On 23 March 2010 President Obama signed a new health care reform act into law. The Patient Protection and Affordable Care Act (ACA) will finally change the way health care is to be delivered in the US. This will provide community paramedic programmes expanded avenues of funding they desperately need. These vital community services will need to find a sustainable source of revenue to continue providing health care to their communities. It is with sustainable funding that the ACA provides solutions to meet these needs. Community paramedics can seek reimbursement within the ACA by developing patient care services that meet established improved patient outcome guidelines. Because of their unique position in the community they can easily integrate with other existing community services that are part of current accountable care organisations (ACOs).
This expanded role of an emergency medical system is a cornerstone of community paramedic programmes. Their ability to work with home health services, primary care physicians and emergency departments directly inside the community is a unique function not being currently used. Helping to fill the gap between scheduled home nurse visits, or discharge from an outpatient clinic or emergency department at a patient's home, is the primary function of community paramedic programmes. These services can all be part of an ACO where community care paramedics can provide a valuable service. They can help provide health care in patients' homes until they can be managed through patient-centered medical home coordinated care process. It may take days to get a home health nurse to a patient's home after discharge. Community paramedics can be there any time day or night.
It is this foundation that the ACA is striving to implement, keeping people out of the hospital and helping people not only stay healthier, but keeping them from getting sicker, all from the comfort of their own home. This is the cost-saving plan for the future of health care. The collaboration of services within these ACOs is well established in the ACA and will provide needed funding solutions.
ACOs are supported legislatively and fiscally, and described as the solution component of reform to the health care delivery model in the ACA (Khan, 2012). This will provide existing community paramedic programmes with options to overcome a major obstacle: reimbursement. Providing coordinated community care that involves delivering patients to appropriate medical care facilities is where the reality of cost saving can be found. These paramedics are already integrated into the healthcare community and in prime positions to deliver care to patients to a variety of services that are available other than a local emergency department (Erich, 2012). These facilities can use community paramedic services to move their patients to the most appropriate healthcare service for cost-effective care. Building and developing upon existing regulatory legislation provides much needed expedited compensation avenues. It is this type of required outside-the-box thinking that makes integrating into ACOs a viable option.
The ACA is encouraging providers to approach the care of episodes of illness by managing their use of resources efficiently, in a bid to help eliminate waste. Part of this approach includes ‘bundle payments’, which are designed to align incentives for organised care (Sasson et al, 2012). The transition from reimbursement based on fee-for service, to payments from alternate sources, is where seeking ACOs can provide new additional revenue for community paramedic programmes. The ability to provide continued care that meets high standards will be rewarded to services that are reimbursable through ACOs. The collaboration of public and private payers gauging the health of a community is a step in the right direction. Reinforcement of existing community and clinical prevention programmes to join forces to develop coordinated care of various readily available resources will allow for significant cost reduction (O'Connor et al, 2013). Managing the overall health of a community is the way community paramedic programmes and ACOs are fulfilling the vision of the ACA.
Defining accountable care organisations
The American Academy of Family Physicians (2014) defines an ACO as:
‘A conglomerate of healthcare providers that coordinate care within a group of defined patient population by sharing responsibility to control cost and quality of delivered care.’
One goal of the ACA is the reduction of costs while improving the level of care, as part of the implementation process. ACO is predicted to propagate as a vital component of payment reform. They provide logical enhancement to patient outcomes while being able to control cost (Zusman et al, 2014). There are currently significant numbers of ACOs providing a wide range of coverage and cost savings to all types of defined patient groups. The delivery of affordable health care is changing, as described by the ACA.
This needed reform has a major component for success in the development of ACOs. Currently, there is a requirement for transportation to an emergency room regardless for the need of treatment as a stipulation for payment. The reform, to be successful, will need to allow for alternative destination locations like physician offices, urgent care centres, dialysis centres or even a shelter or a family member's house. It is this type of alternative patient-centered care that can truly add value and quality to untapped out-of-hospital care systems (Munjal and Carr, 2013). This is where the integration of community paramedic services can find alternative reimbursement models within ACOs.
This model recognises and establishes incentives for providing treatment to patients and delivery of patients to a variety of more appropriate health services to meet their needs, other than a ride to the local emergency department. Recognising a reorganisation of out-of hospital services that are focused on reducing unnecessary costs with expectations of a rational patient-centered coordinated care approach to meet unscheduled needs of the public is well within the infrastructure of ACOs (Munjal and Carr, 2013). Local community paramedic programmes are designed to provide these exact services.
Centers for Medicare and Medicaid Services (CSM) (2011) outlined how hospitals, doctors, pharmacies and other additional ancillary healthcare providers are coming together to provide much needed elimination of wasteful practice. High-performing ACOs are demonstrating that innovative technologies allow for various ways to explore options that decrease over usage of services. There are gaps that have been identified with data-driven approaches that will guide deliverance of enhanced patient care (Perez, 2014). The Department of Health and Human Services indicates that new reform initiatives are needed. The development of community paramedic programmes fills this gap. These programmes are providing services that will allow third-party payers to be able to recognise a significant cost saving by distributing reimbursements for non-transportation practices (Millin et al, 2011).
There are substantial cost savings in using services that perform in home patient assessments to determine treatments, and if needed, transport to appropriate care facilities (Mason et al, 2003). Mason et al (2003) also refer to a report from the Audit Commission (1998), which supports the use of ambulances services to facilitate the management of patient care in their homes.
The use of these services will perpetuate not only cost-efficient needed care, but have successfully demonstrated the management of patients that are at a higher risk of using 911 services for primary care. Keeping people out of the hospital unnecessarily is a pillar of the ACA. Taking care to patients that need it most is the function of community paramedic programmes. These programmes can merge with ACOs to organise care within appropriate community services to develop door-to-door services and reduce unnecessary transports to the emergency department. Treating patients more appropriately is the value-added service of coordinated cost-effective patient care that community care paramedic programmes and ACOs provide.
The United States National Highway Traffic Safety Administrator (2000) described the future role of paramedics as one of integration in the overall health systems by using a patient care community-managed service. The roles of paramedics are rapidly morphing to go beyond responding to an emergency. They are managing responsibilities to include monitoring the compliance of medications for chronic conditions, public health and wellness and prevention, and in-home treatments (Guy, 2014). Community paramedics are helping to alleviate the burden of primary care physicians.
Benefits of joining ACOs
‘Provider organisations in Medicare ACOs are free to use various technologies and explore innovative approaches that will reduce the utilization of services’
A viable out-of-the-box option for community paramedic programmes is the availability to join nonprofit hospitals. These organisations are being significantly driven by the ACA to provide needed benefits to the community (Zusman et al, 2014). Part of this initiative is to support organisations that are developed to serve their community's current health needs. ACOs have recently been recognised by CMS. The Federal Register reports the proposed rule by CMS that ACO payment rewards are to be based on patient outcomes. The benefit to providers is they are being rewarded for taking responsibility in controlling costs that are not necessary and held accountable for any spending that can be eliminated.
These shared savings plans will be able to collect on the monies that are saved. As ACOs develop needed components to meet the demands of the ACA, they will be able to pay these organisations for services that foster cost-effective quality care in the community. The proposed rule offers two options for receiving benefits for managing cost-effective health care. One option is recommended for groups that are smaller and unable to shoulder the responsibility of losses that are greater than the expenditure target. These ACOs will be eligible for a 52.5% reward of cost savings from Medicare.
Option two is for established ACO groups, the standard type of saving plans that all groups will be working toward. This model allows for a 65% return of saved cost. These plans require ACOs to also share in losses. This is different from the first option as they are not accountable for sharing in the losses. All ACOs will be required to migrate to option two by the end of the third year. These funds will be available to be distributed to the services within the ACOs. Community care paramedic programmes are instrumental in these organisations. Controlling unwarranted transport to emergency rooms by assessing patients before they enter the healthcare system will allow for the greatest cost savings. A goal of this healthcare reform is for community care paramedics to be able to determine the need for appropriate in-home care or transport to somewhere other than an emergency room.
The bonus structure is based on 65 quality measures identified in the ACA section 1899(b)(3) (A) (Khan, 2012), of which performance standards are divided into five categories. CMS (2011) list these categories as patient/caregiver experience, coordination of care, patient safety and preventive health, and at-risk populations (such as the elderly and patients with chronic end stage disease). It is the last set of identified patient population that community paramedic programmes can offer the most cost-savings services. The focus of most programmes is to control repeat transport to emergency rooms by establishing a service that would allow for care to be initiated in the home to avoid transport, or to arrange a patient to get to the health service that is appropriate, therefore being cost effective.
Community paramedic programmes fill the gap
Other countries have been doing something similar for years. This is not a new concept, and instead is merely new to the US. With the passage of the ACA is the opportunity to move forward and for paramedics to be recognised through the expanded role of an existing service model, which will be a key component to continued success. Countries like Canada and Australia's drive for community care paramedics differ greatly from the US. These programmes developed out of geographical necessities. They have vast amounts of rural communities that had minimum to no access to any type of health care. The need to get the help to people in rural places drove these valuable programmes in their communities. It was easier and more cost effective to take access to health care to them in place of building a hospital. More recently in the UK, community paramedic programmes are being used to help manage some of the country's community health issues.
The National Association of Emergency Medical Technicians redefined community paramedic programmes in February 2014 as a service that provides patient-centered mobile integrated health care outside the walls of medical institutions. They are in the community in the homes of the people needing urgent management of chronic conditions, making treatment decisions, determining transport to the most appropriate care facility, while limiting transports to emergency departments. As the population of a community ages, their demands on the healthcare system will increase. The majority of these needs can be assessed and managed without a trip to an emergency room.
One side of this coin is efficiently managing these minor acute conditions by using guidelines tailored to shift away from transport, to that of treating and releasing (Mason et al, 2003). This will place the patient into the community care health network. Patients needing follow-up care with their primary caregiver can be done by a community care paramedic. Their care plan is then forwarded to the primary care doctor and they will be able to set up a scheduled appointment, correct medications, and establish an appropriate treatment plan without the patient making an expensive and unneeded trip to the emergency department (Mason et al, 2003). Paramedics make house calls and are in the unique position to give a much-valued insight into the patient's home conditions that can be a significant source of information to a primary care giver. Being part of the ACO the community paramedic can work with the patient's primary caregiver. Not only will this allow for improved care but will be eligible for reimbursement under the guidelines of the ACO.
The other side of the coin is the management of patients with uncontrolled chronic medical conditions that have multiple readmissions. The Institute of Medicine reports 75% of the nation's healthcare costs are from managing patients with chronic medical conditions (Sasson et al, 2012). This is where the benefit of home health organisations can use community care paramedic programmes. The need for immediate care, treatment and/or transport can be managed in the patient's home. Scheduling in-home assessments that can be completed routinely is the value of sending a one-stop shop service that is the epitome of significant cost savings. It is the unique abilities of a community paramedic's range of services of reaching out to a nurse, doctor or social services by specific established guidelines that the continuation of care and assessment of interventions on a daily or weekly basis is keeping patients' conditions under control and preventing costly unnecessary trips to the hospital (Mason et al, 2003).
This model of providing in-home patient care by delivering enhanced coordination of out-of-hospital services is supported by the reform, and where funding is available through ACOs, as outlined within the ACA and recognised by Medicare, for reimbursement.
The shifting of fee-for-service reimbursement to alternative types of payments such as those established by ACOs is ‘bundled payments’ designed to encourage health care providers to work together to provide a more organised approach to patient-centered care (Sasson et al, 2012). ACOs are rewarded for high-quality care that meets positive evidence-based patient outcomes. In essence, healthcare services that collaborate together to provide high-quality, cost-effective patient care will all share in the fiscal rewards.
The goal is to not just treat the patient for what can be reimbursed, but to treat patients to make them better. The ultimate goal is to provide better patient care with streamlined effectiveness. When each component of a patient's healthcare team is working together to provide holistic care, there are significant cost savings that is rewarded with comparable compensation.
ACOs approach to a solution
The business of getting paid is shifting fundamentally from a fee-for-service platform to a fee-for-value approach. ACOs are an aggressive and innovative avenue where the complexity of a capitalist society intersects with public and private health care systems. It is a diverse web of what is, what was, and what will be, for reimbursement options (Perez, 2014). ACOs are leading the way to a new era of reimbursements and now is the time to establish some much needed guidelines for feasible revenue-generating options.
Reviewing different options within ACOs' linking of community paramedics as ‘extended medical staff’ (Khan, 2012) allows opportunity for a variety of options for community paramedic programmes to align with healthcare organisations, physicians and/or physician groups. Sharp (2012) discusses how CMS extended the definition to include non-physicians. For example, Texas paramedics work as an extension of a physician and operate under his or her licence in order to practice medicine. It is this detail that can be a conduit to generate revenue to community paramedic programmes within an ACO.
According to Khan (2012): ‘Nearly 64% of admissions are done by physicians within the “extended medical staff” and primary hospital.’ The author continues with the process of assigning patients to primary physicians or specialty care services in the ambulatory setting. Medicare beneficiaries have determined by research that physicians, as part of medical evaluation and management, do 72% of admissions. Another 64% of admissions are done by ‘extended medical staff’. This constitutes an 82% admission rate, with an elevation of patient populations coming from rural areas.
Pitfalls
There are obstacles to overcome—for example, the information highway and some legal concerns will need to be addressed. These obstacles can be navigated successfully by addressing them in the implementation process. Working through getting all the right information to the right people as quickly as possible is one obstacle. In the past 10 years there have been a variety of electronic patient care reporting options. This should help navigate some of these challenges. Transmitting information today is as easy as hitting send. Getting the information into a multiuser platform may present some challenges but these to can easily be managed.
The Stark Law is another pitfall that will need some type of resolution. It prohibits a physician from either directly or indirectly referring a patient to an entity where Medicare is billed for services where a physician has a financial relationship or is fiscally connected in anyway (Khan, 2012). The foundation of ACOs is offering patients a cost saving by referring them to organisations within the group. ACOs will be distributing funds collected on behalf of a legal entity to its members. To do this legally there will need to be some type of exclusion or exemption.
This problem should be easily managed by the ACA within a platform for testing innovated and novel models of both the delivery of health care and restructuring of reimbursement methods by proposed polices of ‘value-based’ purchasing in place of the volume of services that are provided (Wiler et al, 2012). The authors explain how based on new legislative mandates for healthcare delivery systems is the foundation of the ACO model. Within these networks healthcare providers consist of specialty and ancillary care to further include surgery centres, hospitals, psychological and other social services groups. Placing community paramedics into this realm is not far out of reach.
Conclusions
The US ranks 37th in healthcare outcomes, according to the World Health Organization. The ACA will provide needed healthcare reform but is not a guarantee for better community health (O'Connor et al, 2013). This will come from the access to healthcare services and the integration of these services to provide needed cost-saving benefits to the community. Bringing this integrated care to the doorstep of the patient is just the beginning of true healthcare reform. Taking a step in the right direction with the ACA is the foundation of how community care paramedic programmes can facilitate opening the door, to not only define the transformation of the healthcare system, but will have the furthest reaching impact than any other component (O'Connor et al, 2013). It is critical that public health officials take the important steps that will guarantee prevention. This will benefit patients within communities and help all providers be able to fill the gaps to provide high quality coordinated value added services.