By Roxanne Shanks
Health care policy seems to be in constant change with little clarity on where it is headed. Several policy changes being considered in Washington, from repeal of Obamacare to other, less publicized proposals could have an impact on EMS and how we care for our patients and run our businesses.
Here are five health care-related policy changes that EMS leaders need to be planning for.
1. ACA repeal and replacement
You can’t look at any news media and not see an article on the status of Congress effort’s to repeal and replace the Affordable Care Act. The ACA promised too much. It expanded coverage to millions, which it was intended to do, but also had other consequences.
The law required health plans to cover things they didn’t cover before the ACA, and the ultimate result was increased costs and high-deductible plans. Insurers needed younger patients to sign up to balance out the high-risk patients, but the ACA penalty for not signing up was not robust enough to force people to purchase insurance.
As I write this, the House of Representatives has passed its version of the replacement bill, the American Health Care Act. The key elements of the AHCA are the repeal of ACA taxes and reforms to the individual market and Medicaid financing. Now the Senate is drafting its version of the bill, with many in Washington still unsure whether lawmakers can reach a compromise that can pass both houses.
With the uncertainty surrounding these policy changes, EMS leaders must be aware of the current political climate and take the following steps:
Anticipate what may be coming that could have an impact on your business, such as:
- An increase or decrease in the number of insured patients
- Higher or lower deductible insurance plans
- Improved or worsened access to care
- Increases or decreases in coverage for preventative care
- Increases or decreases in coverage for prescription drugs
Model how changes could impact your organization and key stakeholders:
- Shift in the payer mix of the populations you serve
- Decreased funds and/or per capita limits for Medicaid, especially in states that expanded Medicaid under the ACA
- Bad debt and uncompensated care expenses have been on the rise due to high-deductible plans
- Volume decreases in 911 services if more preventative care is covered.
Prepare action plans for the different potential outcomes based on the modeling.
2. Reimbursement policy challenges and opportunities
Changes in reimbursement policies and participation in programs that piloted new reimbursement models have affected many sectors of health care. As these efforts continue to evolve, they will most likely expand to include more health care providers, including EMS.
Some of the possible reimbursement challenges and changes on the horizon for EMS include:
- Bundled payments: The proposed rule on the Centers for Medicare and Medicaid’s new episode payment models has been delayed until Jan. 1, 2018. This will require health care providers to understand all the costs associated with caring for patients with certain acute conditions, as CMS will now incentivize hospitals to achieve good outcomes, rather than reimburse simply for procedures, tests and other services.
- Risk-based models: Providers working with public and private payers can expect to face either lower fee-for-service rates or more demands to take risk, such as agreeing to care for a designated population for a set payment. EMS leaders need to seek partners who can help them increase efficiencies and avoid taking on risks that are outside of their control.
- Quality reporting: Organizations will need to be particularly careful to ensure they work closely with their electronic health record vendors, as the reliability and reporting can make the difference between penalty and bonus payments in some of the new reimbursement models.
- Medicare fee schedule: Temporary Medicare ambulance fee increases expire at the end of the year. Will these finally be made permanent or will they approve another long-term extension?
- Supplier vs. provider: There are ongoing efforts to shift ambulance services from suppliers of medical transportation to providers of health care, which could lead to increased quality reporting, required standards of care and value-based payments.
- Funding for alternative models: As policymakers and payors continue to emphasize increasing preventative care and decreasing hospital admissions, coverage for mobile integrated health care and alternative transport destinations could also expand.
3. Expanding consumer choices and demands
Consumers are demanding more education, more accurate information, more value-based options and more transparency. Increasingly high-deductible health plans are shifting health care costs to patients, who are also being encouraged to take more ownership of their medical care. This has sparked the entrance into the market of non-hospital innovators who offer attractive alternatives at lower prices.
Consumers also have instant access to information and quality data on health care providers, and direct access to new online marketplaces connecting them directly to out-of-market providers nline market places cover the gamut of services, such as Honor for home health services, Amwell for on-demand telemedicine via video or phone and MediBid for high-end surgeries where providers can bid for care.
Consumers have choices and are getting more involved in how they choose, access, and pay for health care. For EMS providers we must be preparing for this by anticipating the following:
- Public reporting of charges for our services. Conducting an analysis of charges to ensure they are reasonable and defensible will be critical.
- Consumer expectations for on-demand convenient services. Mobile integrated health care and community paramedicine programs could play a huge role in addressing this need.
- An increasingly patient-centered approach to providing health care-related services. EMS needs to continue to find ways to engage patients in decisions about their care.
- An evolving focus on preventative care, which could force EMS agencies that primarily respond to 911 calls to look at expanding their value-added services.
- The need to seek feedback and measure patient engagement and satisfaction. CMS has required hospitals to evaluate the patient experience as part of tying reimbursement to the IHI Triple Aim.
4. Ability to administer critical medications
Administering medications in the prehospital environment can sometimes mean the difference between life and death for a patient, but some regulatory changes have threatened the ability of EMS providers to do so without direct, real-time physician oversight. This past year, multiple industry stakeholders have conducted extensive lobbying efforts to ensure EMS can continue to deliver necessary medications in a timely manner.
On Jan. 9, 2017, the House of Representatives unanimously passed the Protecting Patient Access to Emergency Medications Act (H.R. 304). This vital legislation addresses several critical issues for EMS by:
- Statutorily preserving the ability of EMS agencies to utilize standing orders to govern the administration of life-saving medicines and
- Providing a clear framework to enable the Drug Enforcement Administration to oversee EMS in a consistent manner across the nation and clarify rules to allow for effective patient care but also prevent diversion of controlled substances.
In order to become law, the Senate still must pass this legislation. EMS leaders should actively be communicating with your state’s congressional delegation on the critical importance of this bill.
5. Changes in the competitive landscape
Health care providers traditionally adopted a competitor-centric strategy. They monitored their closest competitor’s performance, analyzed their market share to gauge financial performance and tried to ensure stewardship of community assets.
In the new era of health care this shift in strategy is rapidly moving toward a customer-centric model. Health care providers now focus on providing maximum consumer value, gaining lifetime loyalty and improving quality. How EMS systems expand services beyond emergency care will shape the competitive landscape.
Health care systems will be looking to partner with organizations that bring value-added services that improve quality and reduce costs. The focus will be on preventative care and in-home services. This provides convenience to the consumer as well as low-cost care. Expect this shift to continue to evolve with the next era of health care reform.
Thinking about all the possible changes that could occur with health care and how we deliver services can be very overwhelming. As leaders, if we stay focused on continually improving quality, looking for ways to be more efficient and innovating and adding value, we will be able to respond and adapt to whatever changes come our way.
About the author
Roxanne Shanks, RRT, MBA, FABC, is a senior associate at Fitch & Associates. She serves as the CEO for LifeFlight Eagle Air Medical Program in Kansas City, Missouri, and also as the executive director of the Association of Critical Care Transport. Roxanne has an extensive background in health care leadership with more than 20 years of experience in progressively responsible clinical and leadership roles within an integrated delivery system. She can be reached at rshanks@lifeflighteagle.org.
