community paramedic payment reform december 2 nd,2015 terrace mall- north memorial
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Community Paramedic Payment Reform
December 2nd,2015
Terrace Mall- North Memorial
Improving Care, Health & Cost
Effective Community Paramedic programs inherently support the Triple Aim framework to optimizing health system performance
Primary Care Focus
PROVIDERS ARE UNDER INCREASED PRESSURE TO CONTROL COSTS
•Reduce ED utilization
•Reduce admissions and readmissions
•Expand primary care
•Encourage health care home usage for complex patients
•Community benefit plan - broad goals to improve population health
Patient Care
Payer source Primary Care Referral
CommunityParamedic
The Value of CP in Accountable Care
Enabling Legislation, Credentialing
● Linking Primary Care & EMS
CP: ACOs
How ACOs work
Doctors, hospitals, and other health care providers who volunteer to work together in an ACO are able to access medical records to help coordinate care.
Providers also receive data from Medicare (medical history, medical conditions, prescriptions, medical visits) to be better able to improve care and manage financial risk.
When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.
Several models of ACOs exist across the Country…
Health Care Financing Models Fee-for-service payment is reimbursement for specific, individual services provided to a patient.
This model involves payment for specified care coordination services, usually to certain types of providers. The most typical example of this is the medical or health care home model whereby the medical home receives a monthly payment in exchange for the delivery of care coordination services that are not otherwise provided and reimbursed.
Pay for performance can be defined as a payment or financial incentive (e.g. a bonus) associated with achieving defined and measurable goals related to care processes and outcomes, patient experience, resource use, and other factors.
Episode or bundled payments are single payments for a group of services related to a treatment or condition that may involve multiple providers in multiple settings.
The comprehensive care or total cost of care payment model involves providing a single risk-adjusted payment for the full range of health care services needed by a specified group of people for a fixed period of time.
Hospital Stars Rating
The healthcare industry is under intense pressure to boost the transparency of quality data and provide information consumers can use to make more informed decision about their care.
CMS first applied star ratings in 2008 to nursing homes. Last year, the agency rolled out similar programs for home health providers, large group practices and dialysis facilities.
The survey asks patients about factors such as the responsiveness of hospital staff to their needs, the quality of care transitions and how well information about medications is communicated. The survey is sent out within a few days of discharge. It also asks the patient about the cleanliness of the hospital and whether the patient would refer the hospital to others.
Why a Hospital would use a CP
Hospitals are at risk for up to 4.5% of their total Medicare payments based on readmissions (3%) and value-based purchasing (VBP) measures (1.5%). All-cause readmissions are measured for patients discharged with MI, heart failure and pneumonia diagnosis related groups (DRGs). In October 2014, COPD and hip and knee replacements were added to the list of DRGs. The three-year trend for most hospitals has seen increasing readmission penalties.
CMS added the metric of Medicare spending per beneficiary (MSPB). This evaluates the average spent by Medicare for the three days preadmission, during the inpatient stay and for 30 days post discharge. If the MSPB is higher than the state or national average, the hospital may face additional financial penalties. For some hospitals, the financial incentive to reduce high readmission penalties may outweigh the actual payments they receive for the admission.
Partners for EMS in the CP World
Integrated Health Care Systems
Home Health Care
Hospice
Hospitals and Payers trying to control utilization
Long Term Care
Engaging Potential CP Payers
The realignment of fiscal incentives within the healthcare system has created an environment that encourages providers and payers to work together to right-size utilization.
Providers and payers are often unaware of the true value EMS agencies can bring to their patients through proactive and innovative patient navigation services.
To work in the new environment, you need to become well-versed in healthcare finance, specifically as they relate to the partners to whom you’ll be proposing. Be sure you know things like readmission rates and penalties, value-based purchasing penalties, HCAHPS scores, MSPB and other motivating factors you can use to help build the business case for your CP program.
ACO: CP Value
MEDICARE ACOMEDICAID ACO
Withholds
ER 5%
Medical Home-Care coordination payments for managing complex chronic conditions
Improve financially on Medical Assistance reimbursement
Avoid Withholds
Increase Patient Satisfaction Scores
Quality Measures
Reduce avoidable readmissions
Opportunity to share in the savings produced
Opportunities for CP to impact the ACO achievement of Triple Aim Goals: Improved Patient Care, Enhanced Patient Experience, Reduced Cost of Care
North Memorial CP Medicaid Demo
High-risk patients served by North Memorial are getting home visits from community paramedics, who help them avoid the emergency room by providing care in coordination with their doctor’s offices and clinics. North Memorial uses data from the Department of Human Services to identify those who are most at risk and includes them in its groundbreaking community paramedic program.
Bonus Payments of: $800,000, $1.5 million in year 2.
Initial Data Review-Population
