Feedback Form on the Draft National Framework Document

The project team thanks those that have provided input through the public survey and the meetings in California, New York, and Washington, D.C. We also appreciate your continued participation and input on the recommendations for National Framework Document for Promoting Innovation in EMS. Please scroll down as you fill out the form and when you are finished, please click on the blue "DONE" button at the bottom.

* 1. Please enter your information.

* 2.
CMS and other payers currently reimburse pre-hospital EMS solely on the basis of transportation. Payment should be based on successful outcome of the patient encounter, regardless of whether or not the patient is transported to an emergency department. 


Rationale:  CMS reimburses EMS for levels of care but based on transportation.  Within these levels of care, there is considerable variation in skills.  CHF management at home may involve application of many skills and result with no transportation and $0 reimbursement. There is value to patients, hospitals, and payers with competency-based reimbursement; therefore, reimbursement should be considered for the medical care provided.  There are many things EMS can do; cant do any of them with payment for mandatory transport.  

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 3.
State Medicaid Reimbursement Reform committees should include EMS representation.

Rationale:
Many States have established or are seeking to establish Medicaid reform committees.  EMS advocates need to push for representation on these committees and State entities should ensure EMS representation on the committees. By being included in high level reform and innovation conversations, a state is more likely to direct resources and funding toward testing new payment models or new delivery pathways for EMS that help support the rest of an integrated healthcare system.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 4.
Payers should reimburse EMS for the successful performance of evidence-based clinical bundles proven to improve patient outcomes.
 

Rationale:
If CMS and other payers paid for the successful outcome of the patient, the patient would be more likely to experience improved outcomes by being referred to a physician who knows the patient, enhance the patient’s experience of care by avoiding the unnecessary long wait in the ED, and reduce costs by avoiding the payment for an unnecessary ED visit. Compliance with these clinical bundles, or clinical processes of care, have been proven to improve patient outcomes and speed appropriate medical care. CMS and other payers should collaborate with EMS to design payment models that reward compliance with these clinical bundles to improve patient care and patient outcomes.

  Strongly Disagree  Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 5.
Payers should reimburse EMS providers for arranging, coordinating, and/or participating in telemedicine enhanced clinical care in the field, independent of transportation.
 
Rationale:
Reimbursement for telemedicine services, in general, severely lags behind reimbursement for traditionally delivered healthcare services, and reimbursement for telemedicine services within EMS is even more behind. EMS systems should be encouraged to partner with payers to demonstrate value-based delivery of care focused on proven interventions that improve health outcomes and reduce utilization.  If reimbursement is value-based, then caveats include tracking and trending of data / outcomes and assigning risk / benefit to the reimbursement model.  Payers and EMS may first need to consider reimbursement for telemedicine services in EMS on a FFS-based model to decouple telemedicine reimbursement from the setting of care. As telemedicine services are often limited by state licensure requirements, federal and state governments should reduce barriers to healthcare by allowing interstate access to care for both Medicare and commercial patients by allowing physicians licensed in one state to treat patients in another without having to obtain an additional license for each state. In some jurisdictions, telemedicine is only reimbursed if initiated from within a “healthcare facility.”  For billing purposes, the interior of an ambulance, and/or the location of care being attended to in the field by a trained healthcare provider (e.g. paramedic) should be considered a qualifying healthcare facility.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 6.
EMS should begin to envision the steps and processes necessary to move from a fee for transport reimbursement model to a system more consistent with other similar services within the broader health care marketplace. 

Rationale:
Perhaps the movement towards value based purchasing will create the environment needed for small fragmented EMS agencies in the same market or in nearby jurisdictions to collaborate in order to meet data reporting and quality assurance requirements.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 7.
EMS provider agencies should consider collaborative relationships with other community healthcare stakeholders where they can improve care and reduce costs, while enabling continued innovation, customization, and coordination of the community health services provided. Collaborative relationships should assure that any payment is shared equitably. 

Rationale:
Reimbursement for competencies that a provider possesses independent of specific licensing is recommended.  In many cases, payments for services within the EMS scope of practice are being paid to other provider groups through billing codes and mechanisms already in existence. This would allow EMS and payers to address issues of scope of practice with the best interests of the community and patients and promote payment based on performance. CMS set a precedent for this model decades ago when they agreed to pay for response and treatment of cardiac arrest victims, regardless of ambulance transport.  This was most likely done to reduce the perverse incentive of the ambulance provider to transport patients who were clearly non-survivable simply to get paid for the response. COST SHIFTING will be from cost of transport to costs of non-transport and a transition from supplier status to provider status.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 8.
EMS agencies should develop greater business skills and promote an entrepreneurial culture.
 
Rationale:
EMS needs to acquire the business acumen to be able to evolve with the environment around them. Having a strong grasp and control of your EMS system finances, on both the revenue and expense side, will provide for the strong foundation necessary from which grassroots innovation can emerge. It will further be invaluable when attempting to negotiate financially sustainable payment contracts with payers or others for a new innovative service. To this end, the following recommendations related to measuring costs in EMS and their impacts on innovation are made: EMS agencies need to have leadership with the business acumen and education necessary to create a sound financial structure for the measurement and management of the financial health and well-being of the agency; EMS should provide financial training to its leadership to bolster the skill sets necessary to achieve these recommendations; EMS needs to adopt a standardized industry specific accounting approach so that a common financial language can be garnered and leveraged within the industry; EMS needs to develop a standardized set of financial Key Performance Indicators (KPIs) from which to manage from; EMS needs to benchmark financial data and KPIs within the industry; EMS needs to share best practices in financial management within the industry; EMS needs to set standards by which financial health is gauged; EMS needs to align its financial measurement strategy with future reimbursement reform and emerging pay for performance payment schemes; Partnerships will need to be driven by EMS agencies and will therefore require the business acumen and entrepreneurial knowledge at the local agency level.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 9.
EMS entities need to acquire measurement and analytic skills to prove outcomes for individual patients and across populations, including patient satisfaction and cost effectiveness.
 
Rationale:
Since the basis of bundled payment and to a certain extent, managed Medicare providers, rests on proven outcomes including patient satisfaction and reduced cost, and EMS has typically not measured either of these items, it is critical that these measurement skills be adopted.  The drivers of managed care and capitation is different from that of EMS, and gaps in valid, analytic measurement data will likely make it hard for EMS to create realistic value propositions to these entities. The mathematics of ambulance outcomes largely revolves around response time compliance and certain clinical success metrics.  In order to prove outcome value in EMS innovation, it is necessary to learn the metrics and the language of those who hold aggregated financial risk for patients. Actors include finance experts from EMS who would become educated on outcome metrics and their measurements.  Until EMS can accurately align its data with health plan outcome data, it will be very difficult to negotiate payment contracts for Mobile Integrate Healthcare functions in EMS.  Examples would include understanding population health economics and what, exactly is required to effectively move the needle on cost reduction and patient satisfaction.  Small trials on select sub-groups of patients doesn’t translate well into population health, and that shortcoming makes it hard to create value with financial stakeholders. 

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 10.
The National EMS Advisory Committee (NEMSAC) should create a new long-term vision for what EMS should look like and a strategy for overcoming anticipated obstacles and realizing the vision. 
 
Rationale:
The provision of an economically efficient level of EMS services is currently hampered by the inadequate quantification of positive externalities associated with mobile integrated health and community paramedicine programs.  For example, to the extent that such innovative programs successfully navigate patients with behavioral health issues to appropriate non-ED destinations and/or ensure these patients receive appropriate ancillary services, there should be a corresponding reduction in criminal justice system costs and a reduction in unemployment compensation costs.  However, such benefits to society (i.e., taxpayers) are under-valued (if they are valued at all) by traditional payers for EMS services, and so an inefficiently low amount of these types of EMS services will be provided.  Committee members should work together to connect the dots between EMS providers and all beneficiaries of EMS services to achieve a more economically efficient level of EMS service provision.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 11.
Communities should facilitate partnerships between EMS, public health and social services to pilot innovative programs.
 
Rationale:
There are often positive externalities that benefit other entities that are NOT currently bearing the expense.  This is quite often the case with opportunities related to EMS innovation. The goal of this community level engagement is to allow various societal stakeholders including nonprofits, criminal justice, government, etc. to discuss the benefits that EMS currently provides or could provide that currently do not have a funding stream. Once these externalities have been identified, how can we connect the dots so that beneficiaries might contribute to offset the cost of a program? Each community should develop partnerships that bring local stakeholders in healthcare and social services together to consider and measure the positive benefits of innovative programs and develop agreements to transfer societal benefits back to the entity that bears the expense.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 12.
Small EMS agencies should consider coming together to form a group purchasing organization to help improve negotiating ability for prices of drugs (equipment, and more), or join an existing cooperative. Municipalities should extend their purchasing power to help EMS agencies.

Rationale:
There are  approximately 18,000 different EMS agencies in the country.  This recommendation speaks to the ability for EMS agencies to participate in group purchasing, regardless of the type of agency. The 2 different plans for this recommendation are: Encouraging EMS agencies to pursue this on their own; and recommending government entities take action on this. One current e
xample is the North Central EMS cooperative = SAVVIK. Additionally, the 340b program should be extended to EMS agencies and EMS agencies should advocate themselves for inclusion in 340b program.


  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

* 13.
Section 4: Best Practices Clearing House Recommendation (pending)
 

-Possible 4th finance category = should be best practice clearing house

o   people can share innovations

o   possibly a website

o   bidirectional exchange of data

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

T