Mobile Medicine Strategies and Vision for all Providers

Douglas R. Hooten, MBAExecutive DirectorMedStar Mobile HealthcareFort Worth, TX

Jonathan WashkoAVP – CEMS OperationsNorth Shore – LIJ Health SystemManhasset, NY

EmergencyMedicalServices?

UnscheduledUnscheduledMedical

Services!

E/D’s

9-1-1

Urgent Care

RN Triage

Out ofHospital Care

Ambulance Life Line

Noncompliance

SNF/LTAC

MD/DO Office VisitsAnsweringServices

Unscheduled Episodic Care

Current State of Unscheduled 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

ResultsFrequent 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.

Annals of Emergency MedicineVolume 56, Issue 1 , Pages 42-48, July 2010

Why is this important?

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 c-section (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:

EMD Code % Increase33-Interfacility 11.3%26-Sick Person 10.3%17-Falls 5.9%31-Unc Per 5.2%04-Assault 4.2%12-Convulsions 4.1%25-Psyc 3.8%

10-year % change of MedStar’s overall call volume

EMD Code % Decrease01-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 AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 9-1-1 Nurse Triage

Base Avoided SavingsAmbulance Charge $ 1,668 125 $ 208,500 Ambulance Payment $ 421 125 $ 52,625

ED Charges (ACSC) $ 904 125 $ 113,000 ED Payment (ACSC) $ 774 125 $ 96,750 ED Bed Hours (ACSC) 6 125 750

Observation Admission Charge $ 5,400 Observation Admission Payment $ 2,160

Admission Charge $ 23,838 Admission Payment $ 14,899

Hospice Revocation Charge $ 23,838 Hospice Revocation Payment $ 19,071

Charge Avoidance $ 321,500 Payment Avoidance $ 149,375

Per Patient Enrolled 9-1-1 Nurse Triage

Charge Avoidance $ 2,572 Payment Avoidance $ 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

Per Patient Enrolled CHP (1)

Charge Avoidance $ 2,572 Payment Avoidance $ 1,195

Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 CHP (1)

Base Avoided SavingsAmbulance Charge $ 1,668 104 $ 173,472 Ambulance Payment $ 421 104 $ 43,784

ED Charges (ACSC) $ 904 104 $ 94,016 ED Payment (ACSC) $ 774 104 $ 80,496 ED Bed Hours (ACSC) 6 104 624

Charge Avoidance $ 267,488 Payment Avoidance $ 124,280

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 post-enrollment

– Ambulance transports to ED avoided as of Sept. 30, 2012:

• 44.1% reduction during enrollment• 55.9% reduction post graduation

Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 CHF (1)

Base Avoided SavingsAmbulance Charge $ 1,668 32 $ 53,376 Ambulance Payment $ 421 32 $ 13,472

ED Charges (ACSC) $ 904 32 $ 28,928 ED Payment (ACSC) $ 774 32 $ 24,768 ED Bed Hours (ACSC) 6 32 192

Admission Charge $ 23,838 32 $ 762,829 Admission Payment $ 14,899 32 $ 476,768

Charge Avoidance $ 845,133 Payment Avoidance $ 515,008

Per Patient Enrolled CHFCharge Avoidance $ 26,410 Payment Avoidance $ 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 Avoided Savings

Observation Admission Charge $ 5,400 8 $ 43,200 Observation Admission Payment $ 2,160 8 $ 17,280

Charge Avoidance $ 43,200

Payment Avoidance $ 17,280

Per Patient Enrolled Obs AvoidanceCharge Avoidance $ 5,400 Payment Avoidance $ 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 AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012 Hospice Rev Avoidance

Base Avoided SavingsAmbulance Charge $ 1,668 9 $ 15,012 Ambulance Payment $ 421 9 $ 3,789

ED Charges (ACSC) $ 904 9 $ 8,136 ED Payment (ACSC) $ 774 9 $ 6,966 ED Bed Hours (ACSC) 6 9 54

Hospice Revocation Charge $ 23,838 9 $ 214,546 Hospice Revocation Payment $ 19,071 9 $ 171,636

Charge Avoidance $ 237,694 Payment Avoidance $ 182,391

Per Patient Enrolled Hospice Rev Avoidance

Charge Avoidance $ 26,410 Payment Avoidance $ 20,266

And the Grand Total Is…

Patient Navigation Savings:

Charge Avoidance $ 1,393,544 Payment Avoidance $ 838,959

Expenditure Savings AnalysisBased on Medicare RatesJuly 1 - Sept 30, 2012

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

• “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’…”

Statements to be Banned

The Clinical Call Center

At The Center for Emergency Medical ServicesNorth Shore-LIJ Health System

• 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

Background

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 ExperiencingCleveland 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 (non-

ED) 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 de-escalation 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

Center Integration)

Referral to Post Acute Services (House Calls, Home Care) Referral to urgent care or other doc-in-the-box (Walgreens, Wal-

Mart) Referral to Community Paramedic with treatment or transport

options to all Locus treatment destinations Referral to Emergency Department

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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

CaseMix

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

Hypothetical Model