Quick-Take: Building a sustainable economic model for an EMS telehealth program
Matt Zavadsky // September 14, 2021
Learn where to find willing partners and payers for an EMS telehealth navigation program
NAEMT recently wrapped up a series of three webinars focusing on the use of telehealth in EMS. The first two webinars in the series focused on the keys for operational and clinical success, and this final webinar highlighted best practices for building a successful financial framework for a telehealth program in EMS.
Panelists for the webinar, each with unique insight into EMS and telehealth, provided exceptional insight on how EMS agencies can implement a telehealth program in a way that makes financial sense for the patient, the telehealth provider and the EMS agency. The panelists included:
- Don Jones, an EMS icon and healthcare economics expert and co-founder of Tele911
- Dr. Jerry Allison, the medical director for mobile integrated healthcare programs for Molina Healthcare, a large national health insurer
- Shanel Fields, CEO of MD Ally
These experts responded to a series of questions related to EMS Telehealth programs. Here are 5 takeaways from the webinar.
1. Why would a payer (health plan, etc.) be interested in working with EMS agencies to navigate 911 callers using telehealth?
Health insurers have a goal to ensure their insureds receive the most appropriate care, in the most appropriate setting, and have a great experience with the healthcare system. Often, an ambulance transport to an emergency department does not meet those goals. It’s often not clinically necessary, and not very patient-focused. It’s also generally more expensive than receiving care in other appropriate settings, such as an urgent care, or even care at home by EMS, with a referral to the patient’s primary care network. — Dr. Allison
Payers are beginning to understand that EMS may bring them, and their insureds, more value by helping their insureds ‘navigate’ the healthcare system appropriately. Some people who call 911 don’t need to go to an ED for their medical condition. Using a telehealth platform to consult with providers approved by the payer to help with patient navigation brings great value to the payer. It can avoid preventable and expensive ED visits, and even if an ED visit is necessary, can assure the patient is brought to an ED that is in-network with the payer, which means the ED has access to the patient’s records and past medical history, which enhances patient care. — Jones
2. How do I find out who the largest payers are for our services when we transport people to the ED?
Work with your billing department or agency to run a report on your accounts receivable. This is generally a very basic report that can be sorted from most payments to least payments. You should drill down a bit into the actual payer classes, like Medicare, Medicaid and commercial insurance, and find the actual insurers, by company, for each of those classifications. Through that report, you’ll be able to find out who are your largest payers, and create your priority list for who may be motivated to work with you to fund a telehealth program. — Fields
3. Are there ways we can quantify the value to the payer? How would they calculate an ROI for 911 scene navigation?
Payers have robust analytics to help them determine the value of virtually any care provided to their members. They also know what it costs them when a member goes to the emergency department with a heart attack or an asthma attack, or really anything. They will typically evaluate RIO based on the number of high-cost ED visits that could be avoided through an EMS telehealth program. They will also balance those savings with any additional cost they incur for the program. For example, if an ED visits typically costs them $3,000, and the payment to the EMS agency, including the telehealth provider, costs them $1,000, and it avoids an ED visit, that’s a $2,000 savings to the payer. — Jones
4. We are NOT an ET3 Model participating EMS agency. Can we still get paid for on-scene patient navigation through telehealth?
Absolutely! Medicare’s ET3 program is specific to its fee-for-service population. While this is typically a large part of the EMS payer mix, it is not the only part. Molina is working with several EMS agencies to pay for EMS telehealth and on-scene patient navigation because we recognize the value to bring to the patient and to Molina. Just because you are not part of the CMS ET3 model, does not mean you cannot work with other payers, including Managed Medicare payers, to be reimbursed for EMS patient navigation. — Dr. Allison
5. If we are unable to contract with a payer directly for this enhanced service, are there other potential ways an on-scene telehealth program can be economically advantageous to the EMS agency and the telehealth provider?
Yes, there are different healthcare groups who are financially "at risk" for the healthcare costs for patients. For example, Accountable Care Organizations take on the clinical coordination, and the costs associated with that care, for specific populations. An ACO benefits financially when it meets or exceeds clinical performance, and lowers the expenses for that population. EMS agencies may find an ACO a very willing partner/payer for an EMS telehealth navigation program. — Fields
Local healthcare systems may also be willing to fund EMS for navigation and telehealth-related services. Consider the relatively new "Hospital in the Home" program. Hospitals admit patients, but the patient receives care in their residence. Medical devices are delivered and set up at home, and providers are scheduled to provide care in the home. The hospital receives payment as if the patient was an inpatient and then pays for the care provided in the patient’s home. EMS agencies could be a key partner in this care delivery by either being scheduled to visit the patient in between scheduled visits by docs and nurses, or as a resource for an episodic request by the patient, family or care provider. — Jones
Additional telehealth resources
EMS agencies and patients could significantly benefit from the successful implementation of an EMS/telehealth program. If you’d like more information about how these types of programs can be part of your delivery model, feel free to contact MZavadsky@medstar911.org.