06 Feb Value-Based Payment for Ambulance Service is Coming Fast!
On Thursday, January 26, 2015, in an article in The New England Journal of Medicine, the U.S. Secretary of Health and Human Services, Sylvia M. Burwell, announced that the Centers for Medicare and Medicaid Services have set a goal to “have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018….our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.”
This is an ambitious goal for this year and for the next three years. When this article hit the web, it was made clear to EMS leaders and policy makers that the profession needs to prepare for a switch from fee-for-service (i.e., per transport) to quality (i.e., care reliability) and value (quality divided by cost). The potential switch is no surprise, but the potential time frame is ambitious and very disruptive if ambulance service is included in those goal numbers.
Currently, there are no universal metrics to measure the quality of paramedicine. Where measurement has occurred, it shows wide variation in the results. Imagine then if CMS decides to transition ambulance service to value-based payment, and then services provided are now only reimbursed if they are reliably and cost-effectively delivered. For example, instead of being paid for the transport of a STEMI patient regardless of the quality of care you delivered, you are reimbursed only if 90% of STEMI patients receive cath lab intervention within 90 minutes of their initial 911 call. Most ambulance services aren’t measuring quality in that way and, if you start, you are likely to find wide variation in performance and low reliability. Now also imagine that Fire Department A achieves 90% at $200 per capita, but ambulance services B, C, & D can produce the same outcomes for $140-160 per capita. Are you prepared to reduce your costs while improving or maintaining quality? Alternatively, what if ambulance funding is bundled into the Accountable Care Organizations (ACOs) who are taking the risk of managing a population. This actually may be an easier way for CMS to manage the variation in ambulance services and cost and to eradicate the current fraud in the non-emergent transport side. What if the local ACO is the funder for the delivery of care in the community and not CMS? How might that change an ambulance service’s mission and activities?
The EMS profession in the U.S. has been predicting value-based payment models coming to EMS for some time. From a quality and measurement perspective, the profession is very far behind and completely unprepared. No one knows how CMS is expected to roll EMS payments into the ambitious goals outlined in the NEJM article, but it’s very likely that it will be faster than you would prefer and more disruptive than you expected. It’s critical that EMS systems make it a strategic priority to measure and improve care quality at the same time you reduce your costs. If you wait, it may be done to you. While the short-term prospect of this transition may be bleak and painful, the long-term implications on enhancing the patient experience, improving care, and creating value are worthy aims. This could be the most important pivot in your career.