News & Updates

Lack of privacy affects accurate diagnosis of medical conditions and beyond

Thomson Reuters Mar 01, 2018

Patients are more likely to be misdiagnosed or experience treatment delays when emergency rooms are so crowded that they receive care in a hallway, a survey of physicians suggests.

Privacy and confidentiality are vital in emergency care, particularly for patients who may be reluctant to undress or divulge sensitive personal information in front of companions in an exam room or strangers in a hallway, researchers note in the Emergency Medicine Journal.

To see how doctors think this lack of privacy affects care, researchers surveyed 440 emergency room physicians attending a medical conference in Boston in 2015.

“What we found is that these non-private encounters not only affect the accurate diagnosis of medical conditions, but also of social and behavioral conditions such as domestic violence, human trafficking, suicidality, and substance use,” said lead study author Dr. Hanni Stoklosa, an emergency physician at Brigham and Women’s Hospital and Harvard Medical School in Boston.

“This is quite concerning on many levels because emergency departments are on the front lines of caring for patients most vulnerable to these conditions,” Stoklosa said by email.

Overall, nine in 10 doctors surveyed said they changed or shortened how they took patient medical histories when another person was present, and more than half of the physicians also altered how they did physical exams.

More than three-quarters of the doctors said that, at least sometimes, they did an abbreviated medical history when patients were treated in hallways. Under these circumstances, nearly all of the doctors also reported sometimes, often or always changing how they conducted physical exams.

Even when patients had an exam room, nearly all of the doctors said they at least occasionally altered how they gathered medical histories or conducted physical exams when a friend or family member was present.

While most physicians said patient gender wasn’t a factor, doctors were more likely to change how they did medical histories and exams for female patients, the study also found.

Changes to medical histories and exams were most common with genital and urinary problems, the study found.

Missed cases
Only 26 per cent of doctors said taking an abbreviated medical history had not led them to fail to diagnose a social issue like suicidal thinking or elder abuse, while 54 per cent said changes in a physical exam due to lack of privacy had not caused them to miss such issues.

But more than one-third of doctors said they had missed cases of domestic violence under these circumstances, while
about 12 per cent had overlooked instances of child abuse.

In addition, 47 per cent of doctors thought a shortened medical history was linked to missing substance abuse and 25 per cent said an altered exam had this result.

The study wasn’t a controlled experiment designed to prove whether or how care in hallways or without privacy might lead to delays or misdiagnosed patients. It also focused only on the opinions of doctors at a medical conference, and results might differ with a broader, nationally representative group of emergency physicians.

Even so, the results add to evidence that the environment or surroundings in which patients are cared for may influence their treatment, said Dr. Bernard Chang, a professor of emergency medicine at Columbia University Medical Center in New York City.

“Past work has found that patients treated in overcrowded emergency departments often have delays in medical care and increased risk of medical errors,” Chang, who wasn’t involved in the study, said by email.

A lack of privacy may at least partially explain this increased risk.

“While an ideal situation would be for patients to have their own private space to talk with their providers, in the emergency department, patients are often seen in crowded and at times high stress situations, and the ability to get a private room may just not be practically feasible,” Chang said.

“Patients should recognize that they always have the right to request some space to discuss private matters away from other individuals with their doctor,” Chang added. “It may not mean that they will always get a private room, but most emergency staff will make their best effort to at least temporarily find a place to discuss sensitive topics in a space away from potentially prying ears.”

Related articles:

Why adding beds might not solve the problem of ‘hallway medicine’ anytime soon

Patients needing admission to hospital stuck in ER longer, report says

By Matt Kuhrt | Mar 6, 2018

HHS Secretary Alex Azar outlined four priorities for the agency this week, and accelerating the path to value-based payment systems and reducing healthcare costs are at the top of his list.

In remarks given to the Federation of American Hospitals on Monday, Azar delivered a blunt message.

“Today’s healthcare system is simply not delivering outcomes commensurate with its cost,” he said.

Despite recent advances in areas such as personalized medicine and cell therapies, he said, chronic diseases, including opioid addiction and high healthcare costs are still big problems.

While the administration has expended its efforts to repeal parts of the Affordable Care Act, Azar stated unequivocally that there would be “no going back to a system that pays for procedures rather than value,” and promised that the administration has no fear of disrupting current arrangements, regardless of the special interests backing them.

He also indicated a willingness to embrace “perhaps even an uncomfortable degree” of federal intervention in order to make the system work better for the stakeholders he sees as least well-served currently: patients and taxpayers.

The secretary outlined four broad shifts in policy that he said will accelerate the move toward a system that rewards value:

1. Moving ownership and control of electronic health records from providers to patients.

Azar said lack of interoperability among current systems is the main barrier to patients’ ability to take control of their own healthcare information.

1. Providing payers and providers with incentives to be more transparent about healthcare costs.

The increasing prevalence of high-deductible insurance plans have made consumer awareness of the cost of their care much more important, according to Azar.

He called on doctors, hospitals, drug companies and pharmacies to get more transparent about their costs and outcomes. If they fail to do so, he promised that the federal government has “plenty of levers to pull that would help drive this change.”

1. Using Medicare and Medicaid to drive industry change.

Calling the results of previous efforts to drive innovation such as efforts around affordable care organizations “lackluster,” the secretary promised “bold measures” that will “create a true competitive playing field where value is rewarded handsomely.”

1. Reducing regulatory burdens.

Azar promised that the government would address any regulatory burdens that impede progress toward value-based care provision.

He particularly singled out reporting rules and FDA policies around communications that he said might inhibit collaboration among stakeholders.

By Shelby Livingston  | March 7, 2018

The nation’s largest health insurer, UnitedHealth Group, is following rival Anthem’s footsteps with a new payment policy aimed at reducing its emergency department claims costs.

Under the policy, rolled out nationwide March 1, UnitedHealth is reviewing and adjusting facility claims for the most severe and costly ED visits for patients enrolled in the company’s commercial and Medicare Advantage plans.

Hospitals that submit facility claims for ED visits with Level 4 or Level 5 evaluation and management codes—codes used for patients with complex, resource-intensive conditions—could see their claims adjusted downward or denied, depending on a hospital’s contract with the insurer, if UnitedHealth determines the claim didn’t justify a high-level code.

Minnetonka, Minn.-based UnitedHealth said the policy is meant to ensure accurate coding among providers. But hospitals fear the policy could squeeze reimbursement even further and lead to lower revenue.

UnitedHealth’s policy is different from Indianapolis-based Anthem’s, which has been denying coverage for ED visits that it decides were not emergencies after the fact. But both policies are aimed at lowering the insurers’ spending on ED claims. Taken together, the two insurers’ emergency department payment policies could represent a very real threat to providers’ bottom lines.

“Some hospitals are going to be hit financially, are going to be paid less, either through straight denials or through down-coding to a Level 3, and it is going to be a big hit for some hospitals on the ER revenue … unless they can truly justify they are providing the care or the services that’s really needed,” said Dr. Christopher Stanley, a director at consulting firm Navigant who worked for UnitedHealthcare for nearly a decade, regarding UnitedHealthcare’s ED policy.

While Anthem’s program is meant to ensure low-acuity conditions aren’t handled in the ED, UnitedHealth’s policy is focused on making sure payment for emergency department claims coded for the highest-acuity patients is justified.

UnitedHealth will be using its subsidiary Optum’s tool, the EDC Analyzer, to audit facility claims submitted with Level 4 and 5 codes after a patient visits the ED and is sent home. The Optum tool takes into account the patient’s medical issue, co-morbidities and the diagnostic services performed during the ED visit to determine what UnitedHealth believes is the appropriate code.

Emergency department facility fees are coded on a scale of 1 to 5, reflecting the complexity of care delivered and the amount of resources devoted to the patient. Level 1 codes are for low-acuity conditions, while Level 4 and 5 codes are for the most serious conditions that require lots of hands-on treatment, such as blunt trauma or severe infections. Higher codes are more expensive for insurers.

UnitedHealth’s policy applies to all facilities, including free-standing emergency departments, that submit ED claims with Level 4 and 5 codes for members of the insurer’s commercial plans and Medicare Advantage plans. A December 2017 bulletin published by the insurance company also said the policy applied to members enrolled in Medicaid plans in some states, but that’s no longer the case for now. It’s important to note that the policy does not affect charges for professional services.

UnitedHealth recorded $201.2 billion in 2017 revenue and serves 49.5 million members. Its commercial enrollment totals 29.9 million people, while its Medicare Advantage enrollment is 4.4 million.

There are a few exceptions to the policy. It does not apply to claims for patients who end up being admitted to the hospital from the ED, critical-care patients, patients younger than 2 years old, or patients who died in the ED. The policy also excludes claims with certain diagnoses that often require greater-than-average resources when treated in the ED, such as significant nursing time, according to a UnitedHealthcare bulletin.

“The goal of this revised policy is to ensure accurate coding by hospitals, and ultimately promoting accurate coding of healthcare services is an important step in achieving the triple aim of better care, better health and lower overall cost,” a UnitedHealth spokesman explained.

The policy came about because UnitedHealth said its claims data showed the frequency of claims with Level 4 and 5 severity codes by more than 50% from 2007 to 2016, the UnitedHealth spokesman said. The company estimates that the more frequent use of those codes has increased U.S. healthcare costs by more than $1.5 billion, while also causing patients to spend hundreds more in medical bills.

The American Hospital Association held a webinar with UnitedHealth in late February to explain the new policy to AHA members. An AHA spokeswoman said Thursday that the association is still reviewing the policy and does not yet have an official comment.

UnitedHealth expects only a small subset of hospitals to be affected by the policy, namely those facilities that have shown a lot of variation in what they assign the highest severity ED codes. For instance, one facility billed UnitedHealth $275 for a patient’s ED visit for a fever and assigned the visit a Level 2 code. Three years later, the same facility saw the same patient for another fever and coded the visit at a Level 4. The bill amounted to $1,200.

There is no national standard for hospitals to look to when coding ED visits. Instead, the CMS allows each hospital to set its own guidelines. Hospitals don’t like that UnitedHealth is imposing its own billing methodology on them.

While UnitedHealth said hospitals that experience claim adjustments or denials would be able to appeal the decision, providers argue that appealing the decision will be difficult and time-consuming because they don’t know the ins and outs of UnitedHealth’s proprietary algorithm for determining the appropriate code. For the same reason, they say they won’t know how to align their billing guidelines with UnitedHealth’s to ensure they aren’t downcoded.

“They’ve got this point system out there, but they’re not sharing what that point system is,” said Andrew Wheeler, vice president of finance at the Missouri Hospital Association. “So there’s no way for a hospital to duplicate what they’re suggesting the level of assignment should be.”

Hospitals worry that the policy will be yet another way for insurers to deny claims.

UnitedHealth said the claim adjustments won’t affect a patient’s cost-sharing, but providers argue that if a claim is denied outright, patients could be on the hook for the entire ED visit.

“It’ll just make it more difficult to collect for services, said Jim Haynes, chief operating officer at the Arizona Hospital and Healthcare Association.

Haynes said Arizona hospitals are already having difficulty getting bills paid for UnitedHealth plan members, and in some cases are seeing as many as 20% to 30% of claims submitted to UnitedHealth being denied, though not necessarily due to the new ED policy, he said.

Navigant’s Stanley, however, said the policy is a reasonable one to address increasing ED visits and the severity of the claims associated with those visits.

The number of ED visits per year has steadily climbed over time, reaching 141.4 million in 2014, up 8.4% from 130.4 million in 2013, according to the latest data from the Centers for Disease Control and Prevention.

Meanwhile, the use of Level 5 codes has increased, leading to increased ED spending.

A September 2017 report by the Colorado Center for Improving Value in Health Care backs up UnitedHealth’s data. The organization found that the use of high-severity Level 5 codes for ED visits increased to 33.5% of commercial claims in the state in 2016 from 23.1% in 2009. Meanwhile, the use of Level 4, 3, 2, and 1 codes all decreased over the same time period

Haynes said Arizona hospitals are already having difficulty getting bills paid for UnitedHealth plan members, and in some cases are seeing as many as 20% to 30% of claims submitted to UnitedHealth being denied, though not necessarily due to the new ED policy, he said.

Navigant’s Stanley, however, said the policy is a reasonable one to address increasing ED visits and the severity of the claims associated with those visits.

The number of ED visits per year has steadily climbed over time, reaching 141.4 million in 2014, up 8.4% from 130.4 million in 2013, according to the latest data from the Centers for Disease Control and Prevention.

Meanwhile, the use of Level 5 codes has increased, leading to increased ED spending.

A September 2017 report by the Colorado Center for Improving Value in Health Care backs up UnitedHealth’s data. The organization found that the use of high-severity Level 5 codes for ED visits increased to 33.5% of commercial claims in the state in 2016 from 23.1% in 2009. Meanwhile, the use of Level 4, 3, 2, and 1 codes all decreased over the same time period

First Published in EMS World Magazine  Dec 2016.

Demonstrating high performance and high value is becoming increasingly important to our evolving healthcare environment and changing community expectations. The financial sustainability—and perhaps even the very survival—of EMS may hinge on our ability to prove the services we provide are valuable.

Defining value in EMS has been relatively elusive, as clinical, operational and fiscal performance measures are often disparate from one system to another. But there are common hallmarks of high performance that any EMS agency can use to demonstrate value to stakeholders.

The Academy of International Mobile Healthcare Integration (AIMHI)—an association of EMS agencies committed to providing high-performance and high-value EMS and mobile healthcare services—is excited to partner with EMS World to produce a yearlong series of articles that will discuss the attributes of high-performance/high-value EMS system design and operations. The series will include topics such as:

• Attributes of high-performance EMS;
• International models of EMS system design;
• Using data to maximize operational efficiency;
• Financial analysis and new economic models;
• IT trends and cybersecurity in EMS;
• Managing a diverse workforce;
• Working with elected and appointed officials;
• Developing stakeholder relationships;
• Case studies and lessons learned in remote deployment centers.

The goal of the series is to assist EMS agencies in creating high-performance EMS processes and help demonstrate value to local community stakeholders.

—Matt Zavadsky, MS-HSA, EMT, Chief Strategic Integration Officer, MedStar Mobile Healthcare, Ft. Worth, TX

EMS systems of today, regardless of their design, face unprecedented challenges. Changing stakeholder expectations and rising financial pressures are driving a need to demonstrate that they provide value. Recent local and national media stories illustrate this shift in expectations and challenge the value equation the EMS profession has used for years.1–7

“Police transport a good bet for shooting victims, study finds”

“Need an ambulance? Why you may not want the more sophisticated version”

“Think the ER is expensive? Look at how much it costs to get there”

“Modesto rejects $1M firefighter paramedic grant”

Continue Reading

“Lockport plans to auction off ambulances, cut fire staffing minimum”

“Kalispell voters reject extra taxes for EMS”

“Is the current model for public safety service delivery sustainable?”

EMS agencies that desire to be successful in this rapidly changing environment need to demonstrate value in new ways by delivering high-performance EMS (HPEMS) as the first step to proving high-value EMS (HVEMS). There are generally three main hallmarks of HPEMS: clinical proficiency, operational effectiveness and fiscal efficiency. These hallmarks must be leveraged in a way that balances what is known as the EMS success triad: patient care, employee well-being and long-term financial sustainability. The Academy of International Mobile Healthcare Integration (AIMHI) has articulated several key attributes of a high-performance EMS system that help achieve these three hallmarks:

1. Sole Provider

Clinical proficiency—As a sole provider, an EMS agency will generally be able to maintain a high utilization of the EMTs and paramedics operating within the system. Higher utilization provides the opportunity to refine critical clinical skills such as patient assessment and effective clinical care. Additionally, a single source of quality oversight for all emergency and nonemergency calls helps ensure every provider, regardless of the type of service they provide, shares common credentialing and quality improvement processes.

Operational effectiveness—A single provider can also maximize operational effectiveness for the system. A patient awaiting transport to a skilled nursing facility from Acme General Hospital can be efficiently transported by the ambulance that just brought a chest pain patient into Acme General’s emergency room. The same unit that transports the patient to the SNF can then be posted to provide temporal or geospatial coverage to that area. Having multiple ambulance providers operating in the same market generally leads to underutilized resources and makes the system less operationally effective.

Fiscal efficiency—The provision of 9-1-1 service is expensive, and the reimbursements more challenging. A sole provider can balance the generally lower-cost, higher-reimbursement nonemergency services to help offset high-cost, low-reimbursement 9-1-1 services. A single layer of utility-like cost structure minimizes the financial impact to the taxpayer and other payers. Further, the operational effectiveness of the sole provider, as explained above, helps reduce the overall cost of the EMS system by preventing multiple infrastructure costs and lower utilization.

2. External Accountability

Clinical proficiency—Holding yourself externally accountable for clinical care helps improve the care provided by identifying areas of potential improvement, coming up with a plan for improvement, implementing the plan and evaluating the results. Some EMS agencies are financially incentivized for demonstrating compliance with scientifically proven clinical bundles of care for conditions such as STEMI, stroke, trauma and hypoglycemia.

Operational effectiveness—External accountability for performance measures like extended response times, unit hour utilization, lost unit hours, employee turnover and mission failures encourages the EMS agency to continually improve these metrics.

Fiscal efficiency—Similarly, reporting and being held accountable for financial measures such as cost per unit hour, cost per call, cost per transport, revenue per transport and revenue per unit hour encourages EMS agencies to improve these measures, as well as benchmark their performance to other similar agencies.

3. Control Center Operations

Clinical proficiency—Controlling your own resources helps ensure your units are appropriately utilized, increasing the clinical proficiency of your field EMTs and paramedics. If another agency is controlling the placement and deployment of your units, it is more difficult to assure appropriate utilization.

Operational effectiveness—As with clinical proficiency, relying on another agency to control your assets may reduce operational effectiveness and make it harder to achieve the correct balance between supply and demand.

Fiscal efficiency—Relinquishing control of your assets to another control center operator may increase costs through less effective asset utilization and lost unit hours.

4. Revenue Maximization

Clinical proficiency—Employing system design and business practices that maximize revenue generation within the EMS system allows the provider greater ability to invest in training, equipment and medical oversight that improves clinical proficiency. For example, FirstPass, a valuable tool for near-real-time clinical quality metrics, requires a significant resource investment. The ability to invest in a system like FirstPass is enhanced when the agency maximizes revenue generation.

Operational effectiveness—The same is true for investing in tools and processes to achieve operational effectiveness. Examples could include an investment in software to predict call volume and locations; dedicated departments that stock, maintain and redeploy ambulances with a high degree of reliability; and sophisticated computer-aided dispatch systems designed to maximize resource utilization.

Fiscal efficiency—Clearly collecting the appropriate fees for the services you provide helps make the system more financially sustainable and could even reduce the tax subsidy burden. This is common in some EMS-based fire agencies that provide nonemergency transfer services as a way to increase revenues.

5. Flexible Production Strategy

Clinical proficiency—Effectively matching supply to demand helps ensure enough EMS resources are on duty to handle larger call volumes while minimizing the number of idle units and amount of nonproductive time. This again helps assure field providers are using their clinical skills regularly to maintain proficiency. It also helps prevent burnout (too many calls per provider) and rustout (too few calls per provider).

Operational effectiveness—Using a flexible production strategy helps maintain a healthy and manageable unit utilization through the day and year, making the system more operationally effective.

Fiscal efficiency—Matching supply to demand improves the financial efficiency of the system by minimizing the expense of excess capacity.

6. Dynamic Resource Management (DRM), System Status Management (SSM)

Clinical proficiency—As with the other attributes, moving resources within the system to cover anticipated demand helps enhance utilization and consequently improve providers’ clinical proficiency. It may also help reduce utilization in high call volume areas and prevent burnout.

Operational effectiveness—Having the right resources in the right locations can significantly improve operational effectiveness. If you know there are high-volume areas in your jurisdiction, dynamically deploying resources from low-volume areas allows for enhanced service delivery.

Fiscal efficiency—Matching supply to demand is a first step in achieving fiscal efficiency. The second step is to have those resources in the right places. DRM allows moving available resources throughout the system to meet anticipated call volume. Combining a flexible production strategy with DRM has a significant impact on effectively using your on-duty resources.

The EMS Success Triad

The EMS success triad is a philosophy and business compass that can be adopted within any EMS system type, and its importance is highlighted in any HPEMS system. The triad includes a constant balancing of:

Patient care—When we speak of patient care, we must think beyond the clinical aspects of care and also include the value aspects such as patient satisfaction, patient safety, customer service, response time and service reliability, and outcomes.

Employee well-being—EMS is a service business, and service businesses are founded on their people. EMS must acknowledge this and build systems and processes that acknowledge the impacts of lean design on its teams. Issues such as adequate breaks, workload balancing, employee engagement, just culture, trust, employee safety systems, work-life balance, schedules and scheduling, compensation strategies, organizational and mission passion and decision making involvement are just a few areas EMS must work to improve.

Long-term financial sustainability—Every decision made within an EMS organization has a cost that impacts the triad in some fashion. These costs must be accounted for and balanced. Cost is a relative term and not necessarily financial in nature (e.g., impacts on patient care and employee well-being). No matter the type of business structure or operational philosophy an EMS system has, the concept of “no margin, no mission” always applies. Long-term business, financial and other cost impacts must always be kept in check if an EMS system is to remain sustainable.

While not every EMS agency or community will be able to employ all the attributes of HPEMS, we are convinced many EMS providers can use some of these principles to demonstrate the value they bring to their community.

In next month’s column we’ll focus on providing high-value EMS.

About AIMHI

AIMHI represents high-performance emergency medical and mobile healthcare providers in the U.S. and abroad who deliver care to more than six million people over more than 43,000 square miles and responding to nearly a million calls annually.

Formerly known as the Coalition of Advanced Emergency Medical Services (CAEMS), AIMHI changed its name in March 2015 to better reflect its members’ dedication to promoting high-performance ambulance and mobile integrated healthcare systems.

Member organizations include high-performance EMS systems in locations such as Oklahoma City and Tulsa, OK; Fort Worth, TX; Richmond, VA; Pinellas County, FL; Charlotte, NC; Niagara, ON, and the province of Nova Scotia, Canada; New York, NY; Little Rock, AR; Davenport, IA; Three Rivers, IN; and Reno, NV. Find more information on AIMHI at www.aimhi.mobi.

References

1. Avril T. Police transport a good bet for shooting victims, study finds. Philadelphia Inquirer, 2014 Jan 8.

2. Sun LH. Need an ambulance? Why you may not want the more sophisticated version. Washington Post, 2015 Oct 12.

3. Rosenthal E. Think the E.R. Is Expensive? Look at How Much It Costs to Get There. New York Times, 2013 Dec 4.

4. Valine K. Modesto rejects $1M firefighter paramedic grant. Modesto Bee, 2016 Oct 5.

5. Prohaska TJ. Lockport plans to auction off ambulances, cut fire staffing minimum. Buffalo News, 2014 Aug 27.

6. Loper B. Kalispell voters reject extra taxes for EMS. Daily Inter Lake.

7. Matarese L. Is the Current Model for Public Safety Service Delivery Sustainable? ICMA Publications.

Doug Hooten, MBA, is the chief executive officer of MedStar Mobile Healthcare in Fort Worth, TX. He has over 37 years of experience in EMS, having served as senior vice president of operations and regional director for American Medical Response, CEO of the Metropolitan Ambulance Service Trust (MAST) in Kansas City, and in a variety of leadership roles with Rural/Metro in South Carolina, Georgia, Ohio and Texas. He has expertise in change management, cost optimization, process improvement and clinical excellence. Doug is the president of AIMHI, serves as a board member for the American Ambulance Association and is a member of the National EMS Advisory Council (NEMSAC). 

Jonathan Washko, MBA, NREMT-P, AEMD, is the assistant vice president for Northwell Health’s Center for EMS and leads numerous innovation efforts to improve patient care, employee well-being and the long-term financial sustainability of EMS systems. He volunteers as a board member with the American Ambulance Association, NAEMT, AIMHI and NYMIHA and also serves as a member of the EMS Compass initiative, working to develop standardized industry measures, as well as an advisor to the Promoting Innovation in EMS (PIE) project. Reach him by e-mail at jwashko@northwell.edu

Documenting stroke assessment, 12-lead EKG, and aspirin administration highlight areas for improvement

February 15, 2018 – AUSTIN, Texas – ESO Solutions, Inc., the leading data and software company serving emergency medical services (EMS), hospitals and fire departments, today announced the findings of its inaugural report, the 2018 ESO EMS Index. The Index tracks performance of EMS agencies nationwide across five metrics: Stroke assessment and documentation, overdose events, end-tidal carbon dioxide (ETCO2) monitoring, 12-lead electrocardiogram (EKG) use and aspirin administration for chest pain. Data used for the Index are from January 1, 2017 through December 31, 2017.

“There are changes on the horizon for EMS agencies across the country,” said Dr. Brent Myers, Chief Medical Officer for ESO. “In particular, we are seeing new data and research emerge around the increased importance of stroke assessment and documentation that could improve patient outcomes. Additionally, the opioid crisis continues to be an issue that will have an effect on EMS providers. This newly launched Index is part of our ongoing commitment to the smart use of data to help agencies across the country assess their performance across a handful of metrics.”

Key Findings Include:

• In only 50 percent of situations was a complete stroke assessment documented for a primary impression of stroke. The data show that EMS providers are not completing the entire stroke assessment or failing to document the assessment after a primary impression of stroke is identified.

• Overdose encounters outpaced cases where stroke was the primary impression. There were nearly 12 percent more overdose cases reported in 2017 than strokes, aligning with much of what paramedics are reporting the last few years.

• More men than women overdosed: Men accounted for 28 percent more overdose encounters than women.

• EMS providers recognize the value of end-tidal CO2 monitoring after advanced airway placement. In 94.5 percent of cases, ETCO2 monitoring was initiated after advanced airway insertion.

• Aspirin administration is hit or miss. Just more than half (55.3 percent) of the reported cases of non-traumatic chest pain patients over the age of 35 had appropriately documented administration of aspirin for chest pain.

The full Index can be downloaded at: www.esosolutions.com/index.

About the Index

The dataset for the ESO EMS Index is real-world data, compiled and aggregated from more than 1,000 agencies across the United States that use ESO’s products and services. These data are based on 5.02 million patient encounters between January 1, 2017 and December 31, 2017, representing a full calendar year.

About ESO Solutions

ESO Solutions, Inc., is dedicated to improving community health and safety through the power of data. Since its founding in 2004, the company has been a pioneer in electronic patient care records (ePCR) software for emergency medical services, fire departments and ambulance services. Today, ESO serves more than 13,000 agencies throughout the U.S. The company’s healthcare, public safety and technology experts deliver the most innovative software and data solutions on the market, including the industry-leading ESO Electronic Health Record (EHR); ESO Health Data Exchange (HDE), the first-of-its-kind healthcare interoperability platform; record management system (RMS) for fire departments; and ambulance revenue recovery/billing software. ESO is also playing a leading role in helping EMS provider organizations across the nation successfully transition to NEMSIS Version 3 and new state standards for electronic patient care reporting.

ESO is headquartered in Austin, Texas. For more information, visit www.esosolutions.com.

Article by Shawn Shinneman

Hurst-based Cook Children’s Northeast Hospital will close on April 20 and begin a transition to become an ambulatory surgery center, with the new name of Cook Children’s Surgery Center, according to a news release. Here’s how the release from Cook Children’s Health Care System describes the decision:

In late 2017, the Centers for Medicare and Medicaid Services (CMS) issued a memo defining the overnight census requirement to operate as a hospital. Cook Children’s Northeast Hospital, located at 6316 Precinct Line Road in Hurst, Texas, does not meet the census requirement and will no longer be able to operate as a hospital.

The memo referenced—I believe I’ve located it here—contains CMS’ move to redefine what constitutes who can or can’t call themselves a hospital under Medicare and Medicaid. Under the new definition, things like average daily census and average daily stay can be taken into consideration.

The memo casts those merely as pieces to the puzzle, but it appears Cook Children’s leadership has determined it won’t be able to overcome the census requirement. (I’ve reached out to gauge how they made the call, and I’ll update here or post anew if and when I get answers.)

The release says only that the board that oversees the hospital made the decision on the new direction. Cook Children’s says it will “assume ownership and operations of the Urgent Care Clinic, Imaging Center, and Draw station at this location” on April 23.

The surgical center will open on May 1 and run as a joint venture between Cook Children’s, NueHealth, and physician investors.

The transition will result in 150 lost jobs, the release said.

Editors Comment: Welcome news from our friends in Georgia!  – Another example of payers moving toward economic models for EMS that include reimbursement for patient assessment, treatment and navigation to the most appropriate resource!  And, confirmation of something that Health Affairs journal identified several issues back – Medicaid programs are one of the most innovative payers in the country…

EMS Partners,

As you may be aware, in early 2017 the Georgia State Office of Rural Health (SORH) submitted three proposals to the Georgia Medicaid office requesting changes to reimbursement for EMS. The three proposals requested consideration to reimburse EMS for Treat Without Transport, Transport to Alternate Destinations, and Mobile Integrated Healthcare/Community Paramedicine (MIH/CP) programs.

Our office has recently received notification that Georgia Medicaid has approved Treatment Without Transport and Transport to Alternate Destinations, with the intent of submitting the MIH/CP proposal to the Centers for Medicare & Medicaid Services (CMS) for approval.

Assuming no unforeseen barriers, Treat Without Transport will be effective April 01, 2018.

Submission of a claim will require that the response originate through a “9-1-1” call and the patient receives treatment with pharmaceuticals before refusing transport to the hospital.

The intent behind this proposal was to allow EMS to recover some of the cost associated with providing medication to patients who, ultimately, choose not to be transported for continuation of care.

Assuming no unforeseen barriers, Transport To Alternate Destination will be effective July 01, 2018.

Submission of a claim will require that the response originate through a “9-1-1” call, an approved protocol signed by the Medical Director specific to patient evaluation and transport to an alternate facility exists, documentation of patient agreement for transport to an alternate facility is included, and a receiving facility agreement is on file.

The intent behind this proposal was to allow EMS an opportunity to transport properly screened patients who have non-emergent conditions to facilities appropriate for their needs, reduce over-crowding of emergency departments with non-emergent patients, and allow patients to receive medical attention in a less costly setting. This option may also allow counties with no local hospital and/or limited ambulance service coverage to shorten “turn-around times” and keep resources within county borders for longer periods.

All Medicaid claims are subject to review and audit, therefore, proper documentation on the patient care report as well as all required supporting documents must be maintained and provided upon request.

Currently, four states in the US have received approval from CMS for Medicaid reimbursement for MIH/CP programs. Georgia Medicaid is submitting a proposal similarly structured as those receiving previous CMS approval, and anticipate this proposal will also be approved. However, this is still uncertain, and confirmation of this change will be contingent upon CMS ruling. The State Office of Rural Health will keep our EMS partners informed of the progress of this proposal.

Please share this information with your Medical Director and billing staff.

We would like to thank Georgia Medicaid, and specifically Deputy Director Heather Bond, for their effort in reviewing and approving these proposals. This change is a huge step forward for the EMS industry in Georgia.

Article by Paige Minemyer

Hospitals that aim to reduce readmissions among high-risk patients may want to hire lay-health workers, according to a new study.

Researchers at the University of Kentucky piloted such a program at St. Claire Regional Medical Center, a 159-bed rural hospital in Morehead, Ky. Hospitalized adults deemed at-risk for readmission within 30 days were targeted for the intervention, according to the study published in Health Education Research.

The study team measured 30-day readmissions during a four-month baseline period, compared the data to a six-month window after the lay-health workers were deployed and found a 47.7% reduction in the readmission rate for patients who received the intervention.

Lay-health workers assisted these patients with post discharge needs such as appointment scheduling and transportation. They were also able to serve as a resource for patients during their care journey, according to the study. Because they could offer these services—and could be deployed relatively quickly to address patients’ needs—the model shows promise for high-risk patients with complex social concerns, the researchers said.

“We have the potential of impacting one’s overall health if we can assist with those social determinants, such as paying bills or having access to fresh food, much more so that what we do through traditional medicine that occurs in clinics and hospitals,” said the study’s lead researcher, Roberto Cardarelli, D.O., chief of the division of community medicine at UK HealthCare, in an announcement.

One of the major barriers to expanding programs like the lay-health pilot is that payment structures have not quite caught up to the demand for these services, according to Cardarelli.

“Our dilemma is that our healthcare system does not pay for such services,” he said, “and we continue to see marginalized populations keep coming back to hospitals in an acute crisis.”

There has been increasing focus on targeting social determinants to improve health—poor minority patients, for example, face worse health outcomes than others. But while far-reaching work is necessary to address these concerns, it will require a culture shift in healthcare to fully achieve sustained population health success.

Experts have called for improved data gathering and analytics in this area to establish a stronger foundation for initiatives on the social determinants of health. Issues ranging from patient loneliness to lack of internet access are seen as areas for improvement.

https://www.fiercehealthcare.com/hospitals-health-systems/lay-health-workers-readmissions-high-risk-patients-university-kentucky

Patients often face long waits for emergency care, so the Permanente Medical Group set out to improve patient flow in Kaiser Permanente emergency rooms by deploying staff members more efficiently at high-volume times.

ERs are the busiest on nights and weekends—the least desirable shifts for clinicians—so KP took steps to adjust what its ER nurses were doing and added nontraditional ER doctors to these shifts to avoid delays, wrote Robert Pearl, M.D., a clinical professor of plastic surgery at Stanford School of Medicine and former CEO of the Permanente Medical Group, in a column for Forbes.

The triage process is often redundant and results in nurses asking many of the same questions that patients will answer a second time for admitting physicians. KP made doctors the first point of contact in the ER to move nurses more directly into patient care, especially during high-volume, low-staff times of day, which got more clinicians involved in treating patients.

KP emergency rooms also brought nonemergency clinicians to the ER during high-volume times, Pearl wrote. The organization paired board-certified ED doctors with other physicians, such as pediatricians or family medicine practitioners, who would also be able to treat patients with minor illnesses or injuries.

“By staffing appropriately for the acuity of patient problems, doctors can treat and discharge those with less-emergent issues faster,” Pearl wrote.

Other hospitals have looked at re-engineering the triage process to make emergency care more efficient, as patients with nonemergent conditions often face long waits in the ER. A pilot program at a Chicago hospital streamlined the process so that the sickest patients were treated more quickly, reducing wait times by two hours.

The pilot set a goal of patient admission within one hour of arrival in the ER. In addition to cutting down wait times, the updated triage pilot improved communication between clinical teams and fostered more collaboration on care.

Baptist Health South Florida adopted a “tele-triage” program to reduce overcrowding and treat patients with non-life-threatening conditions more quickly. Patients meet remote physicians in a video conference, significantly boosting the hospital’s ER capacity.

Parkland Memorial Hospital took a different route to improve ER efficiency: a partnership with Toyota. The car manufacturer identified a number of inefficiencies in how the Dallas-based hospital operated its ER, including an inconsistent discharge protocol for nurses that Parkland has adjusted.

Article can be accessed here.

During his six years at the CMS, Dr. Patrick Conway oversaw the agency’s big push into value-based reimbursement. He was deputy administrator for quality and innovation and headed the Center for Medicare and Medicaid Innovation. Late last year, Conway left the CMS Innovation Center to become CEO of Blue Cross and Blue Shield of North Carolina. While he’s now removed from rulemaking, Conway remains passionate about the idea of linking payment to outcomes. He recently spoke with Modern Healthcare Editor Emeritus Merrill Goozner. The following is an edited transcript.

MH: Let’s turn to another one of the major programs that you had at the Innovation Center ACOs and the Medicare Shared Savings Program. How do you see its future?
Conway: Overall, the Medicare ACO program improved quality and improved patient experience and had modest savings. On the savings, it’s important to note the ACOs that were in the program longer saved more money. Physician-led ACOs, on average, saved more money. And those ACOs at two-sided risk—at partially capitated or capitated-type payments like Next Generation ACO—did the best.

I think those programs will continue in Medicare, but they may be modified in some ways. In the private market, including in North Carolina, private payers are putting ACO contracts in place with independent physicians and large health systems. We have an ACO that just reported $20 million in savings, but more importantly, the patients in that system are getting coordinated care. They have nurses calling them to make sure they get the care they need.

MH: To what extent do you see the private sector becoming the driver of these? Do you think that the momentum is
there for them to keep going and expand it even without a push from government?
Conway: I do. In North Carolina, we’re going to work to move the majority of our payments to providers into a partnership model like ACOs and bundled payments where the provider is accountable for quality and total cost of care and quality goes up and costs go down.

MH: There are so many strands of reporting requirements quality indicators, process indicators, outcomes indicators. What can be done to lessen the regulatory burden on physician offices and on hospitals?
Conway: At one point in my career, I led quality reporting for a large health system, Cincinnati Children’s Hospital Medical Center, and we had over 700 measures we were reporting to various entities. You cannot improve on 700 things. As a general rule of thumb, you want to try to get 30 or fewer quality measures and 10 or fewer is even better, for providers to improve on.

Original article can be accessed here.