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National Ambulance Cost Studies What does a ride in an ambulance cost Rural EMS Summit May 2008

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Title: National Ambulance Cost Studies What does a ride in an ambulance cost Rural EMS Summit May 2008


1
National AmbulanceCost Studies?What does a
ride in an ambulance cost?Rural EMS SummitMay
2008
2
Findings ofCost Studies
3
Medicare is single largest payer
  • 12.6 million transports
  • 4 billion annual expenditure
  • 9,000 providers bill Medicare

GAO, Page 1
4
Purpose of Cost Studies
  • GAO, May 2007
  • Study the cost, access, quality and supply of
    ambulance services under the Medicare program
  • AAA, January 2007
  • Validate GAO study data for long term solution

5
Past Medicare Legislation RegulationHow did we
get here?
6
Survey Responses
  • GAO AAA
  • Surveys 500 1,400
  • Responses 321 108
  • Rate 64 7.7
  • No Shared/Full Cost 215 66
  • Rural Responses ? 22
  • GAO, Page 3
  • AAA, Page 9

7
Average Cost per Transport
  • GAO AAA
  • Urban 370 401
  • Rural 409 534
  • Super Rural 538 --
  • Average 415 386
  • Notes
  • GAO Weighted by provider type
  • AAA Weighted by provider size

GAO, Page 19 AAA, Page 33
8
Comparing Cost to Payment
  • GAO AAA
  • Urban -6 --
  • Rural -1 --
  • Super Rural -17 --
  • Average -6 -8

GAO, Page 24, Table 4 AAA, Page 26, Table 2
9
MedicaresShare of Transports
  • GAO AAA
  • of Transports 40 44
  • of Revenue 31 41
  • Medicare to Commercial cross subsidy
  • 150

GAO, Page 11 AAA, Page 35, Table 8
10
Rural
  • GAO AAA
  • Urban 370 -- 401 --
  • Rural 409 1.10 534 1.33
  • Super Rural 538 1.45 -- --
  • Notes
  • GAO Includes providers with substantial
    volunteer labor
  • AAA Only 27 rural full cost providers

GAO, Page 19 AAA, Page 33
11
Substantial Volunteer Labor
  • GAO Report
  • 40 of providers use substantial unpaid staff
  • GAO recognized use of unpaid staff is widespread
  • For analysis to be representative GAO included
    these providers AAA used full cost providers
    only

GAO, Page 10, 32
12
Uncompensated Care
  • AAA/CMS
  • Ambulance 10.8
  • Hospital 5.6 (MR DSH)
  • Physician 4.3 (Balance Bill 5)
  • Ambulance delivers twice uncompensated care as
    hospitals or physiciansOutside scope of GAO
    study

AAA, Page 51
13
Uncompensated Care
  • Uncompensated Care
  • Bad Debt full payment was expected from
    third-party payers or patients
  • insurance denials
  • uncollected patient co-pays and deductibles
  • unresolved payment disputes about coverage or
    eligibility
  • Charity Care no payment was expected from
    patients
  • no insurance coverage

14
Impact of Below-costReimbursement
15
Congress wants to know . . .
  • What is the impact of below cost reimbursement?
  • Commercial payers pay 150 higher rates (AAA)
  • EMTs and paramedics earn 30 lower wages than
    LVNs and 50 less than police and fire (BLS)
  • 40 providers substantially rely on volunteers
    (GAO)

GAO, Page 10 AAA, Page 36
16
Average Annual Wages
  • Registered Nurse 56,880
  • Flight Attendant 53,740
  • Police Officer 47,270
  • Elem School Teacher 46,990
  • Fire Fighter 40,420
  • Massage Therapist 40,210
  • Construction Worker 38,260
  • LPN/LVN 36,210
  • Truck Driver 35,460
  • Lab Technician 33,170
  • EMT/Paramedic 28,440
  • Security Guard 22,690
  • Lifeguard 18,020
  • 27

U.S. Bureau of Labor Statistics
17
Congress wants to know . . .
  • Is quality affected?
  • Difficult to measure
  • Is access limited?
  • Trans/capita 8 lower in super rural
  • Is supply reduced?
  • 2.9 annual increase in providers
  • 14.6 annual spending growth (01-05)
  • 6.2 annual increase in transports
  • 25 annual increase in dialysis trans

GAO, Page 30, Table 7 AAA, Page 63
18
Comparison of Medicare Margins
-8
-3
16
13.5
AAA, Page 53, Table 20-A
19
Volume Growth by Service Area
19
6
-8
GAO, Page 30, Table 7
20
Ask Congress to support . . .
  • Medicare Ambulance Payment Extension Act
  • HR 2164
  • S 1310
  • Cost of readiness is under funded

21
The Starter Kit of EMS Outcome Measures
22
Public Quality Reporting
  • Demanded by
  • Payers
  • Purchasers
  • Government

23
Medicare Public Reporting
  • Public reporting of health quality data
  • Health plans - 1998
  • End stage renal disease facilities - 2001
  • Nursing homes - 2002
  • Home health - 2003
  • Hospitals - April 2005
  • Clinics 2007 (119 Measures)

24
Reasons for Public Reporting
  • Informed Consumers
  • Slow Inflation
  • Good Performers
  • Rewards for Leading Transformational Changes

25
Transforming Health Care
  • Transforming Leads Payment Policy
  • Payment Policy Forces Transformation
  • Cost Controls Outpatient Care
  • Prospective Payments
  • Fee Schedules
  • EMS Unprepared

26
Whats Happening Now?
  • EMS Pay Attention!
  • Medicare 2005 - 2007 Hospital Annual Payment
    Update
  • Full Update ONLY If Reporting 10 Quality Measures
  • Less if Not Reporting
  • (0.4 APU vs 2 Proposed P4P)

27
Current Public Reporting
  • Voluntary - Sort Of
  • Available to the Public
  • Public Not Accessing
  • Confusing
  • Not Educated
  • Hard to Find
  • Some Require Fee

28
Hospital Examples
  • Current Outcome Measures

29
Joint Commission on Accreditation of Health Care
Organizations
  • www.jointcommission.org/ - New Quality Check
    program reports data for hospitals, nursing
    homes, and other healthcare settings

30
HealthGrades
  • www.healthgrades.com - Uses Medicare and state
    survey data to calculate a 5-star rating system
    of hospitals and nursing homes

31
Leapfrog
  • www.leapfroggroup.org - Promotes and rates
    hospitals on 4 patient safety leaps
    (computerized physician order entry, use of
    intensivists, volume, safe practices)

32
Healthcare Facts
  • www.bluecrossmn.com -
  • BlueCross BlueShield of Minnesota - Reports care
    given and safety information in nutrition label
    format for large hospitals

33
Hospital Compare
  • www.hospitalcompare.hhs.gov

34
Hospital Quality Alliance
  • www.aha.org Voluntary System of AHA 3,800
    Participants

35
Minnesota Health Information
  • www.minnesotahealthinfo.org - Information about
    the cost and quality of health care in Minnesota

36
Adverse Events Reporting
  • www.health.state.mn.us/patientsafety/ - Adverse
    Health Events Reporting Law State-mandated
    reporting of 27 NQF Never Events

37
Process
38
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39
(No Transcript)
40
EMS Starter Kit
  • 2005 Consensus Meeting

41
Federal Partners
  • HHS - HRSA Office of Rural Health Policy
  • HHS - HRSA EMS Trauma National Resource Center
  • HHS - HRSA EMS-C National Resource Center
  • DOT - National Highway Traffic Safety
    Administration EMS Division

42
Organizations
  • American Ambulance Association
  • Association of Air Medical Services
  • Coalition of Advanced Emergency Medical Systems
  • National Ambulance Coalition
  • National Association of EMS Educators
  • National Association of EMS Physicians
  • National Association of State EMS Directors
  • National EMS Management Association
  • National Organization of State Offices of Rural
    Health

43
Organizations (cont)
  • National Registry of Emergency Medical
    Technicians
  • National Rural Health Association
  • North Central EMS Institute
  • Rural EMS Trauma Technical Assistance Center
  • Rural Health Resource Center/TASC
  • Stratis Health QIO
  • University of Minnesota Rural Health Research
    Center

44
Whats Happening in EMS?
  • EMS Quality Initiatives
  • Leadership Guide to QI NHTSA
  • Continuous QI in EMS ACEP
  • Quality Management in EMS NAEMSP

45
Specific Programs
  • NEMSIS
  • IAFF/IAFC
  • North Central EMS Institute Benchmarking
  • Leadership Forum on Performance Measures
    NASEMSD/NHTSA/HRSA

46
Leadership Forum 2002
  • There appears to be no commonly stated purpose,
    definition or methodology for performance
    measurement in EMS to serve as a universal frame
    of reference for those undertaking such
    measurements.

47
NEMSIS
  • EMS Data Set
  • Indicators

48
National Consensus Meeting Output
  • All of the Current Activities Should Continue
  • Simple Set Starter Kit (System Level)
  • For Everyone
  • Easy NEMSIS Compliant
  • Useful Local to National

49
Consensus Set Time
  • System Issue Time of Symptoms to Access
  • Internal Benchmark Time of Dispatch to Arrive at
    Patient Side

50
Consensus Set Respiratory
  • Percent That Need Respiratory Support That Get It
  • How Long Did It Take to Provide

51
Consensus Set Accuracy
  • Accuracy Score of PCR
  • ALS Did Patients That Require ALS Actually Get
    ALS Treatment?
  • BLS Time to Defibrillation

52
Late 2005 Outputs
  • Define
  • Indicators
  • NEMSIS
  • NHTSA Sponsored Study
  • Congressional funding cut

53
Phase II (2006)
  • Demonstration Project
  • Participants
  • Minnesota
  • North Dakota
  • Nebraska

54
Goals
  • Are They the Right Measures?
  • Are the Right NEMSIS Fields Captured?
  • Provider Barriers to Web Entry
  • State/Service Barriers to Data Transfer

55
Minnesota
  • Already NEMSIS Compliant
  • Already ImageTrend
  • 100 Participation
  • Data Transfer from State

56
North Dakota
  • NEMSIS Compliant
  • MedMedia
  • 100 Participation
  • Data Transfer from State

57
Nebraska
  • Already ImageTrend
  • Changed Law to Participate
  • Data Transfer from the State

58
Phase III (2008)
  • Validate Report Structure
  • Validate Finding Through Specific Services
  • Meet with NEMSIS
  • Reconvene National Consensus Group
  • Report Results of Pilot
  • Make Adjustments
  • Consider Long Term Aggregating
  • Discuss Health System Outcomes
  • Merge EMS, Hospital Rehab/SNF

59
Collection of the Data
  • Minnesota
  • Data from July 06 Dec 31st, 06
  • Full data set minus HIPAA elements
  • North Dakota
  • Data from July 06 Dec 31st, 06
  • Were unable to import all elements
  • Nebraska
  • Data from July 06 Dec 31st, 06
  • Full data set minus HIPAA elements

60
Data Import Challenges
  • The missing element in NEMSIS
  • How we did it
  • What will we do in the future

61
System Overview
62
Data Overview
  • MN 151,837
  • ND 26,113
  • NE 39,307
  • Total 217,257

63
NCEMSI Benchmark Project
  • Results of 2006 Seven Standard Measures
  • Version 4.0

64
Time of Symptom to Access of 911
Original Results MN and ND Data High
35063 days 23 hours 5 minutes Date was 07/15/1910
Low 0 minutes Report Result 1 days 17 hours 44
minutes
Version 3.0 MN and ND Data Report Result
12 minutes N 19,720
Date Elements Date/Time phone rings (911 Call to
PSAP) minus Date/Time the Injury Occurred
65
Time of Symptom to Access of 911
Version 3.0 MN and ND Data Report Result
12 minutes N 19,720
Version 4.0 MN, NE and ND Data Report
Result 11 minutes N 21,266
Date Elements Date/Time phone rings (911 Call to
PSAP) minus Date/Time the Injury Occurred
66
Time of Dispatch to Arrive Patient
Original Results MN and ND Data High 1
day 1 hour 26 minutes Low 0 minutes Report
Result 14 minutes
Version 3.0 MN and ND Data Report Result
11 minutes N 83, 629
Date Elements Date/Time from when the Responding
Unit Arrived on Scene Minus the Date/Time the
Responding Unit was Notified by Dispatch
67
Time of Dispatch to Arrive Patient
Version 4.0 MN, NE and ND Data Report Result 7
minutes N 107,018
Version 3.0 MN and ND Data Report Result
8 minutes N 83,629
Date Elements Date/Time from when the Responding
Unit Arrived on Scene Minus the Date/Time the
Responding Unit was Notified by Dispatch
68
The Percentage of Patients that required
Respiratory Support that Received it
Original Results MN and ND Data Required
Support 31,365 Received Support 3,435 Report
Result 10.97 Received Support
Version 3.0 MN and ND Data Required
Support 20,557 Received Support 2,614 Report
Result 12.72 Received Support
Date Elements Percentage of Patients with
Provider Impression of Respiratory
Arrest/Distress or Breathing Difficultly that
Receive Some Form or Method of Oxygen
69
The Percentage of Patients that required
Respiratory Support that Received it
Version 4.0 MN, NE and ND Data Required
Support 22,851 Received Support 4,028 Report
Result 17.63 Received Support
Version 3.0 MN and ND Data Required
Support 20,557 Received Support 2,614 Report
Result 12.72 Received Support
Date Elements Percentage of Patients with
Provider Impression of Respiratory
Arrest/Distress or Breathing Difficultly that
Receive Some Form or Method of Oxygen
70
How Long did it Take Provide Respiratory Support
Original Results MN Only High 1461 days
3 minutes Low 0 minutes Report Result 22 hours
18 minutes
Version 3.0 MN Data Report Result 10
minutes N 8,833
Date Elements Patients with Provider Impression
of Respiratory Arrest/Distress or Breathing
Difficultly then Date/Time that Patient Receives
Some Form or Method of Oxygen Minus Date/Time
Unit Arrives on Scene
71
How Long did it Take Provide Respiratory Support
Version 4.0 MN and NE Data Report Result 9
minutes N 14,350
Version 3.0 MN Data Report Result 10
minutes N 8,833
Date Elements Patients with Provider Impression
of Respiratory Arrest/Distress or Breathing
Difficultly then Date/Time that Patient Receives
Some Form or Method of Oxygen Minus Date/Time
Unit Arrives on Scene
72
Accuracy Score of PCR
  • MN

73
Accuracy Score of PCR
  • ND

74
Accuracy Score of PCR
  • NE

75
ALS Subset the percentage of patients whose
condition indicated ALS that actually received it
Original Results MN and ND Data Required
ALS 3,802 Received ALS 1,301 Report Result
56.99
Version 3.0 MN and ND Data Required ALS
2,031 Received ALS 1,388 Report Result 68.34
Date Elements Percentage of Patients with
Provider Impression of Chest Pain/Discomfort then
Date/Time Patient Receive 3-12 Lead ECG
76
ALS Subset the percentage of patients whose
condition indicated ALS that actually received it
Version 4.0 MN, NE and ND Data Required
ALS 3,884 Received ALS 1,812 Report Result
46.65
Version 3.0 MN and ND Data Required ALS
2,031 Received ALS 1,388 Report Result 68.34
Date Elements Percentage of Patients with
Provider Impression of Chest Pain/Discomfort then
Date/Time Patient Receive 3-12 Lead ECG
77
BLS Subset 911 time to defibrillation
Version 3.0 MN Data Report Result 18
minutes N 32
Version 4.0 MN and NE Data Report Result
18 minutes N 38
Date Elements Date/Time the Patient Receives
Defibrillation Minus Date/Time phone rings (911
Call to PSAP)
78
BLS Subset Scene time to defibrillation
Version 4.0 MN and NE Data Report Result
18 minutes N 38
Version 3.0 MN Data Report Result 18
minutes N 32
Date Elements Date/Time the Patient Receives
Defibrillation Minus Date/Time Ambulance Arrives
on Scene
79
What Should I Do Now?
  • P4P IS COMING
  • Embrace NEMSIS State Efforts
  • Develop/Participate With Rest of Healthcare
    System
  • Will Your QIO Spend Some Time?
  • Internal QI
  • Contribute to Continuous Care Be Part of an
    Interdisciplinary Team

80
Questions???
  • Thank you for your time..
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