Friday, April 5, 2013

The Crystal Ball— Obamacare and EMS

The Beginning of Something Different
Over the past year or so, we’ve received questions from our clients about the potential effect of “Obamacare” on the future of Emergency Medical Services in the United States.

Frankly, it’s impossible to provide concrete answers to these questions right now, because no one really knows what the effect will be in its entirety. However, we’ll use this space today to take a look into our EMS billing crystal ball in an attempt to forecast what the future may look like.

The industry is beginning to get hints of where this all may be going. It’s pretty much expected that things will change and we’ll see a different overall healthcare picture in the days ahead. There’s no doubt about that.

But just where will EMS fit into the picture?

Terms
First, let’s be sure that we all are familiar with the terms.

“Obamacare” is officially the Patient Protection and Affordable Care Act (PPACA). It’s often also referred to as just the Affordable Care Act. The Congressional bill itself is a mountain of legislation and accompanying Federal regulations.

Like anything the Feds do, we develop this litany of alphabet soup terms that we’ll need to know a lot about as time goes forward.

In addition to PPACA, be aware of the letters ACO. ACO stands for Accountable Care Organizations, which are at the heart of this new healthcare delivery system. According to the CMS, “ACO’s are groups of doctors, hospitals and other healthcare providers who come together voluntarily to give coordinated high quality care to their Medicare patients.” The ACO will function to keep an eye on reimbursements for healthcare providers while tying those reimbursements to ongoing studies about the quality of care that is being provided to patients.

ACO’s can contract with Medicare under yet another set of letters known as an MSSP or Medicare Shared Savings Program. So a single ACO would be the responsible party for monitoring the quality, cost, care and management a large group of Medicare recipients. The MSSP will reward ACO’s that lower the growth of healthcare costs for the patients they serve while at the same time meeting performance standards on quality of care.

The MSSP’s three key goals will be to:
  1. Promote accountability for the care of Medicare Fee-For-Service beneficiaries 
  2. Require coordinated care for all services provided under the Medicare Fee-For-Service program
  3. Encourage investment in infrastructure and redesign patient care processes
Go on…
Now that you know the terms, here’s how it will work.

Remember, the idea of Obamacare is to control the costs and reign in spending for healthcare in the United States, especially spending that is funded via the entitlement programs: Medicare and Medicaid.

As part of a MSSP, the ACO, under contract with the government, will be given the power to deny or cut reimbursements to any provider of service (doctor, hospital, EMS service?) that can’t meet the quality standards for various treatments and procedures.

The big impact will be to hospitals, where reimbursements can flat out be denied altogether, if a patient is readmitted to a hospital within a three-day window for the same problem they were initially hospitalized for. So, you can rest assured that the hospitals you serve will become much more diligent about the education and follow-up care provided to their patients, in an effort to prevent them from having to be readmitted.

Where Can EMS Fit?

Hospitals and hospital practitioners are typically tied to buildings. Concrete, brick and mortar define a hospital, and the existing paradigm finds most of the activity in the institutional setting tied to those buildings.

EMS, on the other hand, is mobile by definition. We operate in moving vehicles that carry supplies and service providers that can adapt to just about any scenario while having the capabilities to go where the patient is, assess their situation and meet the patient face-to-face.

We’re hearing of EMS systems in certain progressive geographic areas in the United States actively working on pioneering paramedicine programs that can serve the role of the field monitor. These programs would be an EMS/hospital system/facility partnership whereby the hospital would contract (and pay money) to local EMS providers to provide routine checks and evaluations of patients in the field.

With the ultimate goal of paramedicine wrapped-up in promoting quality of life as part of the everyday life activities following medical or traumatic events, it would seem that the inpatient and out-of-hospital practice is on a convergence pathway.

The focus, of course, of these paramedicine visits, then, would be to reach out and touch those persons who have recently been discharged following an inpatient stay to assure that the patient is following all post-inpatient directions, such as taking medications and participating in prescribed rehabilitation mandates, with the underlying goal of helping to keep that patient from being readmitted to the hospital for that same medical condition that hospitalized them in the first place.
Translated…patient avoids readmission; hospital is reimbursed for patient stay by the ACO; hospital rewards EMS for their part by paying a portion of that reimbursement to the EMS agency to provide the follow-up service.

A new EMS revenue stream may evolve. Time will tell.

Until…

Aside from the MSSP and ACO process there is another side of PPACA, and that involves Medicaid/Medical Assistance.

We’ve said this before, but until all this comes into place we fear that EMS call volumes will rise, but without a direct effective reimbursement increase to help offset the costs of the additional volume. Citizens that currently do not have health insurance coverage or are grossly underinsured, will initially be transitioned into the Medicaid roles. We all know that persons who didn’t have coverage and now have coverage can experience a new-found freedom to use their coverage. Therefore, for something as simple as lack of reliable transportation or doctor affiliation, the easiest means of getting from point A to point B can potentially become the ability to activate the EMS system where now a third-party will pay for that service.

Call volumes will initially increase, which means additional expense to the EMS system as a whole in order to adequately cover that spike in activity.

As any of us that follow EMS reimbursement activity closely knows, Medicaid reimbursements, depending on the State, are traditionally a fraction of what it will cost to provide the service. If we’re treading water now in areas where there is a high entitlement population, imagine what things will be like when this starts.

More red ink and more creative budget shuffles will be the name of the game for many EMS systems until the dust settles, whenever that may be.

There are also those persons that believe that this kind of spike may just be offset by a decrease in repeat transports for chronically ill patients who will be discouraged to call 9-1-1 to return for treatment by the above suggested follow-up routine.

That’s certainly a possibility.

What Can Be Done Right Now?
There are a few things that you can do to begin preparing for these changes. We suggest that you begin developing your strategy today.

First, review your numbers. Know your costs. Understand your revenue streams and watch the trending as things may begin to shift. Hopefully, your billing office or billing contractor can provide you with the kind of reports that allow you to do this.

Second, stay on top of the changes. Keep monitoring key industry publications, follow information sources like our blog regularly and/or network with other EMS managers via social networking and the Internet. Have your finger on the pulse and monitor the industry’s, and you own service’s, vital signs more than ever.

Most importantly, begin talking with your local hospitals and health systems right now. Don’t wait until the last minute, because it may be the neighboring service or your competitor that’s already hooked up with the hospital to do field follow-up by the time you contact them to set-up a relationship. This is definitely coming, so why not get out of the gate first? Plus, we’re pretty sure your hospital’s administration will be impressed that you are being proactive regarding these changes!

Join Us…
We hope that you’ll use this blog as a resource for information on a regular basis. As we learn and hear of things that are up and coming, especially concerning the new Obamacare initiatives, you can rest assured that we’ll bring our readers up to date as time goes on.

Enhanced clients have the inside track just by being a client. If you’d like to become a raving fan client of Enhanced Management Services too, drop us an e-mail or give us a call. The e-mail address is chumphrey@enhancedms.com or you can call us toll-free at (800) 369-7544, Extension 108. Be sure to check us out on the web too, at www.enhancedms.com.
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