Matt Zavadsky, MS-HSA, EMT – The Role of EMS in Value-based Care Pt 2

In this episode, we continue our conversation with Matt Zavadsky of MedStar Mobile Healthcare about the role that Emergency Medical Services has in value-based care and how the economics come together to provide value.


How has CMS come to realize the value of the role EMS has in health care through models such as Emergency Triage, Treat, and Transport or ET3?

Yeah, and Medicare for most EMS agencies is our largest payer, right. Whether it’s regular fee for service or Managed Medicare. And they’ve been one of our audiences for a decade with us telling them, you know, if you keep paying us to transport, again, you’re just incentivizing us to spend your money. So, they finally, through the CMI, the Center for Medicare and Medicaid innovation, put together a model, that we actually helped work on with them, that changes the economic model for EMS. And it now reimburses EMS agencies not just for transport anymore, but for things like nurse triage in the 911 center. If you can mitigate that 911 call and not have to even send a resource, and you can get them connected with their doctor, and you’ve triaged them over the phone, that’s reimbursable now for select agencies that are a part of this program. If you get on scene, and you do an assessment, and you do a telemedicine connection with a physician, and that physician agrees that this patient does not need to go to the emergency department, they can be treated at home, and go see their own doctor, we’re now reimbursed for that. And so, by the way, is the doctor that’s doing the telemedicine.

Similarly, if we transport a patient to an alternate destination. So, yep, you know what, you twisted your ankle. You might need an x-ray, but you don’t need to go to an ER for that. Let’s take you to an urgent care that has x-ray. It’s a third of the cost and certainly much more patient-centric perhaps than going to a busy emergency department. And we transport them to an urgent care. That model revolutionizes how EMS is delivered. We’ve often said that, you know, Medicare does not set health care policy, but they do set payment policy. And as they change payment policy, they change the practice of health care. So now we, and about you know 40 other agencies around the country that have been approved by Medicare to test this model, are not transporting every Medicare patient to the ER anymore. We’re offering them an opportunity to stay home.

I did this myself with a patient a couple weeks ago and he loved it. His wife was thrilled. He was in a lot of sciatic pain. We gave him some pain medication, talked to the doc, we had an urgent care, mobile urgent care, come out to the house later in the afternoon, and we didn’t have to put him on a stretcher, and take him down a bumpy road, and take him to a busy ER where he’s going to languish for 2-3 hours because you know he doesn’t have a high priority medical complaint. And the patients love it and it’s much less expensive and everybody benefits. So those are the types of models that we’re continuing to test with now other payers

We just signed a in-network agreement with one of our largest commercial payers where they’re paying us the same way. “Hey. We’ll pay you the same whether you take somebody to the hospital or not. We prefer that you not, if you don’t have to, because it’s going to save us you know $5,000 cost of care at the end of the day.” So those are the types of things that Medicare, and other payers, and a lot of Medicaid offices across the country are starting to say, “Yeah. This is a much better economic model for EMS. Let’s pay them for patient navigation, not just for patient transport.”

How have telemedicine waivers allowed EMS to do on-scene patient navigation?

The telemedicine waivers that were, that have been and they’re still in place, because of the public health emergency, has really stepped up the ability for EMS to use telemedicine in the patient’s home. And again, specifically because of the change in the payment authorization. So, forever, telehealth would only be provided reimbursement if it was from one health care facility to another health care facility, for the most part. A physician providing telehealth services to a patient in the patient’s residence was not a covered benefit. So, there were not a lot of physicians that were doing it for obvious reasons and there were not a lot of patients taking advantage of that because if they did, it typically came out of their pocket. So, when the telehealth waivers were put into place back in April of 2020, seems so long ago, suddenly that now included patient’s residence as a covered origin. Suddenly, there are a whole host of groups that were willing to do telemedicine and EMS leveraged that. We did, a number of agencies did, and we contracted with all of the you know a bunch of different telehealth providers to help us navigate patients. And now the physicians are able to get reimbursed. So, we respond to a 911 call, we engage telemedicine from the patient’s bedroom, living room, whatever, and the we get reimbursed because that’s part of you know the waiver. It’s also reimbursable to the physician.

What we’re all focusing on now is yes this is a waiver. It has worked exceptionally well on the EMS side. Very little fraud and abuse because it’s almost always in response to a 911 activation. So, there’s not the marketing that’s going on for example that OAG might get concerned about you know inflating the encounters. And we’re not bringing a whole bunch of people to the hospital. So, we’re hoping and working with OAG, and with CMS, and MedPAC, to say look, even if you’re going to change the waiver and allow it to expire. Let the EMS component of it remain in place because it is saving healthcare dollars, it’s improving the patient experience of care, and leading to better outcomes. Because instead of someone going to an ER, again seeing a doc they’ve never seen before, having a battery of tests that they need just because the ER doc has to practice defensive medicine, they get referred to their primary care physician, it’s a better continuum of care and that telehealth waiver should remain in place for EMS. And we’re hopeful that that will continue because it has really revolutionized our ability to navigate patients from the scene of a 911 call because we’ve got physicians willing to be a telehealth provider for us in that patient’s living room. And Thomas, the reality is that the ERs are so busy now and you know people with low acuity medical complaints end up waiting for quite a while in a lot of emergency departments across the country. And if we can help decompress the ERs, then everybody even wins further, because the patients who are going to the ER don’t have to wait as long because there aren’t 110 borders in a 110-bed emergency room.

Talk about the need for transforming the EMS economic model and what is the vision moving forward in the value-based care space?

Yeah. It’s really everything we’ve talked about so far. It’s reimbursing EMS for the response, not for the transport. And finding, as we’ve been able to do here in Fort Worth, finding alliances with value-based partners. So, one of our newest partnerships is with a care management organization who has taken on full risk for the care utilization of an ACO population. And they were going to be using CNAs, and RNs, and NPs, and PAs, going out to see these, you know, high utilizers or the problem children if you will, in that population and trying to schedule someone when they call 10 digits to the care management organization that says “Hey. You know, my feet are getting swollen. I’m not sure what’s going on and I’m sleeping with three pillows now instead of one because I can’t breathe when I lie down.” So, instead of having to send an NP, or PA, or other provider out to try and schedule, they just call us and say “Hey. Will you go see Thomas? Listen to his lungs, take a 12-lead, let me know what his edema looks like.” And we’re doing that for them. And it’s much less expensive because of paramedic, quite frankly, is less expensive per hour than the other type of provider. And they are very good at assessments, and protocols, and starting IVs, and giving D50, or giving Lasix, or Zofran, or doing pain management with some medications that they have on board, to really do that good care coordination.

So, finding more of those alliances and likeminded people. We’ve got a couple of Medicaid Managed care organizations that are doing the same thing with their problem populations and using us to help manage those populations. Hospitals have been paying us for readmission prevention for years because the economic model for them is if they have lower readmissions, they get lower penalties from Medicare and obviously the high utilizers. So, the real transformation for EMS is really finding those partners and again it could be commercial payers, Medicare, Medicaid, or IPAs. One of our very first agreements for mobile integrated healthcare was with a very large independent practice association who’s in a full risk contract with United Healthcare to prevent observation admissions. Because observation admissions were being billed at Part B every band aid, every IV catheter, every test was being credited to that IPA in the risk arrangement and they said listen we’re going to send these patients home, will you guys follow up with them for 48 hours to make sure they go see their PCP. And that’s the perfect alignment. We did that back in 2013 and we’re still doing it today because there’s value to the IPA for that. But again, it’s finding its educating people about what the real value of your local EMS agency is, and that value really has nothing to do with the transportation that they provide.

How well equipped are EMS staff to perform more complex triage to determine the appropriate site of care for a patient?

That’s a great question, Thomas. And, you know, paramedics and EMTs see patients all day long just like other healthcare providers do, and we become experts at triage. Really who’s sick, who’s not sick. You know, I haven’t been full-time in the field for a long time, I’m still certified, but I can still tell you. I worked a shift two weeks ago in the streets and 7 calls in 12 hours, and I can look at a patient from across the room and say “Yep. You’re sick,” or I can look at and say “Nope. You’re not.” And now, you take that really good patient assessment process that EMTs and paramedics do multiple times a day and you augment it, for example, with a telehealth program.

Where, you know, OK, I think this patient’s got low acuity medical complaint, but don’t take my word for it. Let’s spend 4 minutes on a video chat with, you know, our contracted IES physician group just to get confirmation. To get a doc on the line. Yep. They do a couple of additional things. We ask some questions. Ask us to do one or two additional assessments, whatever. And now you get a second opinion that, yeah, this patient does not need to go to the emergency room. They can go see their primary care physician. They need to do it in the next day or two. Or not, depending on whatever it is. I’m going to call in a prescription in the meantime, etc, etc. But the ability for EMTs and Paramedics to do that. They do it multiple times a day. They can get additional training if the medical director, or the IPA, or the group that you’re working with, wants some specific training on a specific disease process, or cohort of patients that they want you to help manage or to navigate. But again, telehealth whether it’s video, audio, telepsych we’re doing in a number of cases to help with assessments of behavioral health patients. Just get that second opinion. Very, very safe. We’ve been an ET3 model participant for a little over a year. We have put almost 600 patients who called 911, Medicare patients, who called 911, and some would say that Medicare patients tend to be a little bit more medically fragile than other patients, and you know 600 of those patients have gone through this secondary triage with our EMTs and paramedics on scene. No bad outcomes. Over 500 of them have stayed home and not had to go anywhere, and it’s very safe. And just work with your local EMS agency, they do this all the time. Help them with some secondary triage through telemedicine program and it’s very, very safe.

If an ACO or health system is interested in exploring this model further, where would they begin the implementation of a program such as this?

First, find out who the largest EMS provider is in your region and that’s going to depend on your medical trade area. So, we’ve done a lot of work with a very large ACO in upstate Wisconsin, and they are working with Green Bay fire, Milwaukee fire, a number of fire departments up there to do mobile integrated healthcare, community paramedicine, patient navigation across their medical trade area. Here, we’re doing it along with Dallas fire and some others. So, if you’re in North Carolina or you’re in wherever and you think, “Hey. I’d really like to start working with my EMS agency to not bring every patient to the emergency room.” Who’s the biggest provider? Is it Wake County EMS? Is it Greensboro EMS? Is it whomever? Reach out to their service director, reach out to their medical director, have a quick meeting with them and say “Hey. I got this harebrained idea. I listened to this crazy podcast and this knucklehead was talking about, you know, EMS doing other things. Typically, you’re going to find very willing partners. Because I can tell you that almost every EMS director, every Fire Chief, all the national associations are really promoting this new model for EMS because of what we learned, not only over the last decade, but certainly during the coronavirus pandemic, that this is really the best value that we can bring is partnerships and navigations.

And here’s the example. We’re working now with one of our partners that “Hey. We take a 911 call. It meets a triage criteria for a very low-level medical complaint and trust me it happens multiple times a day. People call for ingrown toenails, blisters on the feet, nausea, vomiting for 3 weeks and now it’s 2 o’clock in the morning, and now we link them up from the 911 center with a telehealth provider. And we stay on the line, but we send them a link, and the caller you know clicks on their smart device, and now they’re talking to a doc by video chat. And we mitigate that “response” without even sending a fire truck, without even sending an ambulance, because the patient got what they wanted, to your point earlier, they got triaged by a telehealth provider. They had a prescription called in that will be delivered to their house within, you know, the next 3 to 4 hours, and a recommendation to call their doctor. There are agencies all over the country that are willing to do that. They just don’t know who you are. So, if you’re listening and you want to be that innovative agency, just reach out and find that that provider.

If you’re having a hard time with that, you can literally call me. We’ll give you my e-mail address. We know almost all the providers in the country, and we are more than happy to hook people up because this really is the right thing for the patient, and the right thing for the system.

Matt, do you feel that there’s anything we’ve neglected to discuss today that would be an important part of this conversation?

I think one of the things that people don’t realize is how nimble EMS agencies can be. We are often now referred to as the Swiss army knife of the health care system. And if you want a program that does, as we said earlier, contact tracing, vaccines, monoclonal antibody infusions, testing, you name it, fall risk prevention, your EMS agency can literally develop a protocol with your medical director, do some training, figure out the data exchange, figure out the metrics that you want to use to measure the effectiveness of the program, and literally do pretty much anything. So, don’t be afraid to ask them.

We had a, during the pandemic, one of the big ACOs here that we partner with said “Hey. We’re going to get a little bit of HEDIS of trouble if we don’t get eye exams for our Medicare population. And nobodies coming into the doctor’s offices because the offices are closed. And we’ve got about 125 patients who haven’t had their annual eye exam. Can you go out with your community paramedics, and you know bring this camera, and take a picture, and send us the image so the doctor can look at it and say that checked the box?” And we did. We stood that program up, Thomas, literally in three days and it was done within a month because I had to get it done by September 30th and they didn’t contact us until the beginning of September. And we did it for them. Those are the types of things that you don’t think about that “Hey. This is a, you know, another Swiss army knife thing that we need, and you know EMS can probably do it.” And we did. So, that would be I think the last message that we want to send. If there’s a gap, your EMS agency, a trusted local provider, if you work on it with them and tell him what protocols you need, and what the economic model, is they can do pretty much anything.