Community Paramedicine: A New Paradigm?

Here’s a really interesting post authored by Kevin Munjal MD (class of 2012).  Kevin is an ED physician at Montefiore Hospital in the Bronx and a passionate advocate for re-thinking our EMS system to provide integrated, higher quality, lower cost care.  Recently, Kevin joined a CMS working group in D.C. on EMS payment reform.  (Also, he makes a SUPERB Cost Benefit Analysis paper-writing partner, just saying).  Read on.

Did you know that Medicare only pays an ambulance when they drop off a patient at an emergency room?  That’s right, no payment for a highly sophisticated dispatch system that must be on on alert at all times; no payment for evaluating a patient in their home or at a scene; no payment for providing life saving or other treatments to a patient on scene.  Furthermore, the EMS agency requires that its providers never tell a patient they don’t need to go to a hospital (even if the patient asks)!  Patients must sign a “Refusal of Medical Aid” statement and occasionally must speak with an online medical control physician before being released from the care of EMS.  If an agency believes that it might not be in the best interest of a patient to go to a hospital, or if an alternative destination such as a primary care office, dialysis center, urgent care center, or public health clinic would be more appropriate, they must choose between the patient’s best interest and their own financial interest.

This kind of perverse financial incentive is rampant throughout our healthcare system.  However, while federal and state efforts at health reform are finally seeking to realign incentives in the rest of healthcare, prehospital care has been left out. Ironically, this is despite a long history of EMS providers trying to change their payment model from the current fee for service system to one that better represents their role as a public good.

The key to understanding the advantages of EMS payment reform is the idea of staving off “downstream costs.”  If an EMS agency is perversely incented to bring a patient to an ER (for whom there is little marginal benefit for being there) in order to collect a $450-750 EMS bill, they have now triggered an ER charge in excess of $1000 simply by having the patient register at the hospital.  This is a swing from $0 for all the care provided by EMS minus the transport to approximately $1500 simply because they transported the patient to the ER.

Alternative payment models might include global payments, block grants, shared savings agreements or even simply a division of fee for service payments to reward all the other useful components of EMS besides the drive to the hospital.  Once you change the payment model, a variety of alternative models of EMS become financially viable.  Systems in which prehospital care agencies transport patients to the most appropriate destination, or not at all, start to make sense.

Can we trust EMS to make these decisions?  Well, EMS agencies already are overseen by physician medical directors and have QA procedures in place.  Certainly, more investment in medical oversight is required but consider the rapidly advancing state of telemedicine / telehealth products.  What might not have been possible without extraordinary investments are now available through personal mobile devices.  Thus, I propose that small investments in prehospital care systems could be offset by dramatic savings in unnecessary ER visits all enabled through a change in the way we reimburse EMS.

A world of possibilities begins to open up.  What if a prehospital care system could refer non-acute patients for followup? What if EMS providers could make referrals for social work, case management, health navigators? What if they could coordinate with a patient’s primary doctor, or with the specialist who has been caring for this patient’s condition that led to the call?  What if they could provide biometric data, basic physical exam findings such as lung auscultation and use a videophone to allow a doctor remotely to have eyes on the patient.  Could some or all of this obviate the need for transport to an emergency room?  Could it do so at lower total cost to the system?  Could this lower a patient’s cost?  Could this avoid missed work days, lost productivity and other costs to the rest of the economy?

Can we go even further?  Can EMS agencies, with their existing skillset function outside of the emergency context?  Can they visit patients in advance of their calling 9-1-1?  Can they work on preventing emergencies rather than just treating them?  I believe that the answer to all of these questions is a resounding yes!  These ideas are encapsulated in a term “community paramedicine.”

Under new experimental payment models such as accountable care organizations, wouldn’t it make sense for EMS to be better integrated into the health care system?  If care management and medical homes are good ideas because they can avoid ER visits, it seems contradictory to not allow EMS to intervene at the point of contact to avoid unnecessary ER visits.  If health systems are training legions of allied health professionals to take their skills into the community and into patient’s homes as part of better quality and patient centered-ness, it seems contradictory to not use a class of health professionals already trained to work in the out-of-hospital environment.  My hope is to realize a new vision for healthcare, one that harnesses the full potential of prehospital care systems in order to achieve better quality and lower costs.

— Kevin Munjal MD

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