of emergency safety net preparedness and aligning EMS financial incentives with the remainder of the health care system.” 2 Similarly, the IOM Report also made the case for integration with the rest of the health care system: “To function effectively, the components of the emergency and trauma care system must be highly integrated. Operationally this means that all of the key players in a given region…must work together to make decisions, deploy resources, and monitor and adjust system operations based on performance feedback.” 3 Going further, we envision an EMS system that maximizes value to the community by bringing definitive care into patients’ homes and providing new and innovative services that support the Triple Aims of improving patient experience, improving the health of populations, and reducing the cost of health care. 4 THE TIME TO INNOVATE IS NOW! Health care has changed dramatically in the past few decades. It has started moving away from fee-for-service medicine and toward realigned incentives focused on value and efficiency. These recent trends have been facilitated and accelerated by the passage of the American Recovery and Reinvestment Act (ARRA) of 2009, which incentivized hospitals and physicians to adopt electronic medical records, and the Patient Protection and Affordable Care Act (ACA) of 2010, which authorized numerous demonstration projects within Medicare including the accountable care organization (ACO). The health care industry is now increasingly focused on creating value through higher quality, less expensive care, and on promoting integration of healthcare across the continuum. The Center for Medicare & Medicaid
Services (CMS) recently announced a dramatic acceleration of the transition to quality-linked payments and alternative payment models. Projected future payment models reflect this change, as shown in Figure 1. 5
FIGURE 1
Target percentage of payments in ‘FFS lined to quality’ and ‘alternative payment models’ by 2016 and 2018
2014
2016
2018
2011 0%
20%
30%
50%
68%
>80%
85%
90%
HISTORICAL PERFORMANCE
GOALS
Alternative payment models (Categories 3-4) FFS linked to quality (Categories 2-4) All Medicare FFS (Categories 1-4)
While EMS has often been a neglected area within the national health policy arena, now that health care is rapidly moving towards population-based care management, it potentially has much to contribute. EMS has the advantage of being mobile, and operates 24 hours a day, 7 days a week rather than just during business hours. It is embedded in nearly every community and has extensive experience working with patients in their homes. While the health care system reorients itself toward community-based care and influencing the social determinants of health, in many ways, EMS providers are a step ahead. With a modest amount of additional training, perhaps they could coordinate care, navigate patients, provide education, and ultimately lower cost and improve
2 “EMS Agenda for the Future.” National Highway Traffic Safety Administration. Last modified 1996. https://one.nhtsa.gov/people/injury/ems/agenda/emsman.html 3 “Emergency Medical Services at the Crossroads.” In Future of Emergency Care Series edited by Gail L. Warden. Washington, D.C.: Institute of Medicine, 2006. 4 Berwick, Donald M., Thomas W. Nolan, and John Whittington. “The triple aim: care, health, and cost.” Health affairs 27, no. 3 (2008): 759-769. 5 Tefera, Lemeneh. “Hospital Value-Based Purchasing Program.” (PowerPoint Slides) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/2013-2015-HVBP-Presentation-.pptx.
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CHAPTER 1
MOUNT SINAI HEALTH SYSTEM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
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