By Ken Brody
Community paramedicine programs employ EMS providers in non-traditional roles to expand access to care for underserved populations. Community paramedics have been used to conduct in-home visits to assist patients with chronic health and other medical issues. They have also been used to assist hospital discharged patients to comply with post-discharge instructions designed to reduce the onset or return of conditions that require ambulance transports to hospitals, and often readmission.
Sadly, although these programs have popped up here and there, their growth has been inhibited by many factors. Here are two of those limiting factors – restrictions on EMS provider practice and funding for prehospital services – and potential solutions to grow the reach and impact of community paramedicine.
Statutory barriers to community paramedicine
Some states block community paramedicine programs by restricting the practice of EMS providers to that of responding to calls for ambulance assistance and providing first response services. EMS providers are educated and trained to perform skills that could be employed to provide patient care in other settings, but they may perform those skills only as permitted by state law. When they provide care within their skills, but outside the statutory confines of their certification, they risk being fined or otherwise disciplined.
The statutory barriers to community paramedicine need to be removed. State legislators need to be educated about the benefit of community paramedicine programs — not only how they can increase access to care for underserved populations, but also how they can reduce health care costs by helping to limit preventable ambulance transports and expensive hospital stays. If your state has not enacted such legislation, and you determine that implementing a community paramedicine program makes sense for your organization, approach members of your legislature to sponsor such legislation, but first do your homework to ensure that your pitch is well-received.
Understand that your voice is not the only one legislators will listen to on the pros and cons of enacting community paramedicine legislation. You need to engage other stakeholders and allies, like your state ambulance and hospital associations.
Under the Affordable Care Act Hospital Readmissions Reduction Program, hospitals that exceed more unplanned readmissions of Medicare beneficiaries than expected for specified conditions are penalized by reductions, up to three percent, of the Medicare reimbursements to which they would otherwise be entitled. Hospitals can be financially rewarded by contracting with an EMS agency that offers a community paramedicine program designed to provide patient care that will reduce hospital readmissions. The money a hospital would pay your organization for providing post-discharge community paramedicine services for select discharged patients is likely dwarfed by what they will save in avoiding Medicare penalties under the Hospital Readmissions Reduction Program.
Approach local hospitals, as well as the state hospital and ambulance associations, for support and to explain the value of community paramedicine. Your state ambulance association should embrace the additional opportunity for ambulance service providers and their EMS personnel to expand their niche in the state’s health care system by delivering services they are well qualified to provide.
Also, seek to avoid, or at least minimize, opposition to community paramedicine programs from other health care providers such as nurses and home health care agencies. They may see these programs as infringing upon their turf. Meet with them and their associations to identify needs in the health care system that they are not addressing and discuss how community paramedicine programs can help to address those needs. Explain how community paramedicine programs are not competing with them and that by filling gaps in access to care community paramedicine programs can be a source of referrals to other health care services. Also, meet with patient advocacy groups to explain the benefits of community paramedicine programs and seek to gain their support.
When you make your presentation to members of your state legislature, it will be most helpful if other stakeholders with some political clout join with you in touting the benefits of such programs. It would also be wise to ensure those legislators that you have discussed such legislation with other stakeholders, such as the state’s home health care agency association, and that they have advised you that they will either support or not oppose it.
Reimbursement for community paramedicine
The next most significant barrier to the expansion of community paramedicine programs is the lack of funding. Medicare and other federal health care programs pay for ambulance transports; with few exceptions, they do not pay for community paramedicine services. Likewise, most commercial insurers do not pay for community paramedicine services.
The lack of funding needs to be attacked at both a state and federal level. While some states have passed community paramedicine legislation, many of them have simply authorized a limited number of pilot project programs funded by grants. In addition to securing legislation authorizing community paramedicine programs on an ongoing basis, your state Medicaid agency and commercial insurers need to be convinced that their coverage of community paramedicine services will reduce their overall payments for the services they cover.
Having EMS providers conduct in-home visits to patients participating in a community paramedicine program, without using an ambulance to do so, is far less expensive than having EMS providers respond to a preventable emergency dispatch and then transport the patient by ambulance to a hospital emergency department. If government and commercial insurers are convinced that community paramedicine programs will reduce ambulance transports and hospital care for their beneficiaries, while costing less than they would otherwise be paying for services they cover, they have an incentive to revise their reimbursement policies to cover community paramedicine services.
Before you approach these insurers to persuade them to cover their beneficiaries for community paramedicine services, you need to gather data from areas in the country where these programs have been implemented. If the data show that these programs have resulted not only in fewer unnecessary emergency ambulance transports, but also a reduction in hospital admissions and costly hospital services, show these insurers thist data to convince them that covering such services is in their interest. Also, show the results to your Congressional representatives and attempt to convince them that they should pass legislation to require Medicare to do likewise.
While acceptance of community paramedicine programs has been expanding, that acceptance by states, commercial insurers and the federal government is still in its infancy. To accelerate that acceptance, much time and effort is needed to overcome existing obstacles. Legislation at state levels to permit EMS providers to provide services outside of their traditional roles through community paramedicine programs must be enacted where no such legislation currently exists. Legislation or other government action at both state and federal levels authorizing federal health care program reimbursement for such services must be achieved. Working with other stakeholders to show your legislators where these programs have increased access to care by underserved populations, and reduced health care costs in serving those populations, will go a long way in achieving these results.
