clinical processes and outcomes, it is possible that it will lay the foundation for payers to base their reimbursement models on something other than transportation. REIMBURSEMENT THROUGH TELEHEALTH An opportunity to find a new source of revenue for EMS agencies may be to harness the opportunity presented by telemedicine or telehealth. As EMS considers new initiatives to bring value to patients, it sometimes becomes useful to connect the care happening in the field in real time to an emergency physician or perhaps a primary care physician or other specialist. Although reimbursement for telehealth services, in general, lags behind reimbursement for traditionally delivered health care services, there are many states where payers are required to reimburse, and sometimes at equal rates with an in-person visit. Perhaps, EMS agencies that employ physicians could utilize this mechanism to bill for non-transport encounters. Currently, reimbursement for telehealth services within EMS is nearly non-existent. In some jurisdictions, telehealth is only reimbursed if initiated from within a “health care facility.” For billing purposes, the interior of an ambulance, and/or the location of care being attended to in the field by a trained health care provider (e.g. paramedic), should be considered a qualifying health care facility. EMS advocates need to make policymakers aware of this policy failure that misses an opportunity to provide patients with improved, telehealth-enabled, prehospital care. Payers might choose to separate EMS telehealth from other types of telehealth in which they are reimbursing the physician only. Perhaps they would consider reimbursing EMS for “delivering” a patient to definitive care, which might include a telehealth encounter with a physician if appropriate. Or they may prefer to develop a code modifier for EMS
encounters that include direct medical oversight via telehealth. Ideally, the reimbursement sought should be uniform across all payer platforms, governmental, commercial, and private, in order to make it feasible for EMS to provide the same standard of care to all patients, regardless of payer type or the ability to pay. IMPROVING EMS BUSINESS CAPABILITIES EMS needs to acquire the business acumen to be able to evolve with the changing environment around them. Having a strong grasp and control of EMS system finances, on both the revenue and expense sides, will provide for the strong foundation necessary from which grassroots innovation can emerge. It will further be invaluable when attempting to negotiate financially sustainable payment contracts with payers or others for a new innovative service. Specifically, EMS agencies should retain or internally develop leaders with the business acumen and education necessary to create a sound financial structure for the management of the financial health and wellbeing of the agency. While a few programs already exist, the industry may need to increase partnerships with institutions of higher education to develop educational curriculums that are geared toward EMS administration. Similar to the issues around provider education, agencies need to recognize the value of these skills and appropriately incentivize the acquisition of these skills. In the end, agencies must be able to dissect their finances until every component of the EMS response, every clinical or administrative process, is understood from a cost perspective. 61 Industry leaders and national associations need to develop key performance indicators and benchmarks for financial data, and share best
61 Lerner, E. Brooke, Graham Nichol, Daniel W. Spaite, Herbert G. Garrison, and Ronald F. Maio. “A comprehensive framework for determining the cost of an emergency medical services system.” Annals of Emergency Medicine 49, no. 3 (2007): 304-313.
MOUNT SINAI HEALTH SYSTEM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
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