Mobile Medicine Strategies and
Vision for all Providers
Douglas R. Hooten, MBA
Executive Director
MedStar Mobile Healthcare
Fort Worth, TX
Jonathan Washko
AVP – CEMS Operations
North Shore – LIJ Health System
Manhasset, NY
Emergency
Medical
Services?
Unscheduled
Medical
Services!
Current State of Unscheduled
Care
Life Line
E/D’s
Out of
Hospital Care
Noncompliance
Urgent Care
Current State of Unscheduled
Care
• 9-1-1 safety net access for non-emergent
healthcare
– 36.6% of 9-1-1 requests are non-emergent
• Past 12 months Priority 3 calls
(37,508/102,601)
• Problems with uncontrolled and
unmanaged access
– Emergency department as the source of
primary care
Current State of Unscheduled
Care
• Incentivized to use the highest cost
transport to highest cost care setting
– And it’s the easiest…
– Same with hospital admissions
Current State of Unscheduled
Care
• Reasons people use emergency services
–
–
–
–
To see if they needed to
It’s what we’ve taught them to do
Because their doctors tell them to
It’s the only option
• Many patients using ED have payer
source…
Frequent Users of Emergency Departments:
The Myths, the Data, and the Policy Implications
Results
Frequent users comprise 4.5% to 8% of all ED patients but account for
21% to 28% of all visits. Most frequent ED users are white and insured;
public insurance is overrepresented. Age is bimodal, with peaks in the
group aged 25 to 44 years and older than 65 years. On average, these
patients have higher acuity complaints and are at greater risk for
hospitalization than occasional ED users. However, the opposite may be
true of the highest-frequency ED users. Frequent users are also heavy
users of other parts of the health care system. Only a minority of
frequent ED users remain in this group long term.
Why is this important?
Annals of Emergency Medicine
Volume 56, Issue 1 , Pages 42-48, July 2010
Our New World:
Our New World:
• ACA tipped the 1st domino
• New partnerships
– ACOs
• Aligned incentives/risk sharing
• Bundled payments/episode of care
– Pay for performance
– Satisfaction-based reimbursement
• EMS impacts 25% of health expenditures
Our New World:
• Changing healthcare market
– Current U.S. healthcare system built on
quantity, not quality
– Most likely payment bundled in some form of
Accountable Care Organization
• Greater emphasis will be placed on
OUTCOMES
– Quality measures
• Likely that your current major payers will
not be in the future
Our New World:
• 5.6 million health care jobs will be created
by 2020 - University of Georgetown
• By 2015, 33% of hospital payments will be
based on patient satisfaction (PPACA)
• 50% of health expenditures occur in last 2
years of life
• Today, 40 million people > 65
– 70 million in next 20 years
• 2010 20,000 docs short
– By 2025 = 140,000 to 214,000 short
Our New World:
• Catalyst for Payment Reform (Yes, CPR)
– Coalition of employers (Wal-Mart, Intel, GE for
example)
– Pushing for value oriented payments to
providers (20% by 2020)
– Aetna – Now paying the same for c-section or
vaginal birth – eliminate incentive for csection (H&HN)
– $1,250 for screening colonoscopies –
regardless of in or out of the hospital (H&HN)
Our New World:
• AHRQ = 1% of patients accounting for 20%
of healthcare expenditures (H&HN)
– There are 4.6 million Medicare beneficiaries
with CHF (AHRQ)
– One CHF admission cost CMS $17,500 (AHRQ)
– 30-day readmission rate for CHF = 24.7%
(AHRQ)
– 52% of CHF patients readmitted within 30 days
did not see their doc between discharge and
readmit (NEJM)
• MedPAC = $12 billion CMS expenditures for
PPR
Our New World:
10-year % change of MedStar’s overall call volume
EMD Code
33-Interfacility
26-Sick Person
17-Falls
31-Unc Per
04-Assault
12-Convulsions
25-Psyc
% Increase
11.3%
10.3%
5.9%
5.2%
4.2%
4.1%
3.8%
EMD Code
% Decrease
01-Abd Pain
2.8%
30-Traum Inj.
3.7%
10-Chest Pain
7.9%
29-MVA
10.4%
06-Breath. Prob. 10.5%
Our New World:
OPPORTUNITY!!
What we Can Offer…
Nurse Triage
• Take low-acuity 9-1-1 calls out of the
system
– 37.1% of referred patients to alternate
dispositions
– Help unclog EDs
• Improve throughput
• Improve patient:revenue ratio
• Improved Press Ganey scores?
• Physician/Hospital call services
• Telemedicine/patient monitoring
– Rx compliance/reminders
• Connect with payer databases?
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Ambulance Charge
Ambulance Payment
Base
$
1,668
$
421
ED Charges (ACSC)
ED Payment (ACSC)
ED Bed Hours (ACSC)
$
$
904
774
6
Observation Admission Charge
Observation Admission Payment
$
$
5,400
2,160
Admission Charge
Admission Payment
$
$
23,838
14,899
Hospice Revocation Charge
Hospice Revocation Payment
$
$
23,838
19,071
9-1-1 Nurse Triage
Avoided
Savings
125
$ 208,500
125
$ 52,625
125
125
125
$ 113,000
$ 96,750
750
Charge Avoidance
Payment Avoidance
Per Patient Enrolled
Charge Avoidance
Payment Avoidance
$ 321,500
$ 149,375
9-1-1 Nurse Triage
$
$
2,572
1,195
Community Health Program
• “EMS Loyalty Program”
– Proactive home visits
– Educated on health care and alternate
resources
– Enrolled in available programs = PCMH
– Flagged in computer-aided dispatch system
• Co-response on 9-1-1 calls
• Ambulance and CHP medic
• Non-Compliant enrollees moved to
“system abuser” status
– No home visits
– Transport may be denied by Medical Director
in consult with on-scene CHP medic
Community Health Program
• 31 patients with 12 month data pre and
post enrollment as of Sept. 30, 2012…
– During enrollment
• 52.2% reduction in 9-1-1 use to the
emergency department
– Post Graduation
• 76.3% reduction in 9-1-1 use to the
emergency department
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Ambulance Charge
Ambulance Payment
ED Charges (ACSC)
ED Payment (ACSC)
ED Bed Hours (ACSC)
Base
$
1,668
$
421
$
$
904
774
6
CHP (1)
Avoided
Savings
104
$
173,472
104
$
43,784
104
104
104
Charge Avoidance
Payment Avoidance
Per Patient Enrolled
Charge Avoidance
Payment Avoidance
$
$
94,016
80,496
624
$
$
267,488
124,280
CHP (1)
$
$
2,572
1,195
CHF Readmission Reduction
• At-Risk for readmission
– Referred by cardiac case managers
– Routine home visits
• In-home education!
• Overall assessment, vital signs, weights,
‘environment’ check, baseline 12L ECG, diet
compliance, med compliance
• Feedback to primary care physician (PCP)
– Non-emergency access number for episodic
care
– Decompensating?
• Refer to PCP early
• In-home diuresis
CHF Readmission Reduction
• For patients with 12 month data pre and
post enrollment (23 patients)
– 44 admissions prevented (46.8%)
• 94 admissions pre-enrollment and 50 postenrollment
– Ambulance transports to ED avoided as of
Sept. 30, 2012:
• 44.1% reduction during enrollment
• 55.9% reduction post graduation
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Ambulance Charge
Ambulance Payment
Base
$
1,668
$
421
CHF (1)
Avoided
Savings
32
$
53,376
32
$
13,472
ED Charges (ACSC)
ED Payment (ACSC)
ED Bed Hours (ACSC)
$
$
904
774
6
32
32
32
$
$
28,928
24,768
192
Admission Charge
Admission Payment
$
$
23,838
14,899
32
32
$
$
762,829
476,768
$
$
845,133
515,008
Charge Avoidance
Payment Avoidance
Per Patient Enrolled
Charge Avoidance
Payment Avoidance
CHF
$
26,410
$
16,094
Observation Admission
Avoidance
• Partnership with ACO
– ED Physician (Case Manager) identifies eligible
patient
• Refer to MedStar Community Health Program
• Non-emergency contact number for episodic
care given to patient
– In-home care coordination with referring physician
– Assure attendance at PCP follow-up next business
day
– Initiated September 1, 2012
• 8 patients enrolled
• No patient’s revisited prior to PCP follow-up
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Obs Avoidance
Base
Observation Admission Charge
Observation Admission
Payment
Avoided
Savings
$
5,400
8
$
43,200
$
2,160
8
$
17,280
Charge Avoidance
$
43,200
Payment Avoidance
$
17,280
Per Patient Enrolled
Charge Avoidance
Payment Avoidance
Obs Avoidance
$
5,400
$
2,160
Hospice Revocation Avoidance
• Enroll patients “at risk” for revocation
• Visit at home
– Counsel – instruct – 10 digit access
– “Register” patient in CAD
• Co-respond with a “9-1-1” call
• Help family through process
– While awaiting hospice RN
Hospice Revocation Avoidance
• 18 patients enrolled
• 13 patients successful in the end
• 1 family called 9-1-1
– Intervened prior to transport
– Still transported based on nature of illness
• Direct admit – no ED visit
• 6 currently enrolled
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Ambulance Charge
Ambulance Payment
Base
$
1,668
$
421
Hospice Rev Avoidance
Avoided
Savings
9
$
15,012
9
$
3,789
ED Charges (ACSC)
ED Payment (ACSC)
ED Bed Hours (ACSC)
$
$
904
774
6
9
9
9
$
$
8,136
6,966
54
Hospice Revocation Charge
Hospice Revocation Payment
$
$
23,838
19,071
9
9
$
$
214,546
171,636
$
$
237,694
182,391
Charge Avoidance
Payment Avoidance
Per Patient Enrolled
Charge Avoidance
Payment Avoidance
$
$
Hospice Rev
Avoidance
26,410
20,266
And the Grand Total Is…
Expenditure Savings Analysis
Based on Medicare Rates
July 1 - Sept 30, 2012
Patient Navigation Savings:
Charge Avoidance
Payment Avoidance
$ 1,393,544
$ 838,959
Patient/Provider Satisfaction
Patient Assessment of Health
Status
Future Opportunities…
• Delivery System Reform Incentive
Payments
– 1115a waiver - Regional Health Partnership
• Hospital-based
– New process for Upper Payment Limit
payments to Critical Access Hospitals
– Paid for programs that:
• Improve Care
• Improve Health
• Reduce Cost
– How can EMS change the landscape of
healthcare?
$4 million
$11 million
$26 million
Director of Primary
Care and Clinical
Partnerships
Statements to be Banned
•
•
•
•
•
•
“We’ve always done it that way!”
“There’s no money to be made in that…”
“It’s what the community expects…”
“We’re an ambulance service…”
“We don’t have the money.”
“There are regulatory ‘issues’…”
The Clinical Call Center
At
The Center for Emergency Medical Services
North Shore-LIJ Health System
Background
• Patient interviews reveal need for 24x7
response to a change in clinical condition
• Provider surveys reveal inadequate coverage
to meet patient demands and lack of access to
patient information
• Because of the lack of 24x7 intelligent clinical
services, patients are directed to or rely upon
ED based care
• Complex patients are admitted at high rates
regardless of whether there is potential clinical
benefit
Emerging Innovative Solutions
• Centralized, system integrated Clinical Call Center
that provides 24x7 access to algorithmically
driven: Clinical Decision Support, Locus of Care
Navigation & Off-hours Call services

E.g. Transitions of care, D/C follow up, CHF readmission
abatement management, locus of care navigation,
Clinically intelligent MD call services
• Integrated Community Paramedic programs

911/Emergency de-escalation to appropriate locus of
care, on demand - on site clinical decision support &
treatment, in-home risk assessment & abatement, PERS
integration
What Others Are Experiencing
Sisters of Mercy – St. Louis, Missouri
• Hospital Based Program
 Centralized 24x7x365 clinical call center
 CHF & COPD patient populations
 Inbound & outbound call management
 Locus of care navigation model
• Results
 10% decline in readmission rates and
remain stable despite the increasing
clinical complexity of admitted patients
 Customer Satisfaction = 91% | Physician
Satisfaction = 89%
What Others Are Experiencing
Cleveland Clinic – Cleveland, OH
• 24x7 Integrated centralized appointment call center
 Same day service program, custom algorithms by service
line, best in class high performance operational model
• 24x7 Community service based RN advice line
 Community benefit based program, risk adverse
escalation to 911/EMS model, locus of care navigation
• D/C follow up program (lower level clinicians)
 Customer service focused, new transitional care concept
• Results
 Significant increased outpatient capture ROI
 Customer Satisfaction >90% | Error Rate <0.5%
What Others Are Experiencing
Medstar - Fort Worth, TX
• EMS Based Program

Multiple health systems and insurance companies
contracting with single EMS provider to eliminate
readmissions for:
• CHF | Asthma | Hospice | System Abuse Management
• Safety Net | Transitional Care
• 12 Month Pilot Results Highlights…




40% Emergency calls referred to alternate dispositions (nonED)
46.8% reduction in CHF readmissions
$14,831 cost reduction per patient to CMS
9% increase in outpatient visits
Our Solution – The Clinical Call Center at CEMS
Synergistic Combination of Best Practices
• Consolidated – Service Integrated 24x7 Clinical Call Center

Paramedic & RN algorithmically based clinical decision support for:
• Inbound & outbound caller programs (transitions of care, readmission
abatement, locus of care navigation, 911/EMS escalation and deescalation capabilities)
• Clinically intelligent MD call services for off-hours
• Integration of CEMS as Community Paramedic Provider




24x7 On-demand, on-site clinical decision support services for
appropriate locus of care navigation, in-home off-hours treatment &
transport to alternative destinations
In home risk assessment, abatement and provider communication
Chronic disease management & readmission abatement
collaborations
PERS program Integration
Our Solution – The Clinical Call Center
Locus of Care Navigation Model

Empowers patient navigation “GPS” to the…





Right - Type of Care
Right - Clinically Appropriate & Customer Acceptable Timeframe
Right - Place
Right - Quality
Right - Cost
• A “Locus” could include (based on patient’s clinical situation):


Self treatment with call center based follow up
Referral to same day or next day appointment with MD (Scheduling Call
De-escalation
Escalation
Center Integration)




Referral to Post Acute Services (House Calls, Home Care)
Referral to urgent care or other doc-in-the-box (Walgreens, WalMart)
Referral to Community Paramedic with treatment or transport
options to all Locus treatment destinations
Referral to Emergency Department
What About the Impact on FFS Service Lines?
• Service Volumes & Down Stream Revenues
 Service volumes will shift away from traditional FFS
pathways




(e.g. ED -> In-patient)
FFS revenues negatively impacted if FFS reimbursement
Cost avoidance if Capitated / Managed Care reimbursement
Services volumes will shift into Primary, Post Acute &
Pre-hospital pathways


FFS revenues positively impacted if FFS reimbursement available
Cost avoidance if Capitated / Managed Care reimbursement
• Girder framework that “bridges the FFS chasm”
 Allows the bridge to be built one capitated contract
“plank” at a time
 Continue to direct FFS populations to traditional
approach
 Point Managed Care populations to new approach
Populations Served for - 1 R.N., 24x7 Coverage
Hypothetical Model
Case
Mix
Number of Calls per Day
Population Served
Inbound Clinical Triage
and Locus of Care
35%
18
2455 / Year
Transition of Care
(4 Calls / 30 days)
37%
21
160 / Month
Daily Diuretic
Management
(30 Calls / 30 Days)
29%
35
35 / Month
Clinical Call Center