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Emergency Medical Services in Value-Based Care

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January 18th, 2017

Emergency medical services (EMS) evoke images of EMTs and paramedics responding to medical crises and transporting patients to the hospital rather than thoughts about value-based care and changes in health care delivery and payment models. EMS leaders are trying to change that paradigm through a movement dubbed “EMS 3.0.”

EMS 3.0 aims to make emergency medical providers active participants in the current health care transformation that prioritizes and rewards value not volume. The effort is not entirely new. In 1996, several national EMS associations developed the EMS Agenda for the Future, which argued that treatment and transport for trauma and acute illness should be just one of three responsibilities for EMS. The other two included the identification and prevention of injury and illness. Despite these goals, the role of EMS largely remained “you call, we haul,” the rapid response and transport of patients in medical crisis.

Of course, rapid response times and effective emergency care for cardiac, stroke, and other acute patients remain the fundamental performance metric and responsibility of EMS.

However, the EMS leaders promoting EMS 3.0 want to position emergency medicine as an integral component of value-based care by building on existing innovative programs that demonstrate the expanded potential of EMS. The National Academy of Sciences recently recommended that Congress and the Department of Health and Human Services “implement mechanisms that ensure the inclusion of EMS as a seamless component of healthcare delivery rather than merely a transport mechanism.” Advocates for broadening the role of emergency medicine believe EMS can help achieve the Triple Aim of healthier people, reduced spending, and an improved patient experience.

EMS 3.0 has momentum. Programs such as 911 nurse triage, mobile integrated health care (MIH), and community paramedic (CP) services exist throughout the U.S. and show early signs of success.

In nurse triage programs, emergency dispatchers and nurses use medically-approved protocols to identify low acuity calls – those involving minor injury, flu-symptoms, and chronic pain – and route patients to the appropriate care location. In some cases, nurses have arranged for a taxi to transport a patient to their primary care physician or have assisted callers in setting up mail-order prescriptions. A 2015 study found that nurse triage programs in Fort Worth, Texas and in Louisville, Kentucky together saved $1.2 million because of directing patients away from the ED. Moreover, 91.2 percent of patients reported satisfaction with the service.

Additionally, other programs are leveraging EMS practitioners and vehicles to provide in-home patient care and education through mobile integrated health and community paramedic (MIH-CP) services. These programs aim to prevent hospital readmissions, assist patients with chronic conditions, and steer patients toward appropriate care centers such as primary care offices and substance abuse clinics. Many of these programs began by identifying frequent 911 callers, evaluating their needs, and developing appropriate services. For example, paramedics may take blood glucose measurements, change a wound dressing, and provide diabetes screening and education. A survey by the National Association of EMTs (NAEMT) found that 81 percent of surveyed programs that had existed for at least two years reported reduced costs, 911 use, and ED visits.

Challenges exist for these programs. Obstacles include laws that restrict EMS to exclusively a response and transport service, scope of practice and educational restrictions that limit the procedures EMTs and paramedics may perform, resistance from home health workers who worry MIH-CP programs threaten to duplicate their services, and, of course, funding.

Still, NAEMT believes these types of programs can cement emergency medicine’s inclusion in value-based care. In response to the proposed Medicare Access and CHIP Reauthorization Act (MACRA) legislation, NAEMT encouraged the Centers for Medicare and Medicaid Services (CMS) to consider developing an alternative payment model (APM) for MIH-CP programs. Though MIH-CP programs may not yet be candidates for APMs, NAEMT’s letter indicates emergency medicine’s commitment to value-based care. Moreover, now that the first performance period for MACRA has begun, NAEMT can work to align new or existing programs with the criteria for APMs.

EMS 3.0 seeks to transform emergency medicine into a service that both reacts to, and works to prevent, acute emergencies and that is integrated into the health care system transitioning to value. Indeed, existing nurse triage and MIH-CP programs exemplify many of the elements of successful value-based programs through their reliance on community assessments, multidisciplinary care coordination, and a commitment to improving patient outcomes while decreasing costs.

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