Paying for emergency care
EMS services now only get paid when a patient is transported to a hospital facility
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As changes in technology and medicine have transformed EMS and ambulance services over the years, the laws dealing with how these first responders get reimbursed have remained unchanged for decades.
Legislation to help alleviate the financial strain on EMS organizations due to a particular kind of 911 call is close to making it to the governor's desk.
House and Senate bills requiring insurance companies and state Medicaid to reimburse ambulance services for calls where EMS personnel respond but don't transport a patient to a hospital have passed and now legislators must simply bring the two versions into alignment before the changes go to Gov. Tom Wolf for his signature.
Carl Moen, executive director of the Southern Alleghenies EMS Council, said the legislation could have a significant impact on ambulance services, "especially at EMS services that are struggling due to their financial situation."
Moen pointed out that EMS services only get reimbursements from Medicaid when a person is transported to the hospital.
"But the costs are still there," Moen said.
Moen said diabetic emergencies are a good example of situations where EMS personnel respond to a 911 call but often don't take a patient to the local hospital.
Ambulance crews are equipped to bring a diabetic patient's blood sugar levels back to normal and as it stands, they bear the cost of the service when the patient doesn't want to go -- or even necessarily need to go -- to the hospital.
While there was a time when ambulances were primarily just a transport service, such as when Medicaid and Medicare laws were crafted, times have changed and paramedics now provide more and more care for patients during calls, AMED Executive Director Gary Waters said.
Waters said the lack of reimbursement for calls with no transport has a tremendous impact on ambulance services, which are not considered health care providers but rather suppliers.
For AMED in 2017, there were 698 calls where people weren't transported, which comes to 4 percent of the 18,000 calls the ambulance service responds to in its 420-square-mile territory.
In dollars, that's $271,560 in billing the service never recovers and ultimately writes off, Waters said. Out of that $271,560, about $113,000 represents calls for people who are on medical assistance. The change in the law would have a real impact on the budget because now AMED must try to recoup those costs through other ways, such as raising rates.
And the costs go up as the price of popular supplies rises, either due to increased demand -- such as Naloxone, or because of a decrease in supply, such as is the case of IV fluid bags since Hurricane Maria devastated Puerto Rico, where a large percentage of IV fluid bags are manufactured.
EMS personnel continue to deliver more care with more expensive supplies, it puts the squeeze on ambulance services, Waters said.
Naloxone is one example. The drug has worked wonders in saving lives in the field for option overdoses, but the cost of the drug has climbed from $7 to $50 a dose, Waters said. Add to it the fact that in the past, patients who were overdosing were taken immediately to a hospital as the only chance to save their life. Now, patients are saved at the scene and when they come around, they often refuse transport.
Moen pointed out that EMS personnel delivering care to patients where they are, called community parasemidine, is becoming more and more prevalent as ambulance services implement programs that help find the best ways to provide care for patients instead of simply loading people into an ambulance and delivering them to emergency rooms.
He pointed out that many patients, such as patients who have just returned home after a hospital stay but don't necessarily need home nursing care, can benefit from on-site services delivered by EMS personnel. By treating people at the scene, EMS personnel can help people and help reduce Herculean costs associated with emergency room visits and hospital stays.
Because the reimbursement is only for hospital delivery, such policy can increase costs overall with unnecessary hospital visits for patients who otherwise could be treated at the scene and simply follow up with their family physician, or be taken to an urgent care facility.
Waters pointed out that AMED has implemented a community paramedic into their service and has seen success when dealing with emergencies that don't require a hospital trip, but in the past tied up ambulance crews. One patient called for an ambulance two or three times a week because she was falling out of bed.
"Our community paramedic went out to find out why she was falling out of bed," Waters said. "She had a nightstand with stuff on it next to her bed and when she would reach to get something off the nightstand she would fall out of bed."
The solution was a simple hospital tray, and after it was implemented, the woman wasn't calling 911 because she fell out of bed.
"Think about how much money we saved the health care system," Waters said.
This kind of work is the future of EMS, Waters and Moen said.
Waters said as the state budget deadline approaches, time is running out for the latest attempt to have the law changed. The Senate passed a similar bill last month that not only requires insurance companies to reimburse EMS services for non-transport calls but also requires Medicaid to do the same, while the House unanimously passed a similar bill last year that didn't include the Medicaid mandate.
Waters said that will likely be the sticking point in the House with the latest effort.
"The insurance industry doesn't want to see this," Waters said.
State Rep. John McGinnis, R-Altoona, said while in most cases he sides with insurance companies, citing they face a number of mandates and issues already, he supports the change in the law.
"The ambulance companies are truly hurting," McGinnis said. He pointed to his own experience with EMS, most recently in November when he suffered a stroke.
"They are great and they know what they are doing," McGinnis said, adding the men and women who work on EMS crews are "so in tune with the hospitals they provide seamless care" from transport to the hospital.
When you factor in the skill EMS crews bring with them to respond and that they are in effect "the gatekeepers" in health care, it's important to give them the proper means to do the job without the burden falling completely on the EMS services themselves.
"They definitely need some help," McGinnis said.
Mirror Staff Writer Greg Bock is at 946-7458.