Changes in law could help fill payment gap for emergency responders
By Laurelle Walsh
Aero Methow Rescue Service does it. Paramedics in the Seattle area do it. And emergency medical service (EMS) professionals across the United States do it all the time. They respond to a 911 call only to discover that the caller hasn’t taken their blood pressure medication, has a cough that won’t go away, or refuses to take their insulin.
Some of these patients are frequent 911 callers who are known to EMS responders because they have chronic needs that are not being met by the current health care system.
These calls may be considered non-emergencies, but EMS still must respond. “If you are sick and call any of the clinics after hours, you are directed to call 911. That call goes directly to Aero Methow. And when a 911 call comes in, we have to go — we don’t triage,” said Cindy Button, paramedic and director of Aero Methow Rescue Service.
So, frequently, the responder examines the patient, takes vital signs, counsels and reassures them, straightens out their immediate issue, and leaves, after determining that the person doesn’t need transport to a hospital.
Aero Methow responders don’t mind coming to your home and, in fact, want you to call if you feel that you need them, Button said. The issue is that the EMS provider only gets paid for treatment that happens as part of transporting you to the hospital.
“The two biggest holes in the system,” according to Button, are the amount of care Aero Methow is allowed to do in the home, and the fact that there is no way to bill for non-transport care.
“Seventy percent of what we do is not emergency care and isn’t paid by insurance companies, Medicare or Medicaid,” said Button. “We’re not reimbursed for that. We are saving taxpayers money by not taking people to the hospital.”
Mobile Integrated Healthcare
The problem is not limited to the Methow Valley. In recent months, the Albuquerque Journal, KENS-5 Eyewitness News in San Antonio, Texas, and the Lexington Herald-Leader have all reported on the issue and local attempts to find a fix.
One solution that’s being embraced in different models around the country is called community paramedicine or Mobile Integrated Healthcare (MIH).
“The fog is lifting on Mobile Integrated Healthcare,” said Button. “In this model the patient is in the center, not the doctor. It’s keeping people safe at home while taking steps to prevent transporting patients to the hospital if not necessary.”
In MIH, paramedics and advanced emergency medical technicians are able to provide chronic disease management, preventative care, and follow-up visits after a patient is discharged from the hospital. They are reimbursed for providing a broad spectrum of appropriate care, not limited to taking patients to a hospital emergency department.
“We can kind of close the loop with doctors in two ways: by letting them know when we pay a visit to their patients and relay to them what the patient tells us. We do electronic patient care reporting already,” Button said.
The model is actually not a stretch for Twisp-based Aero Methow, said Button, since the agency’s parent corporation was Methow Valley Home Health Agency, started in the late 1960s by Button’s father Dr. William Henry, “before EMS was even a thing.”
Button is chair of the North Central Emergency Care Council regional workgroup for Mobile Integrated Healthcare, a group that has been meeting monthly to begin laying the groundwork for MIH in our region.
She has also been consulting with officials from Snohomish County Fire District 1, which is in the middle of a 2-year community paramedicine pilot program. That program showed “impressive data” at its six-month evaluation, where they found a 60 percent reduction in repeat 911 calls and a 50 percent reduction in emergency room visits by the 200 “high system utilizers” in the program, according to District 1 Captain and former Aero Methow paramedic Shaughn Maxwell.
Under this model, “paramedics are able to do more care coordination and connect people to the right resources,” Maxwell said. And in the future it will open up the doors to coordinated care between hospitals, doctors, EMS, public health, hospice and home health by allowing them to share patient records, Maxwell said.
The first barrier to implementing such programs across Washington is the wording of the current law governing EMS that stipulates that emergency medical technicians and paramedics may only provide care under emergency or life-threatening conditions.
“The law is keeping us from helping people and saving taxpayer money,” Maxwell said.
So, Maxwell and other EMS leaders around the state are lobbying to change the law, and have found 10 lawmakers to sponsor Senate Bill 5591 in the current Legislature, which will make it possible for advanced emergency medical technicians and paramedics to provide non-emergency medical care under the direction of a Community Assistance Referral and Education Services (CARES) program.
“This will probably be the most transformative change made in the WAC [Washington Administrative Code] since the implementation of EMS,” said Maxwell, who testified before the Senate Government Operations and Security Committee on Feb. 3.
“It will take legislative action to adopt the changes necessary to make this official,” said Button. “We have to enlighten some of our bosses in Olympia. We’re not looking to add anything beyond what we’re already doing. I see this as lowering the curtain and exposing what we really do.”
A work in progress
Development of MIH is already in Aero Methow’s strategic plan, and the agency’s board of directors has asked Button to budget time to work on it, she said. A working model should be in place within the next two and one-half years, Button said. MIH will be implemented in the next five to ten years, she figures.
In the mean time, Aero Methow has to work out a plan for funding the program, which EMS agencies in other parts of the country have solved by partnering with a hospital, managed care organization or physician practice, or by funding it themselves.
“For us it’s a matter of getting reimbursed for non-transport calls and we want to re-write the protocols to reflect that,” Button said. One thing she knows for sure is that Aero Methow doesn’t have money in the current budget to fund MIH, but she is looking into other options, Button said.
“It’s all a work in progress,” said Button. “We’re moving forward with it, but it’s like climbing Everest and we’re still gathering our tools.”