Promoting Innovation in EMS




capable of, an agency is unlikely to invest in the training, equipment or oversight necessary so as long as payment is linked to mandatory transport. Under the current payment model, the financial sustainability of any innovative program that might potentially reduce the number of transports to the ED is severely limited. 45 There is value to patients, hospitals, and payers for the competent medical care provided by EMS independent of transportation, and thus reimbursement policies should reflect that. If CMS and other payers paid for the successful outcome of the patient, the patient might possibly experience improved outcomes and avoid unnecessary ED visits. The classic example of the misaligned incentive is the case of a 9-1-1 call for a diabetic patient suffering from hypoglycemia. In many cases, EMS can very easily correct the urgent hypoglycemia event and could triage out a portion of patients who would not benefit from being taken to the ED. 46 Potentially, they could coordinate care for the patient with their PCP or endocrinologist, without the need for an ED visit. However, because EMS is only paid if the patient is transported, EMS agencies generally transport such patients to an ED, triggering both the EMS payment and the downstream ED costs.

EMS agencies across the nation face misaligned incentives. CMS and most payers do reimburse EMS at various levels according to the care provided; however those payments are predicated on the provision of transportation. 41 Medical management of a patient may require the application of many skills and consume significant EMS resources, yet if it results in no transportation, there would be no reimbursement. Multiple articles 42,43 and several influential federal documents including the EMS Agenda for the Future (1996), the Institute of Medicine report (2007), and the HHS Draft White Paper on Opportunities for Innovation in EMS (2012) 44 have cited the need for EMS payment to be disconnected from transportation and better aligned with improved health and better health care value. As the proverb says, “you get what you pay for.” Currently, we primarily pay for transportation, not healthcare. Therefore we primarily receive transportation and its possible that the health care we receive is less than it might otherwise be. Although there are many things EMS may be

41 Ambulance Billing Guide. NHIC, Center for Medicare & Medicaid Services; 2010. 42 Munjal, Kevin, and Brendan Carr. “Realigning reimbursement policy and financial incentives to support patient-centered out-of-hospital care.” Jama 309, no. 7 (2013): 667-668. 43 Morganti, Kristy G., Abby Alpert, Gregg Margolis, Jeffrey Wasserman, and Arthur L. Kellermann. “Should payment policy be changed to allow a wider range of EMS transport options?.” Annals of emergency medicine 63, no. 5 (2014): 615-626. 44 “Innovation Opportunities for Emergency Medical Services: A Draft White Paper.” National Highway Traffic Safety Administration (DOT), Office of the Assistant Secretary for Preparedness and Response (HHS), and Health Resources and Services Administration (HHS). Last modified July 15, 2013. http:// 45 Eckstein, Marc. “The ambulance industry struggles to go the distance.” Health Affairs 32, no. 12 (2013): 2067. 46 Lerner, E. Brooke, Anthony J. Billittier, Daniel R. Lance, David M. Janicke, and Josette A. Teuscher. “Can paramedics safely treat and discharge hypoglycemic patients in the field?.” The American Journal of Emergency Medicine 21, no. 2 (2003): 115-120.




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