various legislative efforts to include ambulance services in the legislative language.

Analyzing Senator Hassan’s Binding Arbitration Approach To Preventing Surprise Medical Bills

OCTOBER 18, 2018

Loren Adler, Paul B. Ginsburg, Mark Hall, Erin Trish, Benjamin Chartock

Another Senate bill to address the scourge of surprise out-of-network medical bills was newly released on October 12, the No More Surprise Medical Bills Act of 2018, this time introduced by Senator Maggie Hassan (D-NH) and cosponsored by Senator Jeanne Shaheen (D-NH). As we explained recently, surprise out-of-network medical bills can occur when a patient is unexpectedly seen by a physician who does not participate in their insurer’s provider network either in the course of emergency care or elective nonemergency care at an in-network facility, or when transported in an out-of-network ambulance.

For enrollees in employer-sponsored health plans, the bill takes a largely similar approach to the recent bipartisan Senate bill, taking the patient out of the middle of the dispute and protecting patients in both emergency and nonemergency situations. The big difference is that, instead of prescribing a minimum payment rate from insurer to provider, Senator Hassan’s bill sets up a “binding arbitration” process to determine the appropriate provider payment rate in surprise out-of-network scenarios. And importantly, the arbiter would be instructed to consider Medicare and negotiated network rates, rather than artificially high provider charges, in making their rate determination.

A companion bill introduced by Senator Shaheen would affect the individual market more broadly, capping the amount that out-of-network providers can charge in any situation (not just in situations we would define as a “surprise”) to enrollees in individual market plans (and also to uninsured patients). The bill allows states to choose among three options to set this out-of-network charge limit: 125 percent of Medicare fee-for-service (FFS) rates (with an allowance in rural areas to set payments up to 200 percent of Medicare rates), 80 percent of the “usual and customary rate” (UCR) based on provider’s billed charges, or the insurer’s in-network contracted rate for the service in question.

While these provisions would not directly prohibit surprise bills in the individual market, they could considerably reduce the liability that patients potentially face in such situations by capping the amount that the out-of-network provider could charge. Moreover, by reducing the potential financial benefit to providers of remaining out-of-network, these provisions would likely also reduce the frequency of surprise bills by encouraging more providers to join insurers’ networks.

The rest of this post focuses on the No More Surprise Medical Bills Act of 2018.

No More Surprise Medical Bills Act Of 2018

Senator Hassan’s legislation would protect group health plan enrollees from surprise out-of-network bills through the combination of:

• Restricting the provider from charging the patient any more than what they would owe an in-network provider;
• Requiring the insurer to count cost-sharing amounts for surprise out-of-network bills (which as just mentioned could not exceed in-network amounts) toward in-network deductibles and limits on out-of-pocket costs; and
• Setting up a binding arbitration process to determine payment from insurer to provider in cases where they are unable to reach a resolution on their own.

Provider Bills To Patients

Hassan’s proposal would protect patients from surprise bills in both emergency situations and nonemergency situations at in-network facilities, when they are seen unexpectedly by an out-of-network clinician. An exception is allowed if the out-of-network provider provides an estimate of costs and obtains both written and verbal consent from the patient more than 24 hours in advance. If timely patient consent was not obtained, then the legislation’s surprise out-of-network billing protection automatically kicks in and the patient can be charged no more than what they would have paid if the service were performed by an in-network provider.

Insurer Payment Of Providers

Rather than prescribing the payment rate from insurer to provider for surprise out-of-network services, Hassan’s bill sets up a binding, “baseball-style” arbitration process to resolve payment disputes if the two parties are unable to agree on a payment amount. In this process, the insurer and provider each make a final offer and an independent arbiter contracted by government then chooses which of the two options it considers more reasonable. The theory behind this approach is that it incentivizes each side to make a reasonable offer or settle beforehand, because the arbiter is unlikely to choose an unrealistic offer. Making the results of these arbitration decisions public, as this bill would do (and as New Jersey’s new law does), further facilitates settlement before going to arbitration as both parties learn to anticipate what rate the arbiter would choose.

The legislation provides guidance to the independent arbiter to consider the relevant Medicare payment rate and the local average in-network rate, in addition to the level of training of the physician and complexity of the service, when determining which offer to select. The bill makes no reference to provider billed charges, which tend to be extremely high and are largely untethered from market forces.

Alternatively, Hassan’s legislation allows states to establish their own arbitration process, as New York, New Jersey, Illinois, and New Hampshire have done, as long as the state process is equally protective and the arbitration results are made public. Or states can elect a defined payment standard in place of the binding arbitration process, as long as it is no higher than 125 percent of the relevant Medicare rate or a comparable standard at the Secretary of Health and Human Services’ discretion.

Senator Hassan’s bill improves options for states because currently they are unable to protect patients enrolled in self-insured employer health plans due to pre-emption by the Employee Retirement Income Security Act (ERISA).

Representative Michelle Lujan Grisham’s Fair Billing Act of 2017 also proposes a similar arbitration approach, as did our 2016 white paper, which dives into significantly more detail.

It is necessary to determine a limit on payments to out-of-network providers to provide comprehensive protections against surprise billing to patients without giving providers the unfettered ability to charge whatever they want. The advantage of the binding arbitration approach is that it encourages each side to submit reasonable offers, allows for some flexibility in the rate chosen for differing circumstances, and gives the involved parties more input into what that rate should be than a rate chosen by policymakers or regulators. On the other hand, the binding arbitration approach adds administrative burden to the process, although this could be mitigated over time as the arbitration decisions are made public, which provides more guidance for settlement. Nonetheless, it’s not necessarily clear that the arbiter will always choose the “right” rate or be any better at selecting an appropriate rate than lawmakers.

Yale Professors Zack Cooper and Fiona Scott Morton have recommended an alternative approach. They suggest requiring hospitals to pay emergency and ancillary physicians directly, and to build those costs into their facility rate negotiated with health plans. This approach would more explicitly use the market to determine fair payment rates.                  

Areas For Further Consideration

The No More Surprise Medical Bills Act should be applauded for tackling an important problem in a thoughtful manner. As written, Hassan’s bill would nearly eliminate surprise out-of-network bills for enrollees in employer-provided health plans.

As lawmakers work to refine this legislation, they should consider expanding protections to enrollees in individual market plans and for out-of-network ambulance services. One study found that roughly half of all ambulance rides were billed out-of-network.

Additionally, the notice and consent exceptions in the bill are arguably both too broad and too narrow in parts. It is unclear that out-of-network physicians at nonparticipating hospitals should have to obtain patient notice and consent for nonemergency care before billing out-of-network. And on the flip side, for patients at in-network facilities, it may be inappropriate to ever permit out-of-network billing for ancillary services (e.g., anesthesia, radiology, pathology) because there is too great a risk that patients will sign any such consent forms without true understanding or consideration of reasonable alternatives.

Author’s Acknowledgement:

This analysis is part of the USC-Brookings Schaeffer Initiative for Health Policy, which is a partnership between the Center for Health Policy at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings. Through a grant from the Laura and John Arnold Foundation, Brookings is working to critically evaluate the prevalence, drivers, and policy implications of surprise medical billing, as well as develop potential nonpartisan policy solutions.

Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

Interesting continued coverage of activities related to balanced billing for air ambulance, including the perspective of the anonymous consultant regarding the payment amount vs. costs…

Congress angles for air ambulance cost transparency

BY SUSANNAH LUTHI 

OCTOBER 2, 2018

Last November, a fully insured North Dakotan was dispatched on an 84-mile medical air transport from Langdon, N.D., to Grand Forks. When the charges came in at more than $66,000, out-of-network insurance covered just $16,000.

The patient was left with a $50,000 bill balance from Valley Med Flight. The tab far exceeded the $29,000 to $30,000 average price for a cross-country charter flight on a private midsize jet from Virginia to Oregon—according to an informal estimate by the charter company EvoJets.

According to tallied complaints lodged with the state's insurance department and provided by Blue Cross and Blue Shield of North Dakota, surprise charges for various medical flights from the past four years ranged from $26,000 to nearly $534,000—although the latter number is a major outlier. Most charges fell between $30,000 and $88,000, with the average hovering around $60,000.

One North Dakotan had a lien placed on their home. Another had wages garnished. Families have gone into bankruptcy.

"They have health insurance, but no control over who picks them up," said Jeff Ubben, the state's deputy insurance commissioner.

Like other states, North Dakota has tried to curb the unexpected bills. In 2015 the Legislature passed a law to split the medical air transport companies into two call lists. To make it on the primary call list, the company would have to be in-network with at least 75% of the state's health insurance contracts. All others would have dropped to a secondary call list and would only have been able to respond if none of the companies from the primary list picked up.

In 2016, a federal judge struck down the law after Valley Med Flight sued, just as federal judges around the country have struck down similar state measures for violating the Airline Deregulation Act of 1978. This federal law bans states from regulating rates, routes or services of commercial airlines and continues to overrule state efforts to rein in air ambulance charges.

Valley Med Flight is one of North Dakota's largest medical transportation companies, re-branded this year as Guardian Flight. As a subsidiary of Air Medical Group Holdings, which is owned by the global investment firm KKR, it is one of several sister air ambulance companies operating in the U.S.

Air Medical Group Holdings did not respond to requests for comment.

In 2017, North Dakota tried to tackle air ambulance billing again from a different angle, this time limiting out-of-network insurance reimbursements for these claims. If a person is transported by an out-of-network air ambulance, the transport company must accept the rate of an in-network carrier.

Guardian Flight sued, but the case is still pending in federal court in Bismarck. Ubben told Modern Healthcare his office hasn't received consumer complaints since it went into effect in January of this year.

But Congress would need to change the law to allow states to regulate the charges. Sen. Claire McCaskill (D-Mo.) pushed a bill this year to clarify that the 1978 statute could not prevent states from regulating the medical costs from air ambulances.

Provisions from her proposal made it into the latest Federal Aviation Administration reauthorization bill expected to clear Congress this week, but ultimately lawmakers dropped the crucial measure that would allow states to address the consumer cost question.

The final compromise provision requires the U.S. Transportation Department and HHS to convene an advisory committee of stakeholders to examine transparency measures, consumer education about insurance options for air transport and protections from excessive charges.

Air ambulance companies would also need to list the Transportation Department's complaint hotline and website address on all bills. The Transportation secretary would have to set an industry oversight plan and write guidance for states on how to refer billing complaints.

The provisions concur with some 2017 recommendations from the U.S. Government Accountability Office, which called for greater price transparency and better handling of consumer complaints.

Insurers, insurance commissioners, patient advocates and the medical air transport industry herald the measure as "a step in the right direction," but it's unclear just how significant that step will be.

The Transportation Department already oversees and handles consumer complaints on air transport, but close observers of the balance billing issue say the current process doesn't support patients stuck with tens of thousands of dollars of debt.

"The Department of Transportation has regulatory authority and can determine whether the practices of any airline are fair or unfair, but they don't have expertise on medical billing practices," said Julie Mix McPeak, president of the National Association of Insurance Commissioners and Tennessee insurance commissioner. The association has been working on the issue for the past three years. "However, the department has yet to take action, and states are barred legally from doing so."

The Association of Air Medical Services, or AAMS, the lobbying group for air ambulance companies, supports the final provision as a balanced approach.

"We believe the formation of the advisory committee of stakeholders tasked with solving the complex issue of balance billing is a definite step in the right direction," the group said in a statement. "AAMS advocates for any effort to increase transparency to ensure our patients are not burdened by a bill that they did not expect and cannot afford."

But ultimately the trade group blames the high balance bills on what they deem as inadequate Medicare reimbursements. The AAMS compares the air transport companies' net financial position with that of rural hospitals serving mostly government-insured or uninsured patients.

The AAMS wants Congress to look at recalculating the air ambulance Medicare reimbursements, claiming it's "the only lasting solution" to protect air medical services, especially in rural areas.

Both the House and Senate have introduced bills that would launch this effort, which are supported by the AAMS.

Medicare's base pay for a single helicopter transport is $4,624, then an additional $31.67 per mile. According to data from the CMS, Medicare reimbursement for a typical 61-mile trip is about $6,556.

The AAMS says that based on an independent study by the consulting firm Xcenda, Medicare covered 59% of actual costs in 2015.

But one consultant, who spoke on condition of anonymity, pushed back on companies' claims that their charges correlate to their Medicare reimbursements. He said that the Medicare fee schedule, which moved reimbursements for air ambulances from Medicare Part A to Part B, favored the air ambulance industry when they were set in the early 2000s.

He argued that the industry's claims about compensating for Medicare rates through high commercial and balance bill charges "are more related to underutilization and overcapacity."

"In 1997 there were about 350 helicopters doing this," he said. "Today there are over 1,100."

He estimated that Medicare pays for about one-third of these flights, commercial plans pay another one-third and Medicaid covers roughly 20% of the rest.

"When two-thirds of customers paid at a rate that's favorable, the companies tripled the number of helicopters," he said, adding that the industry's ability to spread its fixed costs over a large number of transports is reduced because there are too many transports.

"The problem is not that operating costs have dramatically increased; rather, companies cannot spread those costs over a reasonable number of flights," he said. "The industry then attempts to use this self-inflicted situation as justification for their extravagant billed charges."

Aaron Todd, CEO of the operator Air Methods Corp., acknowledged in a 2015 investor earnings call that the number of transports may exceed market need.

"And if you ask me personally, do we need 900 air medical helicopters to serve this country, I'd say probably not, maybe 500, 600 could do well, but it's an open market, these are—we don't have certificate-of-need restrictions," Todd said, according to the call transcript.

One insurance lobbyist, who characterized the air ambulance market as "the wild West," complained of the sometimes aggressive ways companies find patients in the limited pool.

"I've seen air ambulances following the police radio and showing up at the scene of an accident," the lobbyist said. "They have all sorts of tactics to get called."

Analysis of one company's data shows the number of medical air transports per base has declined as those bases have proliferated. 

According to numbers gleaned from past annual reports by Air Methods Corp.—one of the largest providers and publicly traded until a private equity firm bought the company last year—69 bases sent out about 39 transports each per month in 2005. In 2013, 179 bases each sent out about 25 transports per month. The company's annual number of total transports during that period increased from nearly 32,000 to just over 53,000.

Rising operational costs for the air transport companies were the result of business decisions, the consultant said. "No one forced it; they just did it by themselves."

He also said transport services develop relationships with the providers who dispatch patients from one facility to another for care. About 80% of transports send a patient from one facility to another, rather than airlifting a person from the scene of an accident.

Even if they don't have a referral relationship with the air transport company, the consultant added, hospitals don't necessarily watch out for the patients' wallets since it isn't their money.

"Again, you don't have a market where buyers or sellers are agreeing to buy some quality or quantity," he said. "None of this is a market situation."

NYT Source Article | Comments Courtesy of Matt Zavadsky

Another example of the ‘value’ challenge of traditional “EMS”. 

Recall that Dr. Elisabeth Rosenthal (now the Editor in Chief of Kaiser Health News) also did an article in the NYT about the value of EMS, and she also did a video interview on the same topic…

• http://www.nytimes.com/2013/12/05/health/think-the-er-was-expensive-look-at-the-ambulance-bill.html
• http://www.businessinsider.com/think-twice-before-taking-ambulance-hospital-elisabeth-rosenthal-insurance-bills-healthcare-hospital-emergency-2017-4

Contrast the message in recent media reports in publications, such as the NYT and Washington Post, extolling the value of “EMS 3.0” MIH services such as community paramedicine, alternate destinations and 9-1-1 nurse triage. 

• http://www.nytimes.com/2016/11/08/health/older-patients-community-paramedics.htm
• http://www.wsj.com/articles/the-revolution-in-ems-care-1474855802
• http://www.wsj.com/articles/paramedics-aren-t-just-for-emergencies-1439832074

These vastly different perceptions of ‘value’ are likely why many EMS agencies are implementing MIH services, and many payers are moving quickly to pay for EMS patient navigation as opposed to being paid simply as a conveyance mechanism!

Tip of the hat to Jonathan Washko from Northwell Health for sending along yesterday’s NYT article!

Uber, Lyft and the Urgency of Saving Money on Ambulances

‘Don’t reflexively call an ambulance,’ a Harvard researcher says. In many cases, a cheaper way makes sense.

THE NEW HEALTH CARE

By Austin Frakt

Oct. 1, 2018

An ambulance ride of just a few miles can cost thousands of dollars, and a lot of it may not be covered by insurance. With ride-hailing services like Uber or Lyft far cheaper and now available within minutes in many areas, would using one instead be a good idea?

Perhaps surprisingly, the answer in many cases is yes.

The high cost of an ambulance isn’t really for the ride. It comes with emergency medical staff and equipment, and those can be very important, of course, even lifesaving.  But they are not things you always need, although you (and your insurer) pay for them with every trip.

“Don’t reflexively call an ambulance,” said Anupam Jena, a physician and researcher with the Harvard Medical School. “Ambulances are for emergencies. If you’re not having one, it’s reasonable to consider another form of transportation.”

The cost of ambulance rides adds up. In 2011, the United States spent about $14 billion on ambulance services, $5.3 billion of which Medicare paid for. Many of those trips might not have required an ambulance. Estimates of inappropriate use vary, but most are around 30 percent.

Although it’s not always clear when an ambulance is warranted, there is evidence of waste and fraud in the industry.

Last year, ambulance companies collectively billed Medicare improperly for at least $700 million.

In 2014, employees of a Philadelphia-area ambulance company received prison sentences for fraudulent bills. That same year, the owners of a Tennessee company were convicted of fraudulent ambulance billing. A 2015 O.I.G. report found that half of questionable billing of Medicare by ambulance companies is from four metropolitan areas: Philadelphia, Los Angeles, Houston and New York.

Other recent evidence from New York suggests a substantial number of ambulance rides are taken for non-emergencies. Scholars from Georgia State University and the University of Colorado Denver studied ambulance rides in New York before and after the Affordable Care Act’s coverage expansion. After the expansion, dispatches for minor injuries rose considerably while those for more severe ones did not.

By 18 months after the expansion, ambulance dispatches for minor injuries were up 150 percent.  An explanation for the results is that a person’s insurance coverage tends not to affect a decision about calling an ambulance in a real emergency. But for minor injuries, people are more likely to call an ambulance if they have coverage than if they do not, even if they don’t really require that level of care.

Using an ambulance also diverts attention and resources from true emergencies. Response times are longer than they could otherwise be if ambulances were used only when needed. One study found that the Affordable Care Act, by expanding coverage and financial access to ambulance rides, slowed ambulance response times by 19 percent.

Uber and Lyft can’t disobey traffic laws the way ambulances can to speed people to a hospital in urgent situations. But they can broaden transportation options for patients and could disrupt the ambulance market. Both have announced new services to provide rides to medical appointments. This kind of non-emergency medical transportation is something many health plans already provide, but Uber and Lyft may be able to do it more cheaply, with better customer service and less waste.

Uber Health would allow health care providers to order rides for their patients. As of March, over 100 health care organizations were using the service. Lyft Concierge is similar and already being used by a number of organizations that arrange rides for people in need of care.

Of course, patients can request Uber or Lyft rides on their own, instead of an ambulance. And these services could help patients avoid missing appointments because of lack of affordable transportation. They may also help patients receive care in more appropriate and lower-cost settings, like a doctor’s office instead of an emergency department. One study found that Uber’s entry into a city reduced ambulance use by 7 percent.

An advantage of arranging your own ride is that you can direct it to a hospital or doctor’s office of your choosing. In contrast, ambulances take patients only to hospitals — and typically to the nearest one, whether the patient would prefer that or not.

This can actually degrade care. Evidence suggests that patients who return to the hospital where they received major surgery have a lower risk of mortality than if they go to another hospital. With an ambulance, there is no guarantee you’ll return to the same hospital.

Although lack of affordable transportation is one barrier to care, it isn’t the only one. A randomized study of Medicaid patients at two Philadelphia-area clinics found that offering Lyft rides did not change missed appointment rates. Patients may miss appointments for other reasons, such as being unable to get off work or to obtain child care.

“We often use higher-intensity care more than necessary throughout our health system,” Dr. Jena said. “Ambulance rides in non-emergencies is just one example.”

For some, the financial setback of an ambulance trip can be immense. An alternative choice for non-emergencies could save a person thousands of dollars and help reduce waste in a system rife with it.

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health.

Health Affairs Source Article | Comments Courtesy of Matt Zavadsky

Interesting counsel from the authors, and, interesting reference to the transport policies in Philly…

When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply?

Sara F. Jacoby  Elinore J. Kaufman  Therese S. Richmond  Daniel N. Holena

OCTOBER 1, 2018

https://www.healthaffairs.org/do/10.1377/hblog20180926.69826/full/

At the University of Utah Hospital last October, a nurse was arrested when she refused to draw blood from an unconscious patient for a police officer who was lacking a legal warrant. Surveillance footage of her arrest and rough treatment drew national media attention. As a consequence, the police officer involved was fired from his job, and the hospital issued a policy that now bans law enforcement activities in patient care areas of its medical center. The Utah Legislature responded as well by passing a bill to outline conditions under which police can obtain blood samples from patients for investigative purposes. 

This case may have been extreme, but conflicts between clinicians and police are not uncommon. Emergency departments are arguably an epicenter of opportunity for this kind of conflict. It is in these clinical settings that intersections between health care and law enforcement activities are most frequent, for example, when police respond to medical emergencies or seek information to inform emerging criminal investigations. The challenge of these interactions is that clinicians and police have distinct professional priorities, and there is notable ambiguity in how best to interpret guiding policy and ethics. 

Clinicians And Police Have Intersecting But Potentially Conflicting Responsibilities 

Traumatic injuries, such as gunshot wounds or motor vehicle crash injuries, are conditions that attract both health care and law enforcement responses. In these circumstances, clinicians and police share a mandate to protect injured people and public safety. However, the police mission to initiate an investigation and solve crimes may compete with the urgency of emergency health care, which is built on protocol-driven systems for rapid diagnosis, medical stabilization, and triage. 

Injured people, themselves, are rarely in a position to advocate for their own medical and legal needs during emergency care. Traumatic injuries can cause physiologic and psychological alterations that limit the ability to fully consent to medical procedures and legal interrogation. Once a person is transported from the scene of an injury and into a health system, health care ethics and laws obligate clinicians to offer help and guardianship. This includes protection of privacy over health information and patients’ autonomy in decisions that affect health and well-being. 

A Complex Policy Landscape With No Clear Oversight 

To date, there are no universal cross-disciplinary policies from which to outline clear expectations for interactions among trauma patients, clinicians, and police in health care institutions. The American College of Emergency Physicians published a statement in 2010 that reinforces the primacy of patients’ rights, dignity, and interests when law enforcement activities take place in health care institutions. Members of the emergency medical community have subsequently advocated for the creation of explicit policy guidance for these activities and offer a sample policy for implementation. Enacting, operationalizing, and auditing compliance to these policies is/would become the responsibility of individual health care systems. This is not necessarily a simple pursuit. In doing so, health systems will need to consider and integrate their own institutional policies and practice norms with relevant but potentially inconsistent federal, state, and local policies. 

The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 prohibits clinicians from releasing information about patients to police without consent or a court-ordered warrant. Exceptions are made when: required by law (that is, state-mandated reporting), where criminal conduct is suspected (as a cause of a patient’s death or during medical care), or to avert a serious threat to public health or safety.

In addition, a 2003 US Supreme Court ruling affirmed the constitutionality of police seeking testimony for a criminal investigation during emergency medical care when an injured non-Mirandized patient was suspected of a crime. 

State laws may actually necessitate interactions between clinicians and police after a traumatic injury, but the conditions for mandated interactions can vary from state to state. In most states, clinicians are required to report evidence of child and elder abuse. In several but not all states, clinicians are also required to report any suspicion of assault, domestic violence, or drunk driving associated with an injury. 

At a local level, municipal policies can influence the ways that clinicians and police interact in response to injuries. In Philadelphia, Pennsylvania, for example, where the rate of violent injuries outpaces the resources available for emergency medical systems, the city permits police to provide direct transport to the nearest accredited trauma center. As a result, a substantial proportion (more than 50 percent in recent years) of patients with penetrating wounds such as gunshot injuries arrive at Philadelphia trauma centers in police vehicles. Across national trauma systems, police transport has been shown to be as effective as ambulance transport and is believed to be a lifesaving intervention for cities with high rates of injuries and proximity to the resources of trauma centers. At the same time, this practice creates opportunities for police to question patients en route to a hospital and offers a direct pathway for law enforcement activities within trauma center emergency departments. 

Lack Of Clear Policies Can Put Patients And Clinicians In Vulnerable Positions 

The danger of the current policy landscape is that any interpretive ambiguities can result in ad hoc negotiations for when, where, and how law enforcement activities take place in health care institutions. This may lead to unintended, informal, and even illegal access to patients and disclosures of their health information to police. It can also promote interprofessional conflict and negative clinical outcomes. If, for example, patients can’t differentiate between questioning in the service of law enforcement and questioning in the service of medical care, they may be reluctant to communicate essential information to their health care team. Our recent research describes how black patients in a Philadelphia trauma center express conflicted interpretations of their interaction with police during emergency injury care. Some perceived police to be acting in their best interest by offering security and expediting transport to the hospital. Others found police questioning as an added stressor and disruption to the medical interventions they felt were essential for their survival. Victims of gun violence in Chicago describe similar impressions of their interactions with police in the aftermath of their injuries. 

The diversity of federal, state, and local polices make it difficult to imagine a singular rule of conduct for all law enforcement activities in health care settings. Professional trauma surgery and nursing societies, however, have the opportunity to articulate the need for boundaries and necessary considerations when law enforcement activities take place within US trauma centers. One pathway toward leadership in this area would be for entities such as the American College of Surgeons Committee on Trauma, which accredit US trauma systems, to mandate and audit compliance to individual institutional policies. Not only would this present the opportunity to better protect injured patients, clarify professional role expectations, and prevent conflict, it would also better prepare legal counsel and ethical consult teams to support clinicians in cases of difficulty in policy interpretation. 

Balancing Patients’ Rights And Health With Clinicians’ Rights 

As institutional policies are developed, the process should ideally integrate multiple stakeholders including community members, police, and a full range of health system actors. There may also be benefit to bringing multiple institutions and sectors together with the leadership of city or state health departments to consider policy interventions that guide intersections between emergency health care and law enforcement that can account for local needs, resources, and environments. Although institutional context may vary, we recommend three core policy goals: 

1. Policies that guide law enforcement activity in health care institutions should make patient health the first priority. Except in extreme cases of public safety risk (active shooter threats, terrorist events, and so forth), law enforcement officers should not interview patients until they are medically stabilized as determined by treating clinicians. Health care institutions and law enforcement agencies should also work together to clearly define how patients who are under arrest or incarcerated are managed in the emergency department to permit clinicians the opportunity to provide the same standard of medical treatment as would be offered to any patient in their care.
2. Patients’ rights are the next priority. Therefore, except as above, law enforcement officers should not interview patients until they are mentally ready to understand and participate (stable, not overly sedated or narcotized). Patients should also have access to appropriate legal counsel at all times, even if this delays questioning. Hospitals and local law enforcement and legal communities should set up systems to facilitate representation.  
3. Although health care personnel are not legal experts, they have a responsibility to protect patients’ health and rights and should be educated about guiding policies and feel empowered to step in as needed. Following the example of University of Utah Hospital, health care institutions need to put into place structures and processes to accomplish these goals. 

Programmatic crossroads between law enforcement and injury and emergency care will likely continue to increase in response to looming public health threats. The Stop the Bleed campaign to prevent death after trauma and Naloxone distribution to prevent the consequences of opioid overdoses are two prominent examples in which health care and law enforcement providers are interacting to promote public health priorities outside of the hospital. While challenging, developing policy to extend cross-disciplinary collaboration within emergency department settings in a way that protects the rights and well-being of patients, health care providers, and the public is an ethical imperative. 

Authors’ Note

All authors are senior fellows of the Leonard Davis Institute (LDI) of Health Economics at the University of Pennsylvania. Support for this work was provided by the LDI Policy Accelerator Program.

Comments from Matt Zavadsky

Governor Edmund "Jerry" Brown vetoed the California Community Paramedic legislation late yesterday…

In his ‘veto message’ back to the stakeholders (attached), Governor Brown states:

• His support for CP programs
• His concerns with the restrictions in the Bill
• Authorizes the continuance of the pilots, and
• Urges the stakeholders to find a way to make CP permanent in California, without the restrictions contained in AB 3115

Tip of the hat to Lou Meyer, the loaned executive from the California Healthcare Foundation to the California Emergency Medical Services Authority, for making us aware of this breaking news. 

The CHCF is a major supporter of Community Paramedic program development in California.

Please support Lou, Dr. Howard Backer and the State EMS Authority, and the numerous other stakeholders in supporting the further development of CP programs for California!

• September 30, 2018 Legislative Update
  
• California AB-3115 Community Paramedicine or Triage to Alternate Destination Act Bill Text
• California AB-3115 Veto Message

JAMA Source Article | Highlights courtesy of Matt Zavadsky

Original Investigation
September 26, 2018

Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies

JAMA Cardiol. Published online September 26, 2018. doi:10.1001/jamacardio.2018.3037

Masashi Okubo, MD, MS¹; Robert H. Schmicker, MS²; David J. Wallace, MD, MPH^1,3; et al Ahamed H. Idris, MD^4,5; Graham Nichol, MD, MPH⁶; Michael A. Austin, MD⁷; Brian Grunau, MD⁸; Lynn K. Wittwer, MD⁹; Neal Richmond, MD¹⁰; Laurie J. Morrison, MD, MS¹¹; Michael C. Kurz, MD¹²; Sheldon Cheskes, MD¹¹; Peter J. Kudenchuk, MD¹³; Dana M. Zive, MPH¹⁴; Tom P. Aufderheide, MD, MS¹⁵; Henry E. Wang, MD, MS¹⁶; Heather Herren, MPH²; Christian Vaillancourt, MD⁷; Daniel P. Davis, MD¹⁷; Gary M. Vilke, MD¹⁷; Frank X. Scheuermeyer, MD⁸; Myron L. Weisfeldt, MD¹⁸; Jonathan Elmer, MD, MS^1,3; Riccardo Colella, DO, MPH¹⁵; Clifton W. Callaway, MD, PhD¹; for the Resuscitation Outcomes Consortium Investigators

Author Affiliations Article Information

JAMA Cardiol. Published online September 26, 2018. doi:10.1001/jamacardio.2018.3037

Key Points

Question  What is the variation in survival after out-of-hospital cardiac arrest between emergency medical services (EMS) agencies?

Findings  In this cohort study, among 43 656 adults treated for out-of-hospital cardiac arrest by any of 112 EMS agencies, there was a median difference of 56% in the odds of survival to hospital discharge for similar participants between any 2 randomly selected EMS agencies, after adjusting for known measured sources of variability and clustering of patients within agencies.

Meaning  This study suggests there is substantial unexplained variation in survival after out-of-hospital cardiac arrest across treating EMS agencies in North America, despite controlling for documented patient and agency characteristics.

Abstract

Importance  Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood.

Objective  To quantify variation in patient outcomes after OHCA across EMS agencies.

Design, Setting, and Participants  This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018.

Exposure  Treating EMS agency.

Main Outcomes and Measures  The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies.

Results  We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency–level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]).

Conclusions and Relevance  We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency–level variables.

News Release

FOR IMMEDIATE RELEASE

Contact:             Mitzi Vince

Phone:                 (304) 346-9864, ext. 3253

E-mail:                 mvince@qualityinsights.org

CHARLESTON, WV (September 20, 2018) – Quality Insights has partnered with the Kanawha County Emergency Ambulance Authority (KCEAA), the Partners in Health Network and Jan Care to produce two educational videos on the impact of community paramedicine in West Virginia.

Community paramedicine (CP) is a form of expanded care – often referred to as mobile integrated health care services – that is delivered by nationally-registered paramedics who have received additional training. CP has been shown to help lessen unnecessary hospital admissions and emergency department visits while enhancing access to quality care for the state’s most vulnerable and rural residents.

“We teamed up with community paramedicine experts in our area to produce these videos as a way to help both patients and healthcare providers understand the positive impact of CP on people with Medicare who live in West Virginia,” Biddy Smith, Network Task Lead for Special Projects at Quality Insights, said.

The videos, which are available on Quality Insights Quality Innovation Network’s YouTube channel (www.youtube.com/qualityinsightsqin), include a patient-focused video titled “Community Paramedicine: Quality Health Care at Your Door” that explains the benefits of CP from the patient perspective. A provider- focused video, titled “Community Paramedicine: Enhancing Access to Quality Health Care,” examines the impact of CP on the healthcare industry.

“Community paramedicine is filling a gap of needs within our communities,” Monica Mason, Director of Community Paramedicine at KCEAA, said. “Once patients are discharged from the hospital, our paramedics go out into the home and visit them to ensure that the plan of care from the hospital is continued to the home until they get back to their doctor’s office for follow-up and further recommendations.”

Like Mason, fellow advocate Jerry Long believes community paramedicine can have a positive effect on decreasing overall healthcare costs by treating patients before they need to call 9-1-1.

“I always felt like there was something more we could be doing,” Jerry Long, Director of Mobile Integrated Healthcare/Community Paramedicine at Jan Care, said. “We’re the second most rural state in the country. Our biggest healthcare crisis, in my opinion, is access. There are a lot of people still using emergency rooms as their primary care physician and that’s just a flawed system.”

A community paramedic can address both medical and social needs. Community paramedics can provide home safety assessments, triage and referral services, chronic disease management education, support for family caregivers, medication compliance support, vaccinations and more.

“It’s our hope that these videos can communicate the benefit of CP, not just for the patient, but also for the healthcare industry as a whole,” Smith said. “We want patients to understand how it can help improve their quality of life and we want providers to understand how CP is filling critical gaps in an effective and efficient way.”

For more information about this project, contact Biddy Smith at bsmith@qualityinsights.org, or call (304) 346- 9864 ext. 3252.

About Quality Insights Quality Innovation Network

Quality Insights is the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Delaware, Louisiana, New Jersey, Pennsylvania and West Virginia. Quality Insights collaborates with healthcare providers, patients and allied organizations across the network to bring about widespread, significant improvements in the quality of care they deliver. We are committed to reaching the Centers for Medicare & Medicaid Services' goals of better care, smarter spending and healthier people. To learn more about the network, visit  www.qualityinsights-qin.org.