Emergency Medical Services Association of Colorado

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1 EMSAC Emergency Medical Services Association of Colorado 2015 Fact Sheet is a non-partisan, not-for-profit association of individual professionals and EMS agencies public and private that respond to injuries and medical emergencies and transport patients to acute medical care. Our members are professionals affiliated with: Ambulance Services Dispatch Centers Fire Departments Search and Rescue Teams Ski Patrols U.S. Military Helicopter Ambulance Services EMS Training Institutions (colleges and hospitals) Hospital Emergency Departments Our membership is: 55% paid emergency medical professionals 45% volunteer emergency medical professionals 7% frontier county residents 42% urban county residents 51% rural county residents Our members are: Paramedics Nurses and Physicians EMS First Responders EMS Educators EMS Chiefs, Managers and Directors Emergency Medical Technicians Researchers and Consultants Our sole interest is the emergency medical portion of public safety and the prehospital segment of emergency medical care. We: Educate by offering state and nationally accepted continuing education through the annual Colorado State EMS Conference, EMS-agency and EMS-system management seminars, rural EMS seminars and special topic seminars. Communicate by keeping members abreast of industry news, events and ever-changing trends of this dynamic profession, especially specific to Colorado. This includes medical, legal, research, training and administrative topics. Advocate by serving as the voice of the profession, speaking to allied medical and emergency disciplines and state and federal regulators and legislators. We offer educational scholarships and honor outstanding professionals through the Colorado State EMS Awards E. Evans Ave., #3-205, Denver, Colorado (303) & (800)

2 A Snapshot of Colorado EMS Depth and breadth of service In 2014 there were 526,861 calls for an ambulance and 380,724 patient transports. Colorado has: licensed ground ambulance services. - 17,209 certified emergency medical technicians (EMT) and paramedics. There are as few as 169 EMTs and paramedics to serve one five-county region (SE) and as many as 4,690 to serve another (metropolitan Denver-area counties). Ambulances are staffed by 8,558 people, of which 26% are community volunteers. 63% of patients require emergency transportation to a hospital. Another 12% need non-emergency transportation to a hospital. Patients not transported can usually not be billed for service. There is no mandate in Colorado law for emergency medical service at any level of government. EMS must respond 24/7/365 regardless of a patient s ability to pay. Ambulance services are operated by: Municipal & county governments Private non-profit organizations (volunteer & paid) Special districts (ambulance, fire, hospital) Public & private hospitals Private for-profit companies Revenue Sources Automobile & health insurance Medicare Medicaid Local taxes Patient payments State & federal grants Ambulance Service Funding The average ambulance bill is 1,262 but the effective collection rate is only 50% (631). Collections vary from 20 80% of charges billed, depending on the payer mix and number of uninsured patients. Medicare and Medicaid pay fixed amounts for ambulance service - 29% and 9% of average Colorado costs respectively - substantially below the cost of providing service. This causes costs to be shifted to commercial health insurers. The cost of EMS in rural areas has been estimated to cost two three times as much as in urban areas due to expansive geography, lower call volume and decreased economy of scale. Many urban areas, and almost all rural areas, require local tax support to fund adequate local EM service. 60% of Colorado s ground ambulance services rely on volunteers, in whole or in part. Volunteer staff size ranges from 4% to 100% of their personnel.

3 For one Ambulance Costs for Equipment and Supplies Cardiac Defibrillator 20,000 IntraOsseous Kit Drugs & Supplies 1,500 Documentation Computer 4,800 Patient Stretcher 3,000 Ambulance Radio KED Extrication Device Traction Splint 259 Scoop Stretcher 703 Airway Suction Unit 1,100 3 Equipment Kits Emergency Airway Kit Patient Backboards 84 2 Crew Radios Ambulance 750 3,800 4, ,000 Total 201,716 Plus annual maintenance 23,400 Source: Denver Health Medical Center Paramedic Division Fleet Operations 6000 E. Evans Ave., #3-205, Denver, Colorado (303) or (800) photographs , Howard M.

4 Community Paramedic A new solution in medical services Opportunity statement Severe Primary Care Shortage currently exists and is on the rise. Vulnerable populations with new health insurance plans will not have access to a provider because of the increase in demand. Cost of healthcare continues to rise with Emergency Rooms being the most available alternative. Access to care problems are exacerbated in rural areas due to higher healthcare provider shortages, a larger elderly population than urban, and transportation barriers. Community Paramedic solution The Community Paramedic (CP) model is an innovative, proven solution to provide high quality primary care and preventative services by employing a currently available and often underutilized healthcare resource. How does it work? A primary care partner refers a patient to Emergency Medical Services (EMS) personnel to provide services in the home that are within their current scope of practice including: hospital discharge follow-up, fall prevention in the home, blood draws, medication reconciliation or wound care. The CP provides care and communicates health records back to the referring physician to ensure quality of care and appropriate oversight. In addition works with Public Health to provide preventative services throughout the community. The goals of Community Paramedic programs include: Improve health outcomes among medically vulnerable populations, and Save healthcare dollars by preventing unnecessary ambulance transports, emergency department visits, and hospital readmissions. Advantages Decreases workload and increases quality and efficiency of managing patients in a primary care and public health settings by utilizing EMS Personnel through non-traditional methods EMS personnel are integrated throughout the healthcare system, improving access and decreasing healthcare cost. CP certification provides a job opportunity where EMS volunteer work is often the only sustainable model in rural areas. EMS personnel currently have the training, expertise and scope of practice to provide essential primary care services. The program has a proven track record locally and internationally. Frequently asked questions Q: Does a CP replace current healthcare systems like home health care or primary care physicians? A: No. CP is an extension of the primary care provider to provide care to patients without access, and does not replace the specialized services available in a home health care model or physician office. Q: Does a CP have the right training to provide primary care? A: Additional education for the CP covers preventive care in the home, within their current scope of practice. However, services provided do not fall out of the currently defined scope of practice for EMS personnel. Q: Is the quality of care compromised by using a CP instead of a primary care provider? A: No. A CP provides care under the supervision of a physician, so the quality of care is consistent with care provided in a clinic setting. Information from the EMS Chiefs, managers and Directors Section of the

5 Understanding ambulance costs Why does an ambulance cost so much? Medicare and Medicaid and transport Costs and Bills Actual Ambulance Average Average Medicare Medicaid cost Bill Write-off Payment Payment Payment When EMS transport costs are not paid, long term agency financial stability is undermined resulting in service cuts and closures. 80% to 85% Of the Cost Are Readiness Costs These are the total costs associated with having trained, equipped and staffed ambulances that are ready and waiting to respond to emergency calls. Service Costs Continue to Rise Salaries, benefits, utilities, medical equipment and supplies, vehicles, insurance, training & education,facilities, fuel, capital improvement. Cost Shifting Chronic under cost payments by Medicare, Medicaid and CICP forces agencies to shift, or pass-on unpaid amounts to other patients through higher ambulance bills. 38% - Average increase in Medicaid patients upon full implementation of ACA. Negative financial ACA impact on EMS providers. 49% - of transport cost is written off to mandatory contractual (Medicare/Medicaid), collections and bad debt 52% - of transport cost are actually paid (all payers combined: Medicare, Medicaid, Insurance, Private). 29% -of costs paid by Medicare 9% -of costs paid by Medicaid

6 and the Emergency Medical Services Association of Colorado Ambulance Costs and payment trends Ambulance Costs & Payment Trends 3,000 The Average Ambulance Bill Cost/Billed/Write Off/Paid 14 Year Trend 2,500 2,000 1,500 1, Transport Cost Ambulance Bill Average Write Off (Uncollected) Average Payment* Data from Ute Pass Regional EMS, Woodland Park, Colo. Factors Impacting Ambulance Costs & Payments Factors affecting costs and payments * Costs are Increasing - Payments are Decreasing - EMS agencies must pay for goods and services received. Costs are Increasing - EMS services and are non-excludable - must provide Reasonable services regardless and of customary a patients ability payments (or below cost. Payments are Decreasing willingness) pay. EMS agencies must * Worsening pay for to goods Payer Mix and - Negative services since full implementation Insurance of companies ACA adopting Medicare payment strategies - lower payments. received. - Expanding Medicare, Medicaid & CICP and declining Insurance & Private Pay. * Insurance Companies are Paying Less Higher deductibles and co-payments. Ambulance EMS services are non-excludable. - Inconsistent methods They used to determine must "reasonable bills applied & Customary" deductibles amounts vary between and co-payments. Bills provide services regardless insurance companies. of a patient s ability go unpaid. (or willingness) pay. - Reasonable & Customary payments below cost. - Insurance companies adopting Medicare payment Insurance strategies - payment lower payments. appeals - increasing - billing & Declining revenue - Higher since deductibles full and co-payments. Ambulance collection bills applied costs to deductibles increase. and co-payments. implementation Bills of go ACA unpaid. Payments from higher - Insurance paying payment private appeals insurance - increasing - billing Insurance & collection costs Companies increase. Paying are shifting to Medicare * Insurance and Companies Medicaid, Paying due Patients to Instead Patients of Agencies - increasing. Instead of Agencies is expanded eligibility. - Insurance companies pressure providers to increasing. contract for below cost payments by processing payments to patients instead of providers. Patients Insurance do not forward companies the payments to pressure providers. providers to Insurance Companies More bills go Paying unpaid. Less contract for below cost payments by processing Inconsistent methods used to determine payments to patients instead of providers. Patients reasonable and customary amounts vary do not forward the payments to providers. between insurance companies. Low Medicaid Rates Undermines Financial Stability More bills go unpaid. Information from the EMS Chiefs, managers and Directors Section of the

7 Colorado EMS Insights EMS Is an Essential Community Service Emergency Medical Services (EMS) is a non-excludable essential community service. Everyday all around Colorado, paramedics, EMTs and other first responders, both paid and volunteer, serve in our communities by responding to and caring for persons experiencing medical and trauma emergencies. These men and women work for EMS agencies that are based out of hospitals, fire departments, private companies, municipal and county third services, search & rescue and law enforcement agencies. They are equipped and trained to provide the best possible patient care whenever and wherever its needed 24/7/365. However, providing good patient care and paying for that care are two different things. Costs associated with EMS operations are rising but payments from insurance, patients, Medicare and Medicaid are declining. Many EMS agencies, especially in rural areas, are struggling to survive. Some agencies are cutting services, close to ceasing operations or have closed. Specific EMS challenges 1. EMS services are non-excludable and non-rival public good; 2. Free-rider problem is increasing; 3. Operational costs raising without increases to operational revenues; 4. Below cost payments from Medicare & Medicaid is worsening. Threatens organizational financial stability causing service reductions; 5. Frequency of insurance companies paying patients instead of providers is increasing. Patients receive payments but do not forward those payments to providers ambulance bills go unpaid; 6. Automobile insurance companies delaying payments; 7. Inconsistent methodologies used by insurance companies to determine reasonable and customary rates paid for EMS services; 8. Insurance companies using Medicare methodologies to determine rates paid for EMS services; 9. Declining availability of advanced life support services especially in rural areas; 10. Deteriorating pool of volunteers in rural areas; and 11. Inconsistent, expensive and unavailable initial and ongoing education and training in rural areas. Recommendations for consideration 1. Consider raising the state Medicaid rate paid to ground ambulance providers; 2. Ease CICP claims processing for EMS providers; 3. Close insurance company payment loop holes - require payments be sent directly to providers & not patients; 4. Require prompt payments be made to EMS providers especially from auto insurance companies; 5. Encourage collaborative & cooperative partnerships between EMS agencies and health/auto insurance companies for reasonable payment structures; 6. Encourage more collaborative, cooperative and inclusive partnerships between EMS and future Accountable Care Organizations (ACOs) & Regional Care Collaborative Organizations (RCCOs); 7. Allow all EMS agencies - public & private - access to the Colorado Central Collection Services for improved collection on delinquent accounts; 8. Support expanded scope services such as Community Paramedic/Mobile Integrated Health Services by EMS agencies; 9. Support federal initiatives to improve EMS function and finance such as H.R. 809, the Field EMS Quality, Innovation and Cost Effectiveness Improvements Act (supported by Colorado s Senator Bennet and Representative Lamborn); 10. Support HB , Interstate Compact EMS Providers; SB , Dispense Supply of Emergency Drugs for Overdose Victims; SB15-067, Second Degree Assault Injury to Emergency Responders; and, SB15-002, Extend Report Date Statewide Radio Communication. Information for 2015 EMS Day at the Capitol from the EMS Chiefs, managers and Directors Section of

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