Our Biggest Challenge may be Our Best Opportunity – Medicare Pay for Performance and EMS

Winding our cot through the hospital hallways, my partner and I we’re trying to efficiently complete the task at hand. It had been a busy morning and this scheduled return trip from the hospital to the nursing home was all that stood between us and a well-deserved lunch. At least, that was what dispatch had assured us as they snagged us out of the report room to take the call. It was simple enough, a short trip from the inpatient Med/Surg unit of BigHospital to a nursing home three miles away. It wouldn’t take us more than a half-hour to get everything all wrapped up.

That is, until we got to the patient’s room.

At the time, I wasn’t the most experienced paramedic in the world, but I knew audible rales when I heard them… from the hallway. The patient was sitting in his bed working as hard as he possibly could in order to breathe. His lungs were full of pulmonary edema and he was obviously in crisis with respiratory distress. I walked over to the nurses’ station, conveniently located directly across the hall from the patient, and asked a nurse about him.

“Oh good, you’re here. He’s going back to NursingHome X. He’s all ready for you to take him. That’s his paperwork on the counter” said Anonymous Nurse. I asked her who his nurse was and if I could speak to her. As it turned out, Anonymous Nurse just so happened to be assigned to our soon-to-be patient.

“Have you checked him recently? He seems to be having some difficulty breathing.” I told her, not really waiting for her to answer my question before I told her why I asked.

“Oh he’s fine, he was having a little earlier but he’s a DNR and the nursing home is ready for him” she retorted.

(Not to get away from the point of this, but the nurse’s statement is why I wrote THIS POST way back in 2009 during an angrier moment in my life, but I digress…)

“Um, I really think you should look in on him. He’s not doing well at all. He’s got rales so bad I can hear them from here. Really, if you listen you can hear them too. <pause for effect> See? I don’t think he’s so ready to go back to NursingHome X yet” I countered.

I’ll spare you the rest of the story because it’s not my main point but as the EMS people in the audience probably know already, the nurse got very angry with me when I refused to take the patient back to the nursing home on the grounds that he was rapidly progressing into respiratory failure and demanded that she call the patient’s attending physician. She was even angrier with me when the doctor had the patient transferred to the ICU based on the phone call. Yeah, she called my boss to complain but luckily there just so happened to be a social worker that overheard our exchange and called my boss as well to commend me on sticking up for good patient care while being just so darn polite about it.

This was the only time I can think of where I stood my ground and refused to take a patient out of a hospital for a discharge transfer because I believed they would die during the transport, but I can think of several times during my career where I have turned around and taken a patient back to an emergency room when they crumped on me during a discharge trip. It seems that it has happened during my career more so than the statistical likelihood should be if the hospitals were always being as conscientious as they could be when discharging patients. And I mean all of the hospitals. I’m not singling out any one of them. Every hospital has occasional times where patients are discharged a little early for a variety of reasons and have to be readmitted back in a very short amount of time.

And today, October 1st 2012 marks the day where that will become a real problem for all hospitals due to a change in Medicare regulations. Medicare will start fining hospitals that have too many patients readmitted for care within a 30-day period.

I don’t want to get all Chicken Little on you all but Ladies and Gentlemen, we have a problem. As I stated before in a previous post, hospitals are going to start to become very interested in how ambulances take care of their patients.  They’re tracking every single scrap of data they can devise a way to get their hands on and in my opinion, they will start tracking the performance of individual ambulance services much more so than they do now. If some ambulance services bring in (or transport back) patients who do better (or are readmitted less) than other services, they’re going to discover that if they don’t know it already. Trust me, they employ an army of people whose only jobs are to devise new ways to track data in preparation for this and other Medicare pay for performance regulations. They have to; there is an unfathomable amount of money on the line.

Read this article for yourself, and read it well. Understand every word because this signifies the coming change that will rock our entire industry: “Medicare Fines Over Hospitals’ Readmitted Patients” (AP)

There are a few quotes I want you to pull out of that and be sure you think about:

“About two-thirds of the hospitals serving Medicare patients, or some 2,200 facilities, will be hit with penalties averaging around $125,000 per facility this coming year, according to government estimates.”

“For the first year, the penalty is capped at 1 percent of a hospital's Medicare payments. The overwhelming majority of penalized facilities will pay less. Also, for now, hospitals are only being measured on three medical conditions: heart attacks, heart failure and pneumonia.

Under the health care law, the penalties gradually will rise until 3 percent of Medicare payments to hospitals are at risk. Medicare is considering holding hospitals accountable on four more measures: joint replacements, stenting, heart bypass and treatment of stroke.”

I am not debating the political ramifications of these regulations. I’m saying that they are here, they’re in effect now, and the amount of money they mean to almost every hospital you can think of is simply staggering. I’m saying that if your ambulance service has a higher rate of patients being readmitted to a hospital due to infection, you have a problem. If your ambulance service has a higher rate of patients who do poorly after being brought in from the field, you have a problem. Also, if you don’t believe me… well then you probably have a problem as well.

EMS needs to be out in front of this! We as an industry have to get up and be out there addressing the problems that these regulations are going to bring! Please tell me that I’m not the only one who sees this… please tell me that I’m just uninformed and there are smart people out there already working on this problem and have already come up with solutions… because if not then we all have a heck of a lot of work to do.

However, this may be the biggest opportunity for our profession that I’ve ever seen.

I believe that the future of EMS lies in community paramedicine. I believe that we have to expand the EMS business model so that we have more ways to serve our patients and generate revenue. To date, the biggest hurdles for community paramedic programs have been finding ways to pay for and generate revenue with them. I assure you that providing post-hospital discharge follow-up care as a way to make patients healthier and avoid subsequent readmissions is very much within the realm of a community paramedic. I also assure you and every hospital person reading these words that paying a community paramedic to perform those services is much, much less expensive than is being fined for having too many readmissions. Trust me, someone could easily pay for a rather expansive community paramedicine system for much less than 1% of their hospital’s total Medicare reimbursement.

I’ll leave you with another quote from the AP article:

"There is a lot of activity at the hospital level to straighten out our internal processes," said Nancy Foster, vice president for quality and safety at the American Hospital Association. "We are also spreading our wings a little and reaching outside the hospital, to the extent that we can, to make sure patients are getting the ongoing treatment they need."

I’ll say it again. We need to be out in front of this issue. Now.

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If you’re interested in what I’ve said on this issue in the past:

Change Medicare, Save EMS

Primary Care Paramedics? I Think it’s Time

  • Rescue Monkey

    Chris, I agree that this will drastically change the environment within hospital systems. With all the Medicare changes, many hospitals are looking to rebrand themselves as a system (in patient, out patient, rehab, home health) rather than individual business units.

    I am not sure how transporting a patient to a nursing home who then gets admitted back to a hospital within 30 days is a reflection on the ambulance service or the level of patient care of said ambulance service. There are few times where this scenario will be caused by the ambulance service. I would like to hear more on what the ambulance services can do to affect this.

    • Ckemtp

      Joel, did you read my article one-previous to this one? (I linked to it in this article). I absolutely believe that there is a link between ambulance transportation back to a nursing home and readmission. It’s small, but I believe it would probably be statistically significant.

      Imagine if you will that Hospital uses both Ambulance service “A” and Ambulance service “B” for discharge trips. They track who they send each patient with. If they determine that patients who get transported by ambulance service “B” have even a 5% readmission rate due to nosocomial infection, then they will identify the infection control process of ambulance service B to be lacking and possibly sever their contract. I would.

      These numbers are going to be tracked if they’re not being tracked already. Things we see as small will be analyzed and corrective measures will be taken. If we are contributing to readmission rates due to any of our processes, those processes will need to be identified and corrected.

      Remember, NOTHING is insignificant when millions of dollars are on the line. We should all remember the story of the Airline and the Olive.

  • hospital readmission has very little to do with the care provided by an ambulance service, its mostly a function of how well the patient’s physician and  nurses at the nursing home take care of them, so I bet Hospital X is going to be breathing down the necks of SNF’s to do better

  • dave

    I do not claim to know if hospitals will look to ambulances to lower the readmission rate, but we all need to be vary scared of this regulation. The larest effect of this law will be on the hospital admission policies. The intent of this law is to make hospital give better care but the result will be to withhold care to pt’s that they see as too much of a risk. This will blow back in the faces of EMS crews and our pt’s care will suffer. This is a bad law and we all should do what ever we can to get rid of it. Peoples lives are on the line.