As a Paramedic for a major metro area, i'm on the "front lines" of the ACA battle, so to speak. Mostly how the effects are applying to 911, EMS and Emergency Departments.
Prior to 1 Jan, our service was warned to expect an additional 10 to 15% increase in call volume above the 3 to 4% annual increase we have been seeing. The state said this was to be due to the Medicaid expansion based off the increase seen several years back when they made the last Medicaid expansion.
We were also informed of the effort going into the merging of EMS with the accountable care organizations (ACOs) being set up. (yeah, those "death panels" that will monitor and control reimbursements for healthcare providers while also monitoring the quality of the care being provided. Who will be able to deny or reduce payment if the provider isn’t meeting quality standards. For example, reimbursement can be denied when a patient is readmitted to a hospital within three days for the same problem. It’s therefore in that hospital’s interest to make sure the patient doesn’t get readmitted for the same problem.)
Yesterday, we had an inservice about ACA's focus on "Patient-Centered Care" and how that effects us on the street.
More after the squiggle, very long though.
On the first point, the expected increase in call volume, as I wrote on 8 Jan (http://www.dailykos.com/...) it happened. This is our "slow time", people are indoors not out side late at night, drive a little safer/slower, do less stressful activity. We are still averaging 300+ calls a day vs the "normal" 230 to 250 winter. The rate, if it follows what the state says, won't go down.
The second point, this is mostly a behind the scenes thing right now, the ACO's are getting organized, trying to figure out what the rules are, what has to be reported, how they can do what they are to do under the law, etc. No one expects this to make much of a change or effect right away because no one knows exactly how they are to work. Sure it is easy to say "it is in the Hospital's best interest to make sure re-admit rates are low" but what can they do about that under the law? (meaning you could keep it low by saying if you were admitted in the last 30 days you have to go some place else, but that would be illegal? right? Do the regulations say that? Is it ok to treat a person then transfer them to a different hospital to be admitted there?)
ACO's are going to take several court cases to work out I think. (my view only, but shared by many in the EMS)
The most contentious was point three.
Patient Centered Care.
Is an idea advocated by the Institute of Medicine (IOM) as part of their 21st century Health Care platform. ACA embraced the idea. Basically, this is a very simple explanation of a thousand page law and regulatory rules, Hospitals and EMS, will have two main performance bonus/penalties criteria: 1) is from reducing readmission rates for specific diagnostic related groups (DRGs) like myocardial infarction, heart failure and respiratory problems.
Way 2) Value Based Purchasing - "which brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. It’s important to note that VBP is different from limited efforts to negotiate price discounts, which historically have reduced costs but did little to ensure that quality of care was improved." - (from the inservice hand out)
In other words, if you can find a way to lower cost with out hurting care, you can get a bonus payment over the long term. Part of that maintaining "quality" care is to include "the Patient Experience of Care". This will account for about 30% of the total performance score (TPS) of the Hospital and by extension EMS.
The VBP links a portion of the hospital’s payment from the Centers for Medicaid and Medicare Services (CMS http://www.cms.gov) to performance on a set of quality measures, which include: the Clinical Process of Care Domain, which accounts for 45% of a hospital’s total performance score (TPS); the Patient Experience of Care Domain, which accounts for 30% of TPS; and the new Outcome Domain, which accounts for 25% of TPS. This will be rated by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey on the Patient Experience of Care Domain.
Hospital Consumer Assessment of Healthcare Providers and Systems
So how does the HCAHPS work? For starts it is a mandatory survey of 32 questions for discharged patients about their recent hospital stay. The survey contains 21 core questions about critical aspects of a patients’ hospital experience, including:
Communication with nurses and doctors; The responsiveness of hospital staff; The cleanliness and quietness of the hospital environment; Pain management; Communication about medicines; Discharge information; Overall rating of hospital; and if they would recommend the hospital. (again taken from an inservice hand out from the CMS, Bold added by me)
Now this inservice was aimed at the Hospital system, but it applies to the EMS world also. The ACA was very vague about EMS in it, but so much of what EMS does relates to the Hospital system most often with the Emergency Department (ED).
Since the major payor of EMS is the CMS, they decided to apply this to EMS also. Starting in 2016 (and likely private insurance will follow if they can see they will pay out less) EMS can expect to have to meet this.
The major effect is that if Paramedics don't improve the "Patient Experience of Care" we could take a hit in our budgets. Something most EMS budgets can't take as they are stretched thin now. (In our metro area no new hire was approved, only 6 ambulances were approved for replacement, only one paramedic course was offered and it was limited to just 10)
This was the most discussion and questioned inservice i've been to in a long time. The biggest point of discussion was the Pain Management part. It is also a key point of worry for ED Doc's also.
We make a lot of calls for people who are not happy. No one ever called 911 because they were having a good day. People assume that since we show up at their emergency in mobile intensive care units when they called 9-1-1, we have all the clinical expertise on hand that a hospital has. We are able to do everything the ED can do for the first 30 min of a heart attack, (with 1/4th the people, in 1/8th the space and at 70 mph), but we don't have answers. We are not doctors, just working under a doctor. We can't tell the person if they are having a heart attack or indigestion, not with out blood lab work, x-ray's, and maybe a stint or two (surgical procedure you really don't want done in an ambulance driving down the road).
I've had people get upset that I could not "fix" them at their house, and had the nerve to want to take them to the Hospital…when they called 911. These people won't rate EMS very well.
But the pain management part is the killer for us and the ED. People these days want zero pain at all times and want it now. We also have high numbers of people who are chasing drugs. They call with a complaint like "chest pain", describe a non-specific pain in the chest but can't take our first two drugs we normally give. The only drug we could give is a controlled substance. (though with a recent change in our protocols that is gone now and we don't give any pain med for chest pain, much to the disapproval of the patient.) They also go to ED's when their prescribed pain meds run out "too soon", and to make their case more believable, they call 911. After all if you were just seeking pain meds, why would you call an ambulance that cost $1,200 for transport?
There is very little we do in the field to treat pain. We manage it as much as we can with out drugs, those are our last use. The "emergency" part of EMS requires that don't just make the pain go away. Take enough of any drug and that will happen. We stabilize, treat, and transport. You get better but you're not "fixed".
One idea the CMS is looking into is the moving of anyone prescribed pain medication to a "non-survey" list and not count their negative reviews against service.
EMS and Para-Medicine, the ultimate abusive relationship
EMS also will be dealing with the Patient Experience with the hits on "why are you not going fast with the lights and siren?" and "how come i'm being put in the waiting room, I came by ambulance" issues.*
People (and many Hospital administrations) don't think of EMS as medical providers but rather as "transport" (the 911 taxi). I suspect that when the VBP goes in to effect and Hospitals are finding their ratings are affected by the EMS bringing people into the ED, they might change their minds.
As for people, well, i'm worried that the HCAHPS is going to hurt EMS repayment due to the nature of EMS.
*My service has been sued for: cutting someones pants off to get to a broken leg; sending a bill for transport that resulted in the person being placed in the waiting room; not giving a person suffering cramps pain medication; taking someone to the hospital instead of treating them at home; not taking someone to the doctors office just to the ED; for pain and suffering from being placed on a backboard and c-collar (spine motion restriction by using a plastic collar that holds the head in place, straps you to a long hard board, and tapes your head down to reduce movement and possible spine injury or further injury. very uncomfortable); and cutting off someones wedding band while their hand was swelling. - these are cases I or a partner have been named in. Nothing came of most of them, none made it to court. But I bet not one would have rated their care very highly.