Mobile integrated healthcare: some questions

[RICollegeEMT]

Im placing this under ALS because in my state it can only be done by ALS providers. However admin if you think there’s a better spot that’ll generate more opinions please move it!

And I saw a bunch of notifications but it didn’t tell me what about, sorry I haven’t been active. I recently recovered from a bad accident and am trying to get back into the field full force.

So my state implemented a program about 6 months ago under our new protocols. Called Mobile Integrated Healthcare. They didn’t give us much info to work on, but more or less they copy and pasted NAEMTs program and called it a protocol.

Now I work for a private company, so far none in my state have latched on to the idea. A few FDs have played with it to mixed success— but truthfully they were doing it more as a “if we get down time we’ll ensure Grandma took her meds” type deal as opposed to full on.

Recently my state underwent a hospital closure which has innundated local systems. So I’d like to approach my management (I changed companies a while back, this one cares less about making tens of millions and more about making sure their millions are earned right) about perhaps trying to get a program up and running.

So I’m going to ask a couple questions. If you can answer I’d appreciate it.

1) has it been helpful in your state for patients?
2) has it helped reduce hospital visits?
3) since it’s a private I’ve obviously gotta answer the question (hence why I’m asking you guys!) how does billing work on that? Do insurance companies pay for “house visits” or how does that work? The company cares about patient care but since we recently major raises I doubt theyll agree to volunteering!


Thanks guys and girls!

 

[NomadicMedic]

Dr Antevy from Florida just did a fantastic presentation on several variations of MIH in his area. There’s really only one business model that’s self sufficient, and that’s one which provides homecare services to patients of a full risk HMO, like GenMed. I’d bet if you sent him an email he’d be happy to share his ppt with you.

 

[EpiEMS]

full risk HMO

Could work for an ACO, too, conceivably. But in general, agreed.

 

[RICollegeEMT]

Sorry guys, had a busy shift on account of receiving a few inches... of snow that is

Anyway thank you both, I’ll see if I can send him an email.

What is “a full risk hmo”? And what’s an “aco”. I’m sorry I’m completely daft when it comes to types of insurance.

 

[SpecialK]

Sierra has been in place since 2012. In Auckland SER1 and 2 operate during the day and SER1 only at night. Each is staffed either by a Paramedic or an ICP and they target calls identified by Control as "low acuity" (all GREY calls and some GREEN automatically, and other GREENs only upon further triage by the Clinical Hub) and primarily for non-transport or non-ambulance transport.

The non-transport rate is very high and I don't know of any adverse incidents but I'm sure there's been one or two probably, invariably there'll be one sooner or later if there haven't been any to date, but I highly doubt this.

There is also the Clinical Hub which does proper triage (not that rubbish MPDS bollocks) of all GREY and GREEN calls and wherever possible the pt is sent off somewhere else without a physical response. I believe the rate of doing so is about half but might be a bit higher or lower I don't know. A huge addition to the Clinical Hub is the recently started up mental health line which takes most mental health calls and puts the person onto an experienced mental health nurse and I believe the Police control room can also do the same not just Ambulance.

This is of course all in addition to the fact all ambulance personnel at EMT or above can assess, treat and discharge.

Works a treat and is going to expand in the future; there'll be a time when transporting somebody somewhere by ambulance will become the exception.

 

[RICollegeEMT]

Thank you sir, I replied by pm hoping to get a little more info.

 

[EpiEMS]

What is “a full risk hmo”? And what’s an “aco”. I’m sorry I’m completely daft when it comes to types of insurance.

Here's a decent primer from the NYT's "Upshot" blog.

And from ACHE, here's something useful on capitation.

 

[RICollegeEMT]

Here's a decent primer from the NYT's "Upshot" blog.

And from ACHE, here's something useful on capitation.

So if I’m reading this right (and please correct me if I’m misunderstanding!) hmos essentially say “here’s $10,000 for John Doe for this year” if JD only needs $5,000 then the healthcare group pockets the remaining $5k, but likewise if JD needs $20,000 worth of care then the healthcare group loses $10k?

And acos are more “John Doe here’s $10,000 for your treatment” and JD can use that at any healthcare group he wants?

Please If I’m misinterpetting let me know, I’ve never been good with understanding insurance and billing.

 

[RocketMedic]

Pretty much. Its known as "risk sharing". The model effectively amounts to contract labor with provider profit coming from providing enough of the right care the first time to avoid having to provide costlier care. Problem is that many providers and payors balk at the cost of quality, sufficient first care and impose limits on how much quality care is provided that makes it hard to do.

 

[EpiEMS]

@RICollegeEMT More or less correct, as @RocketMedic said. The idea is that given a fixed amount of money per patient to spend (capitation), you'll spend more efficiently - and focus more on prevention where you can.

So for an ACO or HMO, it makes perfect sense to have a community paramedic who can help somebody avoid, say, a $1,500 ambulance ride and $3,000 ER visit, when all they need is help changing their catheter or what have you.

 

[RocketMedic]

The problem being that most payors don't actually pay those rates to providers and thus see little reason to fund preventative care that is expensive, and providers are reluctant to start offering those services on a widespread basis for fear of endangering their current primary revenue streams. After all, if a community medic can replace a Foley for $100 and telemed can reorder insulin for $5/call, why is the STEMI team really $30k?

 

[Carlos Danger]

The fatal flaw of this reimbursement scheme - the main reason it will fail as badly as the previous system - is that it places very little (if any at all) responsibility for the cost of service on the consumer themselves. Because the person receiving the care isn't paying for it, they have no incentive to seek value, or even to maintain a healthier lifestyle.

This scheme attempts to replicate the incentives for value that are naturally created by a free market, but it won't work.

 

[RICollegeEMT]

I’m sorry guys just got to these.

I appreciate all your inputs.

Remi I get your points. I swear welfare has jaded me. But regardless we all pay taxes even if they won’t help themselves if we can find a way to make a $3000 Er call cost only $2000, they may not help themselves but we’re helping ourselves!

 

[Carlos Danger]

Remi I get your points. I swear welfare has jaded me. But regardless we all pay taxes even if they won’t help themselves if we can find a way to make a $3000 Er call cost only $2000, they may not help themselves but we’re helping ourselves!

Yeah, I was more talking about the overall picture of the healthcare system in America, since the discussion turned towards reimbursement schemes.

Our healthcare system is collapsing because our overlords in DC ignore basic economic principles in designing these programs. Until the consumer has a real stake in things, they will continue to over-consume healthcare resources indiscriminately, and healthcare service providers will continue to lack any real incentive to innovate (not to mention the countless regulations that make real innovation either very difficult or even illegal). Trying to replace those natural and highly effective market forces with top-down management like has been an abject failure so far, yet we are doubling down on it.

OK, end of rant. Off my soapbox now.

Efforts like this are certainly worth a try, because regardless of anything else, they may improve quality and efficiency of care, and those things should be our top goals anyway.

 

[EpiEMS]

After all, if a community medic can replace a Foley for $100 and telemed can reorder insulin for $5/call, why is the STEMI team really $30k?

Price vs. cost

And as for the STEMI team, I think the main thing going on here is that like a trauma team, there is a cost to have folks sitting around ready to respond. Secondarily - obviously - like trauma teams, many (most?) patients who need the services don't actually pay the quoted rate.

Until the consumer has a real stake in things, they will continue to over-consume healthcare resources indiscriminately, and healthcare service providers will continue to lack any real incentive to innovate (not to mention the countless regulations that make real innovation either very difficult or even illegal).

This, this, this - 100%. The Oregon Health Insurance Experiment has shown this - people with insurance use more services & don't have better outcomes - and a huge body of research (such as the RAND HIE)shows that people use services more efficiently when they have to bear direct costs.

 

[RICollegeEMT]

I’m sorry guys, sorry it takes so long to reply— no excuse this time, saw the emails and frankly just forgot. Sorry.

I get what you’re saying remi and company.

It’s disheartening. I mean hell in my state they’ve literally issued a memo saying “we know rsi is in your scope, yes a doctor on-line can order you to do it if they feel it’s the best solution. But ya know what we don’t like it so nope”. Literally happened. I emailed the governor, asking for some support furthering EMS... still haven’t heard back doubt I will.

In terms of Washington. Ehhh I’m surprised I even bother voting anymore.

Honestly this country is effed.

End rant.

I get what you’re saying. I certainly wanna try to influence change. But I know it’s probably lost cause.



Now let me ask you guys this. And I know we typically are avoidant to journalists (they’re annoying). My alma Marta had a journalism programme. Think reaching out to them might help? Assuming they hop on the story.

 

[FiremanMike]

I think you need to lay out the objectives for your program and then work backwards from there.

First and foremost, you need to sit down with your administration, layout your end goal, and make sure they’re on board with this program being cost negative for the foreseeable future. I believe there may be some MIH programs that are running in the black, but that entire process is unbelievably complicated and depend on hospital involvement as well as local laws regarding reimbursement of non transport scenarios.

For us, we started our program from the approach of improving our community as opposed to revenue generation. We knew that there were folks within our jurisdiction that lacked resources and/or personal tools to manage their personal medical problems and we wanted to impact their lives in a positive way. Not only have we yet to receive even a penny of reimbursement from insurance or our local hospital system, but big picture our department is actually losing money on the program through both manpower costs as well as decreased transport reimbursement (well managed patients call 911 less). But, as stated, we chose to pursue our program as a community resource and continue to accept the investment in it.

So how do we quantify success and/or efficacy of our program? Well that’s what we’re trying to determine now.. Our MIH team/medical director have spent the last few months debating what data points to monitor and how to determine if we’re actually making a difference. Going back to our internal goal of community improvement, it’s easy to say that patient X is better off now that we’ve given them the tools to help improving their day to day life, but it remains difficult to find metrics to say that our community is XX% better now thanks to MIH.

I’m sorry, I know you were probably hoping for the magic formula to sell this, but the fact of the matter is that MIH is absolutely in its infancy and no one really has the answers yet. I do encourage you to reach out to our community paramedic who’s email I sent to your inbox. He is infinitely more knowledgeable than I and happy to answer any of your questions..

 

[RocketMedic]

MedStar in Fort Worth also is a wealth of information regarding community paramedicine. They're willing to share, IIRC.

As for RSI...don't take offense, it's risk management. Sure, its necessary, effective and safer than some alternatives, but it also takes a significant investment in training to do safely and effectively and there is an argument to be made for improving capital before it is allowed as well (video scopes, vents). For a business oriented at the bottom line, it doesn't necessarily make sense to spend that money and assume that liability for a procedure that can generally be alternatively managed and deferred to the ED. Improved SGA, nasal intubation, good BLS airway management, etc.

 

[Tigger]

We run a profitable MIH program in rural Colorado. The solution was not coming up with services to offer local partners, may those be hospitals, healthcare networks, doctors offices, county health, or whomever you identify. None of these entities want to do things your way, they have what they think works for them. If you want to make actual money doing MIH then you are going to have identify a local entity who is struggling to meet their own mandate. Then you identify how you can work to provide their service with your resources.

We provide mobile mental health crisis response and treatment. Notice I didn't say treatment. We provide a relatively basic, flow-chart based assessment along with some diagnostic testing (EKG, saliva drug test, alcohol PBT, and Chem8 with an iStat). From their we make a transport decision in consultation with the local mental healthcare Regional Care Coordination Organization. These are state identified organizations that work to provide services for ACOs. They in turn pay us per patient for these services.

This works because the RCCO has a mandate to provide mobile crisis response and they were not able to do that in our area as it was not logistically feasible to do so. We provide exactly the same service they do in areas that they can afford to serve.

The more traditional MIH schemes of "navigating" patients to appropriate destinations and preventing readmission avoidance are difficult to get paid for. Patient navigation (ie the patient who has no idea what do about their non-emergent complaint) just doesn't pay. It should, but most entities have not been successful in getting long term grant funding to make this a reality. Same goes for readmission, though there are a few success stories there.

 

[Bullets]

I run a private agency that is contracted with a municipality to provide 911 BLS (EMT/EMT) service.

I have started to get this going in this town. It is not intended or expected to make us money. We are doing this to help our residents have a better quality of life and give our residents better service. Right now i am just doing them in my down time, i take the list of transported residents from the previous day, head down to the ER and get dispositions on everyone (which i was already doing).

I then take this list and visit each person. A typical visit will include reviewing discharge notes, making appointments, calling in prescriptions, arranging delivery, and doing a home assessment. Are the loose area rugs everywhere? is the 4 miles of nasal cannula tubing, is their walkers/rollator/wheelchair/cane in good condition or need repairs?

If it goes well, and it seems like it is, i will start having the crews do a few during their downtime as well. I have a couple of medics working for me so they will probably be the pointy end of the stick.

As tigger said, dont bother trying to involve the hospital. I started that way and it was a miserable experience. At first they didnt understand what we were doing, then they wanted stuff that we couldnt provide. Ultimately you need to figure out what services are missing in your catchment and try and fill that gap. We have a large senior population but no in town senior services department or a decent senior center and APS is overwhelmed.