After the passage of the Affordable Care Act (ACA), community paramedicine began emerging within the EMS industry. To many, these programs were the realization of common-sense thinking. Utilizing trained paramedics to prevent emergencies is a far better approach than using them only to respond to emergencies.
Momentum began building for a fundamental shift in the way paramedics were utilized. However, one large problem still remained: how does EMS get reimbursed for providing community paramedicine and mobile integrated health care services?
Inadequate EMS Reimbursement
EMS has been perpetually plagued by under-funding and a reimbursement structure which pays largely on the distance a patient is transported. EMS has also shouldered the responsibility to be integral to the nation’s health care safety net by responding to every emergency call for the service.
Much like hospitals, which can’t refuse a patient needing care in emergent situations regardless of ability to pay, EMS agencies respond to all requests for service.
First responder agencies and ambulance services are responsible for large numbers of uninsured or underinsured patients. Private businesses and local governments (and occasionally state governments) underwrite the cost of those unable to pay for EMS and hospital care they receive. For those patients without insurance, the large-scale Medicaid expansions under the ACA were a key part in assisting with the costs of providing EMS service. However, these expansions weren’t implemented in all 50 states.
If the ACA is repealed or restricted, it could have a significant impact on the agencies operating in states which implemented the expansion — unless the state government steps up to increase funding for under- or uninsured patients.
In the post-ACA age of population health, EMS leaders have been looking toward sharing a percentage of payments being paid by insurance companies to hospitals, sharing in the reduction of the hospital’s expenses by providing care in the community or sharing in the reduction of readmission penalties that Medicare has begun imposing on the hospitals in an effort to improve care and control costs. Readmission penalties created under the ACA could possibly face extinction despite proof that they work.
Change is Inevitable
Despite the outcome of the ACA, it is a certainty that the reimbursement methods of our health care system must, and will, change. Regardless if it happens under the Trump administration or in the future, the current EMS fee-for-service model will eventually be replaced. When this change happens, it will impact the EMS industry a great deal, since fee-for-service is at the roots of our current reimbursement-per-mile system.
That’s worth saying again. Regardless of what happens to the ACA, the reimbursement system for health care, and EMS, will ultimately be overhauled. That’s good news for both the transport side of the industry and the community paramedicine side. Ideas being floated as replacements still center around the concept of population health and are exactly where community paramedicine plays a crucial role.
In these proposed changes, bonuses and penalties, such as those implemented under the ACA, play a key role in helping the system transition from fee-per-service to the so-called value-based reimbursement. It’s still possible that community paramedicine programs will be integral to helping hospitals achieve bonuses and reduce penalties.
When reimbursement is ultimately overhauled and reimbursement is based on the health of a given population, community paramedicine might achieve its full potential. When the outcome of the patient takes priority over the amount of turns an ambulance’s wheel makes on the way to the hospital, we’ll see widespread utilization of preventative care by paramedics. This is destined to happen eventually (read decades), regardless of changes a repeal or replacement of the ACA might bring.
About the Author
Stephen Hatez is a paramedic, writer and MBA/MA Candidate at Johns Hopkins University.