Payment Reform In EMS & Mobile Integrated Healthcare: Presented by: G. Christopher Kelly, Esq.

Community Paramedicine/ Mobile Integrated Healthcare What is it? “The provision of healthcare using patient- centered, mobile resources in the out-of- hospital environment that are integrated with the entire spectrum of healthcare and social service resources available in the local community.” (NAEMT, NASEMSO, NAEMSP, ACEP, NEMSMA, AAA…) MIH can use EMTs, nurses, PAs, MDs…and yes, even Paramedics

Mobile Integrated Healthcare The Goal- Institute for Healthcare Improvement’s (IHI) “Triple Aim Initiative”: Improving the Patient Experience Improving the Health of Populations Reducing the per capita cost of healthcare

Mobile Integrated Healthcare Getting the right patient, to the right care, at the right time. Being more than a transport benefit- being a partner: ACOs- shared cost savings model MCOs- Medicaid cost savings model Bundled Payment models- based on H stays

Mobile Integrated Healthcare- Payment & Funding: Grants- (“Seed Money”) State and/or Federal Cost/Loss Avoidance- Internal- the uninsured patient Hospital- Uninsured patients Readmissions Hospice- Disenrollment incentives Insurance Payors- Frequent Flyers Observational Admissions

Mobile Integrated Healthcare Can’t get traction without ties to payment: Hospital readmission prevention: CHF Heart Attack Pneumonia Chronic Lung Disease CABG surgery Example: $100M in Medicare + 1.5% penalty = $1.5M annual cost for readmits https://sca.advisory.com/Maps/Home/MapView?v ar=p4p

SCA example- Provider ID 040134 Provider Name Arkansas Heart Hospital State AR Zip Code 72211 Base Operating Amount $ 39,930,409 Medicare IP Revenue $ 43,397,127 Estimated P4P Net Impact Total Impact ($) -$ 926,385 Total Impact (%) -2.13% Hospital Readmission Reduction Program (HRRP) Final Readmissions Adjustment Factor 0.9768 Readmission Impact ($) -$ 926,385 Value Based Purchasing (VBP) Final VBP Adjustment Factor No Data

Mobile Integrated Healthcare Could there be more? Insurance payment for EMS under cpt codes Payment for treatment without transport Payment for emergency transport to MD Payment for transport to minor med/clinic

Possible CPT codes: 9-1-1 Nurse Triage Services 98967: Telephone assessment and management service provided by a qualified non-physician healthcare practitioner.   Mobile Healthcare Paramedic Visit – Routine 99349: Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Mobile Healthcare Paramedic Visit – Episodic/Emergent 99341: Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity

Payment for Treat-No Trans. A0998- ambulance response and treatment- no transport Anthem/BCBS- Hospital Emergencies- no pay unless needed On scene treatment = $360 Cheaper than an ER bill!

Possible Alt. Dest. Codes- Ambulance Transport, Emergency, Alternate Destination A0429 (modifier) D: Diagnostic or therapeutic site other than P or H when these are used as origin codes E: Residential, domiciliary, custodial facility H: Hospital N: Skilled nursing facility P: Physician’s office R: Residence S: Scene of accident or acute event   Examples: HCPCS Code 9-1-1 Ambulance, Scene, Transport to Urgent Care A0429 SD 9-1-1 Ambulance, Scene, Transport to Primary Care Clinic A0429 SP 9-1-1 Ambulance, Home, Transport to Urgent Care A0429 RD 9-1-1 Ambulance, Home, Refer to PCP, scheduled App’t A0998 RP

Minnesota – Treat, but No Transport MHCP covers no transport calls ONLY if ambulance staff provides medically necessary treatment to patient at the pickup point. When billing, use procedure code A0998 (ambulance response and treatment, no transport) Do not use a modifier As of Jan 1, 2017, BCBS of MN follows same guidelines.

California Alternate Destination Project (Details to come)

PA House Bill 1013 Proposed legislation requires reimbursement even if patient refuses transport but following conditions are met: ALS or BLS unit is dispatched by county 911 center EMS provider MUST have provided medically necessary treatment even if patient declines transport. Bill is currently pending in PA Senate’s Banking and Insurance Committee.

Other Payment Reforms? Alternate Destinations- Emergency to Physician Emergency to Clinic Emergency to Mental Health Facility Why Non-traditional Destinations? Quicker Access Lower Cost New Challenges- Not the ER experience

Contract Template Between EMS and Alternative Destination Sites Getting to an understanding- Avoiding uncertainty Things to consider: Operating hours Volume limits Stretcher accessibility Scheduled unavailability- Doc on Diversion Getting home

Patient Consent Form Similar to refusal form Can be combined Must show a clear understanding of the patient Must allow for acceptance of alternate destination Should provide financial impact information Should allow for higher level of care if necessary

Telemedicine- calling EMS Telemedicine= “origination site” to “destination site” via live audio/video feed “Telecommunications System”- Not cell phones or Skype Origination= Health Provider Shortage Area (“HPSA”) Destination= MD/Practioner, hospital, or clinic Ga Medicaid allows EMS to be “telemedicine facility” Q3014= $25 ($20 @ 80%) Modifiers: GT = interactive audio/video telecommunications GQ = asychronous (store and forward) telecomm. Facility fee, professional fee, or both?

Questions, comments, concerns: ckelly@pwwemslaw.com