Ever since the coronavirus pandemic began sweeping across the U.S., ambulance crews have been treating some patients at home rather than risking a hospital surge — and aren’t getting paid for it. At a time when ambulance services are on the frontlines of care, not just transport, Medicare is treating ambulances like expensive taxicabs.
Treating people in place — at the scene of a medical emergency, which can include the home, a long-term care facility, or other location — has become the expected standard of care, especially during the pandemic. Some states even mandate it. But the Centers for Medicare and Medicaid Services, which oversees Medicare payments, refuses to pay companies for the cost of providing medically necessary health care services if the patient is not transported to a hospital or other designated destination.
As a result, ground ambulance organizations that are fighting the Covid-19 pandemic on the frontlines by treating people with everything from low blood sugar to dehydration are taking a massive financial hit. And it’s coming at the worst time.
Private services like mine are critical to our country’s EMS infrastructure, providing emergency ambulance services to one-third of communities in the U.S. But virus-related costs are piling up for these companies, their frontline providers aren’t being given priority access to personal protective equipment, and they aren’t even eligible for death benefits that are available to governmental and not-for-profit ambulance services.
The reasons aren’t entirely clear. Some may be locked in an old way of thinking that focuses on ambulance services as moving patients from their homes or accident scenes to a hospital. They don’t recognize that ground ambulances have been transformed into mobile units that provide critical health care, often referred to as mobile integrated health care or sometimes as community paramedicine, that other health care providers and public health officials have come to rely upon.
Following strict doctor-created protocols, or with a doctor providing oversight via telehealth, my team has treated countless people in their homes. Here are some of the things we have done in just the last few months to help reduce the hospital surge and to reduce the risk of exposing patients to Covid-19 in health care facilities:
- treated patients with diabetes and chronic lung problems (some who had Covid-19 and some who didn’t) in their homes.
- treated patients who were dehydrated and/or had fainting episodes who could safely recover at home.
- treated routine chronic seizures and referred the patients to their neurologist rather than taking them to the hospital.
- responded to cardiac arrests that are Covid-19 related. Many of these patients are not being transported due to the resource intensive nature of their illness, but still require a high level of care.
- provided naloxone for patients with suspected opioid overdoses who can remain at home and be monitored to safely recover.
Medicare says it lacks the legal authority to grant a waiver to allow payment without transportation and needs Congress to intervene. In response, some lawmakers are now openly talking about including a “treatment in place” waiver in the next round of coronavirus relief, which could come as early as next month. Ambulance companies and the patients they support and protect need Congressional help to address this gap in coverage and reimbursement.
But we shouldn’t have to wait for Congress to act — the Centers for Medicare and Medicaid Services has the authority to grant this waiver on its own, just like it’s done through a pilot program that was scheduled to begin in May.
To address the unique needs of patients during the pandemic, CMS has already waived limitations in other parts of the Medicare program. For example, for patients who have respiratory illnesses, including Covid-19, and can be treated in the home, Medicare waived the long-standing restriction of the home respiratory benefit so it is available to patients with acute or short-term breathing problem, not just those with chronic lung problems.
Treatment in place also fits within other activities to meet the Trump administration’s goal of hospitals without walls. Allowing coverage and reimbursement of treatment in place would make it possible for patients to receive the right care in the location that is right for them during the pandemic. It would promote and ensure that the different players in health care can work together and help each other reduce hospital surges and provide optimal patient-centered care.
Ground ambulance services fit into this picture by providing care that the state and local governments have indicated they are qualified to provide in the home or at the scene with the oversight of a medical director. Temporarily eliminating the requirement that ground ambulance companies must transport patients to be paid for the care they provide would fit within this goal of the administration.
Hanan Cohen is a paramedic and director of corporate development at Empress EMS, a partner of PatientCare EMS Solutions, which operates in New York in the Bronx and Westchester County.
The word “ambulance” seems to cloud discussions of MIH. If ambulance transport isn’t the focus or intent, then MIH must “distance” itself from a profile or billing schedule that even touches on implied “ambulance service”.
Clearly, the leaders in the MIH movement know this and routinely explain the details in great detail. But, say “paramedic” and ambulances aren’t out of most people’s thoughts – including law makers, regulators, payers or – the most important group – patients.
It is a nice problem to have as most people have a positive view of EMTs, paramedics and EMS. But, the very reasons they like EMS are the same reasons MIH sometimes gets lost in the concept explanation.
Clearly, some markets have MIH figured out in great detail. And in these cases, MIH has come to life and – while not easy – payments sometimes follow. But, it takes a major effort to introduce any “new product or service” in any field, certainly including any new element of treat and release or MIH services.
MIH will get there, including for the best reason of all: MIH is an excellent clinical model and worth every cent paid. But, the world is always slow to accept “new” simply because “old” is known.
MIH’s time has arrived in US healthcare, but the work to make it understood, appreciated and routinely paid for is not a sprint – it is a long distance run.
Hang it there. MIH is hear to stay. But there is still hard work ahead, including around understanding, billing and payment.
– Bill Atkinson
Raleigh, NC
I think that treating patients and leaving them at home is not a good practice. There is a reason that diabetic patient is hypoglycemic and that reason should be addressed by a doctor at a hospital not a paramedic in the field. I do agree with you that not all patients need transport to a hospital but I don’t think that it should be our practice to treat the majority of our patients and leave them home.
It’s sad this is even an issue today. These heroes are the first ones at our sides, treating, determining, managing everything until we arrive at hospital… they are paid. What difference does geography matter, they take care of the patient. Pay these people, imagine how much you would pay out if the person was at the hospital.
To say that….”Centers for Medicare and Medicaid Services, which oversees Medicare payments, refuses to pay companies for the cost of providing medically necessary health care services if the patient is not transported to a hospital or other designated destination.” is a misleading statement and, worse perhaps intentionally confusing to those who are venerable and frail, yet wish to remain and in their home. Home health care, a benefit provided by Medicare covers the services discussed in the article. What we need is to look at the provision of health care ACROSS all providers, in order to assess needs and possible changes in provider reimbursement. Let’s stop putting providers against each other and consider the larger goal of delivering the right care, at the right place, for the right price.
CMS pays for cardiac arrest patients. There has also been some movement on payments for these types of emergencies as well as payment for transport to alternative destination w medical command guidance.