News & Updates

Kindred Healthcare (NYSE: KND), the nation’s largest home health care provider, is in advanced talks to be acquired by insurance giant Humana Inc. (NYSE: HUM) and two private equity firms, the Wall Street Journal reported Sunday. The newspaper cited “people familiar with the matter.”

Kindred and Humana did not immediately respond to requests for comment from Home Health Care News on Sunday afternoon.

Louisville, Kentucky-based Kindred would be divided up as part of the complex deal, WSJ reported.

Under terms of the rumored deal, private equity firms Welsh, Carson, Anderson & Stowe and TPG would acquire Kindred’s 77 long-term care hospital and 19 rehabilitation facilities. The private equity firms and Humana would acquire Kindred’s home and hospice business.

The deal values Kindred’s stock at $9 per share, giving the company a $750 million market value with a total enterprise value of $4 billion, according to the Journal. KND shares were trading at $8.60 at market close on Friday. Kindred’s share price was buoyed last month, when the Centers for Medicare & Medicaid Services (CMS) announced it would hold off for now on a controversial new framework for reimbursing home health agencies.

The latest takeover rumor comes as Kindred has been in a period of transformation, and follows other reports that potential takeover bids had not been successful.

After its $1.8 billion merger with Gentiva Health Services, completed in 2015, Kindred became the largest home health and hospice provider in the United States but also increased its debt load. Since then, it has made a big move to divest its large skilled nursing business.

This potential Humana deal could be announced “soon,” WSJ reported, but noted that it still could fall through.

Insurers making big moves
Humana, which is also based in Louisville, is a major health insurance provider, with more than 13 million customers. The company also has some home health care operations and executives recently expressed their desires to expand the home care business line, in discussing third quarter earnings.

Should it materialize, the Humana transaction would come on the heels of another major health care deal; at the beginning of the month, CVS Health (NYSE: CVS) announced it will be acquiring Aetna (NYSE: AET), the nation’s third-largest health insurance provider, for $69 billion.

Early in 2017, Humana and Aetna called off their proposed $34 billion merger, facing federal opposition due to antitrust concerns.

Humana’s home care division, Humana at Home, took a hit at the beginning of 2017 as the health system experienced a $400 million loss. In February, the company announced 500 home care workers were laid off in its Ohio and Florida locations.

But both Humana and Kindred have touted their ability to enhance coordination between acute and post-acute settings in general, and home health in particular, as a way to improve outcomes while keeping costs down in value-based payment models.

The CMS announced on Thursday that patient experience scores and star ratings have been added to the Physician Compare website for patients and caregivers to view.

The site will now display physicians’ 2016 performance under the Physician Quality Reporting System as star ratings.

Patient survey scores from the Consumer Assessment of Healthcare Providers and Systems surveys will be listed on “group pages” that show the overall performance of a physician practice instead of individual doctors.

The measures used to get a composite 5-star rating score for doctors involve preventive care, patient safety, care planning, diabetes, behavioral health and heart disease.

Physician Compare was also updated to show 2016 data from the Shared Savings Program.

Earlier this week, the CMS also announced it added four new quality measures for healthcare consumers to view on the Inpatient Rehabilitation Facility and Long-Term Care Hospital Compare websites.

The CMS’ suite of Compare sites were mandated under the Affordable Care Act and designed to encourage Medicare beneficiaries to seek out high-quality healthcare. However, a few of them have been flagged for having incorrect information. As recently as last week, the CMS said an update to its Hospice Compare website would be delayed while some information was corrected.

CMS Administrator Seema Verma has publicly touted her commitment to improving patients’ access to information that allows them to shop for their care.

In what is believed to be the first study to measure the impact of Uber and other ride-booking services on the U.S. ambulance business, two researchers have concluded that ambulance usage is dropping across the country.

A research paper released Wednesday examined ambulance usage rates in 766 U.S. cities in 43 states as Uber entered their markets from 2013 to 2015.

Co-authors David Slusky, an assistant professor of economics at the University of Kansas, and Dr. Leon Moskatel, an internist at Scripps Mercy Hospital in San Diego, said they believe their study is the first to explain a trend that until now has only been discussed anecdotally.

Comparing ambulance volumes before and after Uber became available in each city, the two men found that the ambulance usage rate dipped significantly.

Slusky said after using different methodologies to obtain the “most conservative” decline in ambulance usage, the researchers calculated the drop to be “at least” 7 percent.

“My guess is it will go up a little bit and stabilize at 10 to 15 percent as Uber continues to expand as an alternative for people,’’ Moskatel said.

Slusky said he and Moskatel are submitting the paper to journals for peer review.

San Francisco-based Uber quickly distanced itself from the notion that hailing an Uber driver is an acceptable substitute for calling an ambulance.

“We’re grateful our service has helped people get to where they’re going when they need it the most,” said company spokesman Andrew Hasbun. “However, it’s important to note that Uber is not a substitute for law enforcement or medical professionals. In the event of any medical emergency, we always encourage people to call 911.”

Moskatel, however, said many patients “tend to be pretty good at assessing their state and how quickly they need to come in and how sick they are.”

But at least one prominent Bay Area emergency room physician disagreed.

Paul Kivela, president of the 37,000-member American College of Emergency Physicians, said he believes that for those low-risk patients who can’t drive themselves to the emergency room, Uber is a good service.

But many people, he said, may not be able to differentiate between a life-threatening emergency and an innocuous medical issue. So, he said, calling 911 is always the safest bet.

“A paramedic has the training and the ability to deliver life-saving care en route,” Kivela said. “Where I really have a hard time is believing an Uber driver is going to attend to you.”

Kivela noted that in addition to his work as an ER doctor at Queen of the Valley Medical Center in Napa, he is also the medical director of an ambulance company in Solano County.

The researchers, however, insisted that ride-booking services such as Uber and San Francisco-based Lyft can sometimes be the best way to get to the hospital in a hurry.

Previous research, Moskatel said, “suggests that a fair number of people are using ambulances to get to the hospital because they simply don’t have another way to get there’’ — particularly those who live in areas with limited taxi service.

And, Slusky added, with health care taking a big chunk out of most people’s budgets, many consumers these days have to weigh a few factors before calling an ambulance.

“They have to think about their health — and what it’s going to cost me,” he said. “And for many of us with high-deductible plans, an ambulance ride would cost thousands of dollars.’’

Slusky added: “If we want to reduce (health care) spending, we have to find ways to do things cheaper — and that’s in all kinds of situations where you don’t need the most expensive resource. We don’t all need to fly first-class all the time.”

Moskatel and Slusky said they focused only on Uber because they needed a broad set of data and the company had been operating for a longer period of time than competing services, allowing the researchers to assess a greater number of locations.

Because Uber was not involved in the study, Moskatel had to painstakingly map all the dates the company entered a certain market, based only on the company’s public announcements.

Ambulance rates were obtained from the National Emergency Medical Services Information System, or NEMSIS, a national repository for emergency medical services data.

Slusky said Salt Lake City-based NEMSIS agreed to run the numbers for each city, but an agreement between NEMSIS and its members prevents any release of information that could be used to identify rates for specific regions at the state, city or ZIP Code level.

In Santa Clara County, Emergency Medical Services director Jackie Lowther said there had been “no significant decrease in volumes in Santa Clara County, other than the usual seasonal variation for this time of year.’’

Travis Kusman, Lowther’s counterpart in Alameda County, did not respond to a request for comment. Nor did officials from Lyft.

A person in Missouri, walking along the side of a street, was suddenly struck by a car. The patient was taken to the emergency department, where multiple imaging studies revealed that despite bad scrapes and contusions, there were no broken bones. In another case, a patient who was potentially experiencing a stroke received tPA, a life-saving medication used to dissolve blood clots in the brain, and was admitted to the ICU.

In several other instances, Missourians have sought care in the ED for what they thought were broken bones.
Indianapolis-based health insurer Anthem denied payment for each of these cases under its new program meant to curb inappropriate ED use, according to emergency physicians and hospital administrators in Missouri, where the policy took effect in June.

Under the controversial policy, which nabbed plenty of headlines when it was rolled out in some states in mid-2017, Anthem won’t cover ED visits for conditions that the insurer decides were not emergent after a review.

Now, several months after the policy went into effect in Missouri and Georgia—it was rolled out in certain parts of Kentucky in late 2015—hospitals and patients are feeling the impact. Hospitals say the claim denials are piling up, and they’re forced to go through burdensome appeal processes. Patients are reeling from large medical bills for conditions they believed were emergencies. And emergency physicians worry that the policy will have a chilling effect on patients seeking care in an emergency, which could lead to worse health outcomes.

“If they get burned one time by a large bill, the next time they will delay going to the ED when they really need to be there,” said Dr. Jonathan Heidt, an ED doctor and president of the Missouri chapter of the American College of Emergency Physicians. “They are going to have a worse outcome from their illness or injury, or it could even lead to a patient death because they were too scared to go the ER for getting a large bill.”

Insurers and self-insured employers have long tried to encourage plan members to seek care at lower-cost settings. They usually do this by providing incentives, such as lower co-pays, if the patient chooses an urgent-care center over an emergency room when accessing medical care.

Anthem’s ED policy, which will expand to Indiana, New Hampshire and Ohio next year, takes the concept much further by denying payment altogether based on a retrospective view of a claim. Anthem said the policy is meant to promote delivering non-emergent care in the appropriate setting, such as retail or urgent-care clinics, or via telehealth. The insurer will cover non-emergent care in the ED if there is no clinic within 15 miles of a patient and a nurse is available to help plan members decide where to seek care. The policy applies only to commercial members, not Medicare, an Anthem spokeswoman said. Anthem also recently started denying coverage for MRI and CT scans on an outpatient basis in hospitals.

Anthem implemented the ED program because of “an uptick in emergency room visits for non-emergency treatment, despite education campaigns to inform the public about the costs and inconvenience of going to the ER for non-emergent care,” the spokeswoman said in an email. She added that in Missouri, for instance, ED visits have increased 20% since 2014, and many of those were for non-emergency ailments, including itchy eyes from seasonal allergies, treatment for ingrown toenails and suture removal.

The policy “doesn’t reflect the reality of the situation facing physicians and patients. Sometimes we need to do a fair number of tests to figure out if a patient’s condition is emergent or not. It’s not fair to expect patients to know,” said Dr. Laura Burke, an emergency physician and researcher at Beth Israel Deaconess Medical Center in Boston.

Diagnostic codes rarely tell the whole story, physicians said. A patient who shows up in the ED with chest pain could be having a heart attack, or the patient could be suffering from heartburn, Heidt said. It may take tests to determine what’s really going on. Deciding whether the ED visit deserves payment based on the final codes fails to take into account the circumstances surrounding a patient’s choice to go to the ER.

“They are not looking at any medical records at all. It’s difficult enough to determine what a patient was thinking based off an ER note, let alone just ICD-10 codes,” Heidt said.

A Missouri Hospital Association analysis of Anthem’s list of more than 1,900 diagnostic codes for avoidable ED services found that only 15% of the codes are classified as non-emergent when compared against the widely accepted New York University ED classification algorithm. Of those, fewer than 100 codes of the total 1,900 on the list are considered non-emergent beyond a doubt.

An Anthem spokeswoman said that particular list pertains to Missouri only and is outdated, though she would not provide the updated list, adding that the list is “continually evolving based on experience and further evaluation.”

Nine diagnostic codes on Anthem’s list deal with arm pain. In a letter to the American Heart Association sent late October, the Missouri hospital and medical associations explained that the average person may suspect that symptoms of arm pain could mean a heart attack. In 2016, almost 4,500 ED visits in Missouri had an initial diagnosis related to arm pain. Of those, 1 in 3 patients was diagnosed with a secondary cardiovascular condition.

Physicians are concerned that Anthem’s policy violates the long-standing prudent layperson standard, which is a law in 47 states and included in the Affordable Care Act. The standard gives patients protection to seek emergency care and hospitals’ assurance that they will be reimbursed. It holds that ED insurance coverage should be based on whether a prudent layperson, defined as someone with reasonable medical and health knowledge, could reasonably expect their health to be in jeopardy in an emergency, and not based on the final diagnosis codes.

Anthem said its policy complies with this standard.

But even when hospitals come out on the winning end of a disputed claim, they are coming up short.

A patient recently visited Cedar County Memorial Hospital, a critical-access facility in El Dorado Springs, Mo., with symptoms of gastrointestinal illness, dehydration and fainting. The patient had initially gone to a local clinic where a provider directed her to visit the ED. Anthem denied coverage for the visit, but later overturned the decision after an appeal. Jana Witt, Cedar County’s CEO, said the hospital has yet to receive payment, however.

“It does take a substantial amount of time to deal with fighting a denial like that,” Witt said. But patient outcomes are her primary concern. “The patient actually was experiencing a gastrointestinal illness, dehydration, and fainting—how is she to judge? Anthem’s policy is leaving that patient to decide, and they don’t have the knowledge to do so.”
Of course, some ED visits are avoidable. U.S. healthcare spending continues to climb, topping $3.2 trillion in 2015, or nearly $10,000 per person, according to the CMS. Emergency department spending is a piece of that, albeit a small part, despite public belief to the contrary. ED visits rose to a record high of 141.4 million in 2014, according to the Centers for Disease Control and Prevention. But the CDC also found that only 4.3% of ED visits were because of non-urgent symptoms that year. Other studies back that up.

Anthem has not disclosed how much of its claims costs come from ED visits. And it’s unclear how the policy will affect hospitals’ bottom lines in the long run. The revenue hospitals receive from emergency care varies by hospital and depends on payer mix, contracted rates with insurers, and other factors.

Hospitals and associations are now collecting stories of patients whose claims for emergency care have been denied by Anthem. Georgia’s insurance department has also said it is tracking consumer complaints related to Anthem’s policy. Because the policy is new and so far has been implemented in only a few states, it’ll be hard to bring enforcement action against Anthem, said Laura Wooster, ACEP’s associate executive director of public affairs.

Herb Kuhn, the Missouri Hospital Association’s CEO and a former CMS official, fears the policy will trigger a “cat and mouse game between healthcare providers and insurers,” forcing providers to seek legislative changes to block insurers from implementing policies that discourage ED use.

“Rather than working together on what we all ought to be—that coordinated care is better than uncoordinated care—instead, we’re all just chasing one another, trying to go to regulators and legislators to legislate protections in areas like this,” he said.

For years I wondered why despite being a confirmed urbanite, I love camping. Then I realized that camping gives me full permission to improvise—to make creative use of the limited materials I have to get the job done. Hence, shirt tails are fair game for wiping coffee grounds out of measuring spoons.

Similarly, I am inspired by people and groups that use the resources we have at our disposal in health care in creative new ways. Like the first explorers, these folks are testing approaches to provide care that are more effectively than the status quo. Given the escalating health care costs, we need to be looking for ways to make the available financial resources work better for us. And, studies have shown that health care delivery includes a lot of wasted time, resources, and supplies, due in part to use of higher-priced services with no health benefits over less-expensive alternatives.
At a recent meeting on patient safety, I heard about a novel way of using a previously untapped resource—emergency medical technicians (EMTs), those courageous first responders to 911 calls. I followed up with Matt Zavadsky, MS-HSA, NREMT, who is the chief strategic integration officer at MedStar Mobile Healthcare, which provides emergency medical services (EMS) in the Fort Worth, Texas area, to learn more about it.

Here’s what he told me.

For decades EMS units have been paid only to respond to emergency calls and transport people to the hospital. If they were to transport a person who needed less intense care to a lower acuity setting, like a walk in center or a clinic, they would not be paid—representing overuse of higher-priced services. In addition, EMTs, especially those based in fire departments, often spend a substantial portion of their shift waiting for emergency calls—representing underutilized human resources.

The idea to change the EMS system to better match patient needs with transport location emerged decades ago, but the fee-for-services payment system provided an incentive to bill for the most intense services rather than the services actually needed by the patient. In 2010, the passage of the Affordable Care Act allowed for payment based on value (delivering what the patient actually needs) instead of volume (more high acuity, hospital admissions and emergency department [ED] visits).

Zavadsky described three examples where EMS agencies are providing care navigation rather than only transporting people to the hospital. As he pointed out, these new models of care delivery are only sustainable where the EMS units are being reimbursed for the care of a population of patients rather than the number of ambulance transports completed. Today, large health insurance companies are signing capitated agreements (for example, an in-advance per-member-per-month fee) with EMS units to use their available resources to coordinate care and help covered patients navigate to the correct setting based on their needs.

9-1-1 Nurse Triage
A 911 dispatcher uses a protocol to identify calls for non-urgent medical issues, which are transferred to a nurse who works in the 911 call center. The nurse queries the caller to determine the appropriate level of care and assists with transportation if needed. For example, if a parent calls about a child with fever, sore throat, and vomiting, and the pediatrician’s office is closed, the nurse can direct the parent to the after-hours pediatric clinic at the local children’s hospital and can provide arrange for paid transport to and from the clinic. The child avoids a long wait in the ED and has access to follow up care at the clinic if needed—and the insurance payer avoids the costly and unnecessary ambulance visit and ED cost. Plus, the EMTs and ambulance are freed up to serve people with high-acuity, emergency needs.

High-utilizer programs
Hospital case managers provide EMS agencies with information about patients who are frequently seen in the emergency department or who frequently call 911. EMTs identify the unmet needs that are driving the high ED utilization and provide or facilitate in-home care, health coaching, and round-the-clock access to health care. For example, a young man who had developed an opioid addiction after a work-related back injury was visiting one of 10 EDs every day to obtain more prescription drugs. EMTs provided education and coaching, then worked with him to complete a pain management contract. Within 12 weeks he was opioid-free and remained so when interviewed several years later. A study of the program showed that ED visits and hospitalizations were significantly reduced—and participants’ reported quality of life improved.

Readmission management
Using a similar approach to that for the high-utilizer programs, at discharge hospitals refer to the EMS agency patients believed to be at risk for a preventable readmission. Paramedics visit these patients at home, review discharge instructions, provide health education, and ensure medication compliance and safety. They also ensure that patients are following up with their physicians and facilitate care in the home or at low-acuity settings, as needed.

According to Zavadsky, these programs can be very cost effective. His organization estimates that their nurse triage program saves $1,100 per patient caller (avoided expenditure for ambulance transport and ED visit), their high-utilizer program saves $17,000 per patient enrolled (avoided expenditure for ambulance transport, ED visits, and inpatient admissions), and their readmission management program saves $9,000 per patient enrolled, using average Medicare expenditure data as a comparison.

These models sounded intriguing but I wondered about quality measures—what mechanisms were in place to prevent withholding care at high-acuity settings when it is needed? Zavadsky sent me a list of the metrics that have been developed collaboratively with input from more than 50 stakeholder groups, including EMS associations, accrediting bodies, payer associations, and patient safety organizations. I was pleased to see the list included not only cost and utilization metrics, but also measures of adverse outcomes, unplanned acute care utilization, and patient and primary care provider satisfaction. Consistent with the overall move to value-based economic models, EMS agencies are reporting a subset of these metrics as part of the new models, including capitated agreements.

In addition to these existing programs, Zavadsky explained another way that EMTs—which he described as a “standing army of resources”—could work to improve care delivery. Just as firefighters conduct building inspections to reduce fire risks, EMTs could conduct home assessments for people at risk for injury in the home, malnutrition, or elder neglect. They could then contact health care providers or community services as indicated. EMTs could complete these assessments during existing downtime during their shifts. In addition, during 911 calls for medical services firefighters could use a simple checklist to identify homes with safety concerns.

These models of care delivery are exciting because they use existing resources in a novel way and represent a triple win, with benefits for patients, care providers, and payers.

The CMS on Thursday released a list of 32 reporting measures under consideration for Medicare’s quality reporting and value-based purchasing programs.

The number of measures under review is much smaller compared to last year when CMS considered nearly 100 measures. The move is in line with CMS Administrator Seema Verma’s focus on reducing regulatory burden for providers. The agency recently launched the Meaningful Measures initiative to identify measures that will have the greatest impact on quality care improvement.

This year, CMS selected 32 measures for consideration out of a pool of 184 submitted by stakeholders. About 40% of measures on the list are outcome measures, which quality experts say are most valuable to patients and need more development.

Some of the measures focus on functional status changes after surgery and diabetes control.

The CMS publishes a list each year of quality and cost measures for consideration and works with the National Quality Forum to get input from patients, clinicians, commercial payers and purchasers, on the most suitable measures.

The NQF’s Measure Applications Partnership will present its recommendations to the CMS by Feb. 8.

In March, NQF made the unusual decision to suggest to the federal government remove 51 of 240 measures in an attempt to remove measures that no longer have value for patients or providers.

“NQF is committed to meaningful measures that focus on outcomes and aspects of care that are most important to patients, while also identifying leading measure gaps that must be addressed to achieve the nation’s healthcare priorities,” Shantanu Agrawal, president and CEO of NQF, said in a statement.

Texas Health Aetna, a joint venture between Texas Health Resources and Aetna, has launched a new app aimed at providing patients with more immediate, virtual emergency care.

Emergency physicians are often at the “front line of an undesirable healthcare experience” for many patients, so it was to the benefit of both physicians at Texas Health Resources’ 24 Dallas-Fort Worth-area hospitals and Texas Health Aetna members to develop the Texas Health Aetna ER Doc app, said Genevieve D. Caruncho-Simpson, chief operating officer at Texas Health Aetna, in an interview with FierceHealthcare.

“To change healthcare there needs to be a recognition that there needs to be better local healthcare solutions,” Caruncho-Simpson said. “Healthcare is fundamentally a local market.”

Patients with the app can text, send photos or video chat with an emergency doctor and are guaranteed a response within three minutes, she said. Most (90%) of patients’ needs can be resolved in these conversations.

When patients do need to see a doctor in person, the app helps coordinate the appointment with doctors in the ER at Texas Health Resources hospitals.

A transcript of the virtual visit will be sent to the patient’s primary care provider, and the clinicians working with the app can schedule same-day or next-day followups with primary care providers, Caruncho-Simpson said.

The independent doctors working with the app are on staff at Texas Health Resources facilities and in its emergency departments, but when they’re on-call for the ER Doc app, that will be their only focus.

Patients can use the app 24 hours a day, seven days a week, and there are no copays for a consult.

Caruncho-Simpson said patients so far have been surprised that they could have this type of care experience, but those that try it tend to become regular users.

“It’s a bit of a paradigm shift for many of our consumers,” she said.

A number of hospitals and health systems are turning to telemedicine to reduce emergency room overcrowding and wait times.

Baptist Health South Florida, for instance, offers “tele-triage,” which allows patients to connect with doctors through video conferences to move them through emergency care more quickly. Predictive analytics can provide a guide for future usage trends that allows providers to develop more effective strategies.

Original article can be accessed here.

An ambulance crew transporting a terminally ill woman to a local hospital on Australia’s east coast last week took a small diversion to a nearby beach after the woman said she wanted to see the ocean, perhaps for the last time.

“Tears were shed and the patient felt very happy,” the Queensland Ambulance Service said.

The caption appeared beneath a photo on Facebook showing the woman on a gurney, with paramedic Graeme Cooper at her side, overlooking Hervey Bay from a small beachside bluff on Wednesday.

Cooper told reporters the patient was on “her last journey back to (palliative care) where she was going basically to pass away,” news.com.au reported Thursday. “We popped her up on the hill where she could see the pier and Fraser Island and right through to Point Burrum and she was ecstatic with it all.”

Cooper, who got permission for the side trip from his superiors, said if it hadn’t been such a rocky coastline he would have taken the patient right down to the water.

“I thought the next best thing was I can get some ocean and bring it to her,” Cooper said. “She actually tasted the salt water.”

Danielle Kellan, who took the photo of the poignant scene, said she asked the elderly woman what she was thinking as she looked over the incoming waves at Hervey Bay.

“She said, ‘I’m at peace, everything is right.'” Kellan said, according to news.com.au.

What would Americans do if federal law compromised how and how quickly paramedics can treat them or their child in a medical emergency? Thanks to an increasingly outspoken group of emergency physicians and bipartisan congressional collaboration, the bill that today became law ensures that they will never have to find out.

Yet this victory is just the first step in upending long-enduring misconceptions of emergency medical service’s (EMS) role, which hampers patient care quality and raises emergency medical treatment costs nation-wide.

The ability of EMS providers, such as paramedics, to provide rapid medical care relies on a combination of training and “standing orders,” which allow them to immediately perform certain procedures without waiting for a physician director’s permission. Any such delay in care can make a critical difference in the patient’s survival and suffering – but this exact delay nearly became law.

A few years ago, the Drug Enforcement Agency (DEA) began deliberations on an unenforced provision of the 1970 Controlled Substances Act (CSA), which required a physician-written prescription to administer controlled substances. Despite intervention led by the National Association of EMS Physicians (NAEMSP) and allied stakeholders, the DEA proceeded with the intention to criminalize EMS administration of certain life-saving standing orders.

If this does not seem terribly frightening, consider what this would mean for patients. For example, a three-year-old girl having a seizure would be deprived of medication until paramedics got a physician on the radio or phone and then detailed her information or worse, until she arrived at the hospital – all while the seizure continues. Or consider a 50-year-old man with a mangled leg from a car accident, unable to receive pain medication as he is excruciatingly pried from his vehicle and transported to a distant trauma center.

The passage of the Protecting Patient Access to Emergency Medications Act means this tragic scenario will not come to pass. Guided by NAEMSP, the law does exactly what its name professes: protect every patient’s timely access to life-saving emergency medications. For that, and the years of determined advocacy and support from the EMS industry and congressional supporters, all of us are grateful.

But this narrowly-avoided crisis is just one consequence of a major, unresolved problem harming patient care quality and raising emergency medical care costs: the government’s fundamental failure to recognize EMS as a critical part of the U.S. healthcare system.

Immediate medical intervention for emergencies is a public expectation, but we only need to go back half a century to find a time when this was not the case. Fifty years ago, ambulances were simply a mode of transportation to the hospital, devoid of medical professionals capable of providing life-saving treatment. EMS has since matured into the nation’s front line of healthcare, but it’s not reflected in the laws governing it. Some of these laws exacerbate patient costs, shortchange the value of paramedics’ work, and stunt the advancement and even threaten the efficacy of this system of care. Few realize that Medicare reimburses EMS as if it were a taxi: by the miles traveled, not the care received, and only if transport to a health care facility takes place. This not only fails to recognize EMS as a provider of health care, but also incentivizes transport to hospital emergency departments – whether or not it’s the most appropriate facility.

We hope that the quiet passage of this important bill is the beginning of a change in how the government recognizes and utilizes EMS. In an era of unsustainable growth in health care expenditures and ever-more crowded emergency departments, we must put the needs of patients first with high-value, low-harm care. EMS is eager to be part of the solution through initiatives such as mobile integrated healthcare, which could treat patients in their home or take them directly to the most appropriate facility for each patient’s needs. Indeed, the industry is already making advancements through small initiatives led by dedicated individuals and organizations, such as NAEMSP. But in order to sustain these efforts and build a better system of care for all Americans, the federal government’s understanding of EMS and its reimbursement structure must modernize to recognize EMS’ contribution to the health and prosperity of the communities they serve, as well as to give patients the medical care they need and deserve.

The brave and highly-trained first responders who make up EMS and America’s front line of health care have pledged to help us in our most vulnerable moments. It’s time all of our laws and health care systems reflect their place in the health care continuum, so they can help build a better system and continue to keep this pledge, as they did today.

Dr. Sahni is the Medical Director of the Lake Oswego Fire Department, Clackamas County EMS, and Washington County EMS, and is NAEMSP’s Advocacy Committee Chair and Past-President. Dr. Dorsett is a Senior Clinical Instructor of Emergency Medicine and Emergency Medicine and EMS Physician at the University of Rochester Medical Center and a member of the National Association of EMS Physicians. Dr. Moy is Medical Director for ARCH/Air Methods Helicopter EMS system in Missouri, Assistant Medical Director for Christian Northeast, Assistant Medical Director of Saint Louis Fire Department, Assistant Professor of Emergency Medicine at Washington University Saint Louis, and the Communications Committee Chair for NAEMSP.

One patient got a $3,600 bill for a 4-mile ride. Another was charged $8,460 for a trip from one California hospital that could not handle his case to a facility that could. Still another found herself marooned at an out-of-network hospital, where she’d been taken by ambulance without her consent.

These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting California and 20 other states to pass laws protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.

Patients choose to go to the doctor or a hospital, but they are vulnerable when they call 911 — or get into an ambulance. The dispatcher picks the ambulance crew, which, in turn, often picks the hospital. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911.

Betsy Imholz, special projects director at the Consumers Union, which has collected over 700 patient stories about surprise medical bills, said at least a quarter concern ambulances.

“It’s a huge problem,” she said.

Forty years ago, most ambulances were free for patients, provided by volunteers or town fire departments using taxpayer money, said Jay Fitch, president of Fitch & Associates, an emergency services consulting firm. Today, ambulances are increasingly run by private companies and venture capital firms. Ambulance providers now often charge by the mile and sometimes for each “service,” like providing oxygen. If the ambulance is staffed by paramedics rather than emergency medical technicians, that will result in a higher charge — even if the patient didn’t need paramedic-level services. Charges range widely from zero to thousands of dollars, depending on billing practices.

The core of the problem is that ambulance and private insurance companies often can’t agree on a fair price, so the ambulance service doesn’t join the insurance network. That leaves patients stuck in the middle with out-of-network charges that are not negotiated, Imholz said.

This happens to patients frequently, according to one recent study of over half a million ambulance trips taken by patients with private insurance in 2014. The study found that 26 percent of these trips were billed on an out-of-network basis.

That figure is “quite jarring,” said Loren Adler, associate director for the USC-Brookings Schaeffer Initiative and co-author of recent research on surprise billing.

The KHN review of complaints revealed two common scenarios leaving patients in debt: First, patients get in an ambulance after a 911 call. Second, an ambulance transfers them between hospitals. In both scenarios, patients later learn the fee is much higher because the ambulance was out-of-network, and after their insurer pays what it deems fair, they get a surprise bill for the balance, also known as a “balance bill.”

The Better Business Bureau has received nearly 1,200 consumer complaints about ambulances in the past three years; half were related to billing, and 46 mentioned out-of-network charges, spokeswoman Katherine Hutt said.
While the federal government sets reimbursement rates for patients on Medicare and Medicaid, it does not regulate ambulance fees for patients with private insurance. In the absence of federal rules, those patients are left with a fragmented system in which the cost of a similar ambulance ride can vary widely from town to town. There are about 14,000 ambulance services across the country, run by governments, volunteers, hospitals and private companies, according to the American Ambulance Association.

For a glimpse into the unpredictable, fragmented system, consider the case of Roman Barshay. The 46-year-old software engineer, who lives in Brooklyn, N.Y., was visiting friends in the Boston suburb of Chestnut Hill last November when he took a nasty fall.

Barshay felt a sharp pain in his chest and back and had trouble walking. An ambulance crew responded to a 911 call at the house and drove him 4 miles to Brigham and Women’s Hospital, taking his blood pressure as he lay down in the back. Doctors there determined he had sprained tendons and ligaments and a bruised foot, and released him after about four hours, he said.

After Barshay returned to Brooklyn, he got a bill totaling $3,660 — which is $915 for each mile of the ambulance ride. His insurance had paid nearly half, leaving him to pay the remaining $1,890.50.

“I thought it was a mistake,” Barshay said.

But Fallon Ambulance Service, a private company, was out-of-network for his UnitedHealthcare insurance plan.

“The cost is outrageous,” said Barshay, who reluctantly paid his nearly $2,000 of the bill after Fallon sent it to a collection agency. If he had known what the ride would cost, he said, he would at least have been able to refuse and “crawl to the hospital myself.”

“You feel horribly to send a patient a bill like that,” said Peter Racicot, senior vice president of Fallon, a family-owned company based outside Boston.

But ambulance companies are “severely underfunded” by Medicare and Medicaid, Racicot said, so Fallon must balance the books by charging higher rates for patients with private insurance.

Racicot said his company has not contracted with Barshay’s insurer because they couldn’t agree on a fair rate. When insurers and ambulance companies can’t agree, he said, “unfortunately, the subscribers wind up in the middle.”

It’s also unrealistic to expect EMTs and paramedics at the scene of an emergency to determine whether the company takes a patient’s insurance, Racicot added.

Ambulance services have to charge higher rates for patients they transport because the crews must be ready around-the-clock even if no calls come in, said Fitch, the ambulance consultant. When ambulance crews drive out to a call, a third of the time they end up not transporting any patients and typically aren’t reimbursed for the trip, he added.

In part, Barshay had bad luck. If the accident had happened just a mile away inside Boston city limits, he could have ridden a city ambulance, which would have charged $1,490 instead of $3,660, according to Boston EMS. That’s still “a huge bill,” said Imholz of Consumers Union.

There is little protection for consumers: Very few states have laws limiting ambulance charges, and most state laws that protect patients from surprise billing do not apply to ground ambulance rides, according to attorney Brian Werfel, consultant to the American Ambulance Association. And none of the state surprise-billing protections applies to people with self-funded employer-sponsored health insurance plans, which are regulated only by federal law. That’s a huge exception: Sixty-one percent of privately insured employees are covered by self-funded employer-sponsored plans.

Some towns that hire private companies to respond to 911 calls may regulate fees or prohibit balance billing, Werfel said, but each locality is different.

Insurance companies try to protect patients from balance billing by negotiating rates with ambulance companies, said Cathryn Donaldson, spokeswoman for America’s Health Insurance Plans. But “some ambulance companies have been resistant to join plan networks” when insurance companies offer Medicare-based rates, she said.

Medicare rates vary widely by geographic area. On average, ambulance services make a small profit on Medicare payments, according to a report by the U.S. Government Accountability Office. If a patient uses a basic life support ambulance in an emergency, in an urban area, for instance, Medicare payments range from $324 to $453, plus $7.29 per mile. Medicaid rates tend to be significantly lower.

There’s evidence of “waste and fraud” in the ambulance industry, Donaldson added, citing a 2015 study from the Office of Inspector General at the U.S. Department of Health and Human Services. The report concluded Medicare paid over $50 million in improper ambulance bills, including for supposedly emergency-level transport that ended at a nursing home, not a hospital. One in 5 ambulance services had “questionable billing practices,” the report found.

Most cases reviewed by Kaiser Health News did not appear to involve fraudulent charges. Instead, patients got caught in a system in which ambulance services can legally charge thousands of dollars for a single trip — even when the trip starts at an in-network hospital.

That’s what happened to Devin Hall, a 67-year-old retired postal inspector in Northern California. While he faces stage 3 prostate cancer, Hall is also fighting a $7,109.70 out-of-network ambulance bill from American Medical Response, the nation’s largest ambulance provider.

On Dec. 27, 2016, Hall went to a local hospital with rectal bleeding. Since the hospital didn’t have the right specialist to treat his symptoms, it arranged for an ambulance ride to another hospital about 20 miles away. Even though the hospital was in-network, the ambulance was not.

Hall was stunned to see that AMR billed $8,460 for the trip. His federal health plan, the Special Agents Mutual Benefit Association, paid $1,350.30 and held Hall responsible for $727.08, records show. The health plan paid that amount because AMR’s charges exceeded its Medicare-based fee schedule, according to its explanation of benefits. But AMR turned over his case to a debt collector, Credence Resource Management, which sent an Aug. 25 notice seeking the full balance of $7,109.70.

“These charges are exorbitant — I just don’t think what AMR is doing is right,” said Hall, noting that he had intentionally sought treatment at an in-network hospital.

He has spent months on the phone calling the hospital, his insurer and AMR trying to resolve the matter. Given his prognosis, he worries about leaving his wife with a legal fight and a lien on their Brentwood, Calif., house for a debt they shouldn’t owe.

After being contacted by Kaiser Health News, AMR said it has pulled Hall’s case from collections while it reviews the billing. After further review, company spokesman Jason Sorrick said the charges were warranted because it was a “critical care transport, which requires a specialized nurse and equipment on board.”

Sorrick faulted Hall’s health plan for underpaying, and said Hall could receive a discount if he qualifies for AMR’s “compassionate care program” based on his financial and medical situation.

“In this case, it appears the patient’s insurance company simply made up a price they wanted to pay,” Sorrick said.

In July, a California law went into effect that protects consumers from surprise medical bills from out-of-network providers. That means if a patient goes to an in-network hospital, then takes an out-of-network ambulance to transfer facilities, the law could limit the patient’s bill to in-network rates. But Hall’s case occurred before that law took effect, and the state law doesn’t apply to his federal insurance plan.

The consumer complaints reviewed by Kaiser Health News reveal a wide variety of ways that patients are left fighting big bills:
• An older patient in California said debt collectors called incessantly, on Sunday mornings and at night, demanding an extra $500 on top of the $1,000 that his insurance had paid for an ambulance trip.
• Two ambulance services responded to a New Jersey man’s 911 call when he felt burning in his chest. The private ambulance company charged him $2,100 for treating him on the scene for less than 30 minutes — even though he never rode in that company’s ambulance.
• A woman who rolled over in her Jeep in Texas received a bill for a $26,400 “trauma activation fee” — a fee triggered when the ambulance service called ahead to the emergency department to assemble a trauma team. The woman, who did not require trauma care, fought the hospital to get the fee waived.

In other cases, patients face financial hardship when ambulances take them to out-of-network hospitals. Patients don’t always have a choice in where to seek care; that’s up to the ambulance crew and depends on the protocols written by the medical director of each ambulance service, said Werfel, the ambulance association consultant.

Sarah Wilson, a 36-year-old microbiologist, had a seizure at her grandmother’s house in rural Ohio on March 18, 2016, the day after having hip surgery at Akron City Hospital. When her husband called 911, the private ambulance crew that responded refused to take her back to Akron City Hospital, instead driving her to an out-of-network hospital that was 22 miles closer. Wilson refused care because the hospital was out-of-network, she said. Wilson wanted to leave. But “I was literally trapped in my stretcher,” without the crutches she needed to walk, she said. Her husband, who had followed by car, wasn’t allowed to see her right away. She ended up leaving against medical advice at 4 a.m. She landed in collections for a $202 hospital bill for a medical examination, which damaged her credit score, she said.

Ken Joseph, chief paramedic of Emergency Medical Transport Inc., the private ambulance company that transported Wilson, said company protocol is to take patients to the “closest appropriate facility.” Serving a wide rural area with just two ambulances, the company has to get each ambulance back to its station quickly so it can be ready for the next call, he said.

Patients like Wilson are often left to battle these bills alone, because there are no federal protections for patients with private insurance.

Rep. Lloyd Doggett (D-Texas), who has been pushing for federal legislation protecting patients from surprise hospital bills, said in a statement that he supports doing the same for ambulance bills.

Meanwhile, patients do have the right to refuse an ambulance ride, as long as they are over 18 and mentally capable.

“You could just take an Uber,” said Adler, of the Schaeffer Initiative. But if you need an ambulance, there’s little recourse to avoid surprise bills, he said, “other than yelling at the insurance company after the fact, or yelling at the ambulance company.”

California Healthline correspondent Chad Terhune contributed to this report.
This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.