Care Providers and Insurance

ACA and EMS The implementation of the Affordable Care Act (ACA) is sure to change the way EMS operate in the coming years. Accountable Care Organizations (ACO), for instance, are now responsible for overseeing how reimbursements are paid out to those agencies that provide health care -- and at the same time they are responsible for gauging whether or not quality care is delivered by providers (Koury et al., 2014).

This is a tall order for a new functioning body and the ACOs tasked with these orders will have an indirect impact on how EMS operates. To see how that impact will be effected, an examination of the ACOs and hospitals interact requires examination -- because it is that interaction that will inevitably alter the way in which the EMS goes about their business. This paper will examine the relationship between the ACA, ACOs, hospitals and EMS and show how an EMS Administrator might prepare for the changes.

Specifically, this paper will discuss the ACA legislation, what Emergency Care means, how insurance coverage is a factor in impacting EMS, where revenues come into play, how sustainability will be a factor to consider over the long-run (with ACA co-ops already closing their doors, the long-run outlook is having a decidedly short-run impact), and how healthcare integration will alter EMS. This alteration will be the main focus of the paper.

ACA Legislation One of the most direct ways in the ACA legislation impacts EMS is the awarding of "competitive grants for regionalized systems for emergency care response" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). These grants go to provide monetary support to local or regional pilot projects "that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care and trauma systems" (ACA, 2010, Sec. 1204, 124 STAT., p. 518). Emergency services is defined as service that provides "acute, prehospital, and trauma care" (ACA, 2010, Sec. 1204, 124 STAT., p. 518).

These monies for pilot projects are reserved precisely for networks of care providers, who form an integrated emergency services care plan complete with transports, facilities, tracking resources, and an interfacility data management system that "submits data to the National EMS Information System" among various other agencies (ACA, 2010, Sec. 1204, 124 STAT., p. 519). In short, the legislation states that the federal government will grant money to health care providers who work to integrate EMS, hospitals, and tracking services and uniting these entities under a single umbrella.

Holding that umbrella will be the federal government, which will collect the data and evaluate the variables that impact prehospital care as well as outcomes related to interfacility actions. The ACA thus sets up local and regional actors to be integrated into a federalized system of care. This may be viewed as akin to what the state governments of the original thirteen colonies underwent when the ratification of the U.S. Constitution presented itself as fact: the matter of states' rights vs.

federal authority would no longer be a question -- the federalization of power was made a reality by the consolidation expressed in the Constitution. In the ACA legislation, consolidation is the driving force, and the federal government is the pivot upon which health care providers will turn. As for EMS, the concept of emergency care will likewise undergo a federalization and take on new meaning and new dimensions as a result.

What Emergency Care Means and How Healthcare Integration Will Change the EMS Emergency Care according the ACA is that type of service which provides acute, prehospital and trauma care for individuals. However, as the legislation is enforced and regional and local providers begin to integrate and compete for federal grants, this definition is likely to incorporate new concepts and be expanded to fit the needs of the ACOs which will monitor the quality of care delivered by integrated health providers, including EMS.

With new oversight comes new expectations and a need to conform to new standards and regulations. EMS, for instance, will be expected to alleviate the pressure placed upon hospitals to ensure that quality of care expectations are being met (Ludwig, 2013). This will include obliging EMS to make home calls to patients post-discharge for up to three days in order to reduce the risk of complications arising and patients needing to be re-admitted.

Re-admittance is a factor that will serve as a red flag to ACOs and cause hospitals to lose reimbursement funds that would otherwise be granted them through the ACA. Additionally, EMS will be encouraged to take patients to separate care providers or to a different level of care facility so that the same hospitals are not tasked with accepting the same patients again and again -- which would also cause them to lose Medicare reimbursements under the guiding principles of the ACOs.

This in turn would burden EMS with the need to be part of an integrated tracking system that monitors where patients have been recently and which facilities are willing to accept them (Ludwig, 2013).

In other words, the ACA and the ACOs will ultimately place greater restrictions on hospitals by demanding specific bureaucratic goals be met that will in turn cause EMS (intermediaries in emergency cases) to shoulder the responsibility for helping hospitals and other healthcare facilities to comply with ACO regulations so that the latter might not lose out on federal reimbursement monies. This sets the stage for a number of potential dramas -- none of which will appeal to an EMS Administrator. First, it ups the ante on fraud.

Medicare fraudulence is most prevalent among hospitals and healthcare providers/facilities precisely because of hospitals' need for reimbursement (Hill et al., 2014; Iglehart, 2010). Healthcare costs are not made more affordable by the ACA -- but more pressure is placed on providers to give regulators and overseers like the ACO the impression that quality care is being given so that they can receive federal funds (Ludwig, 2013).

The main issue here is that some patients with whom EMS is continually in contact are patients who use ED services in order to secure Medicare coverage because normal healthcare providers refuse to treat them. Such patients allow medications to run out and rely upon EMS to transport them to hospital EDs.

Now, with ACOs placing restrictions on the number of times a patient may be readmitted within days of discharge in order for reimbursement of Medicare to be given, hospitals will look to steer such patients away -- even from EDs. This puts EMS in an unenviable position of having to find a facility that will accept patients whose situation is such that they only receive Medicare if they can find a provider who can afford to treat them continuously.

Thus, healthcare integration will cause EMS to pursue slightly different aims in the future, having to adjust to the needs of hospitals seeking to avoid being blacklisted from federal funds as a result of missing ACO guidelines. EMS will be on the receiving end of this adjustment, being forced to adjust the manner in which the deliver patients in need of emergency services and care. As Alpert et al.

(2013) report, somewhere between 12% and 16% of all EMS runs result in patients who may be safely delivered to non-ED destinations because of the nature of the calls. The issue according to Alpert et al. (2013) is that EMS should be reimbursed both by Medicare and private insurers for redirecting patients to destinations where they will receive adequate care. Hospitals would also support this arrangement as it would solve an issue related to reimbursement and ACO oversight on their end.

The issue is complicated, however, by the nature of the ACA itself, and how the Supreme Court has interpreted it -- as both a law and a tax -- and all agencies and individuals are impacted by this decision, which has many scrambling to make sense of how and whether they should and can afford to comply with recommendations (Hall, 2013). What an EMS Administrator Can Do Recommendations for an EMS Administrator include taking into consideration this alteration and being prepared for when it happens (Ludwig, 2013).

As Eckstein (2013) reports, "the need for EMS will increase dramatically over the next several years as more Americans gain health insurance under the Affordable Care Act" (p. 2068). Indeed, this increase is likely to "generate approximately 900,000 additional emergency department visits annually" (Eckstein, 2013, p. 2068). Where this become an issue is at the EDs, where individuals will ultimately need to be delivered. If hospitals are not admitting patients with too frequent ED visits, the problem begins to weigh on EMS and the type of service they are expected to provide.

As Eckstein (2013) observes, "government-provided health insurance rates of reimbursement do not lend themselves to a successful business model, especially one in which lives are on the line" (p. 2068). The question that EMS Administrators will have to answer is whether their ambulance services can survive in such an economic climate, where the incentive to avoid treating expensive patients becomes all too apparent. The Administrator must approach this question based on the type of provider he/she oversees. In this case there will be the private operator and the public operator.

A public operator will likely need to train first responders by cutting costs and utilizing vehicles owned by the municipal fire department. A private operator may need to adjust its billing rates by pledging to work in a municipality free of cost to taxpayers and make its money directly from individuals who request ambulatory services. This would be akin to private billing, private-pay -- yet the same problems may arise when it comes to seeking reimbursement from insurance companies.

Already insurance companies are withdrawing from the ACA program because of soaring costs associated with treating patients whose healthy makes them unwelcome consumers. The promise of the ACA was that young, healthy people would buy into the program to avoid paying the tax -- but so far that has not been the case. In fact, young people are finding it more affordable to pay the tax than to pay the premiums for health insurance month to month that they feel they do not need, since they are healthy.

This has created a vacuum in the system, and insurance companies, unable to support the rising costs associated with older patients, are pulling out entirely. Coverage rates among young persons continue to be lower than in previous decades and this is negatively impacting insurers' balance sheets (Berk, Fang, 2016). And as the study by Ahmed et al.

(2015) indicates, "even with an inclusive statewide trauma system and an emergency department that does not triage by payer status, uninsured patients presenting to the trauma center were at increased risk of traumatic death relative to patients with commercial insurance" -- in other words, costly patients are not receiving the care they need, and few care providers are able to do anything about it. How Insurance Coverage Factors In How insurance coverage factors in is of paramount importance for the EMS Administrator.

After all, it is the issue of reimbursement and settling costs that is at the heart of the ACA and the new alterations that EMS can be expected to now face. Insurance coverage is still in flux as more and more co-ops drop out of the system, and big insurance agencies become more stringent and what they will and will not cover.

In spite of the legislation of the ACA, insurance providers will issue policies that get around legislative requirements be either meeting bare minimum standards or else isolating treatment and limiting the degree to which particular services will covered. Insurance thus factors into the role and dynamic of the EMS in a major way.

Who will cover the costs associated with ambulatory services -- the municipality (taxpayers)? -- or the private citizen (the insurance company)? As municipalities look to cut costs in the wake of an economy that is shrinking ever more every day, EMS will need to be able to ensure that its own services can be provided for by one or another means, even as they seek a solution to the problem of where to send patients requiring emergency care.

Making the decision between an ED delivery and a non-ED delivery could also play a significant part in how the cost-coverage ratio plays out. These are factors that the EMS Administrator will also need to consider in order to provide the adequate and proper guidance for all persons involved in the process.

Revenues In order to ensure that revenues do not drop and that service has to be cut, the EMS Administrator should decide upon the two courses -- whether to work with municipalities and contract services out to departments already engaged in making emergency runs (i.e., the local fire department) and thereby bill directly to the municipality for all costs, or to work with private citizens and bill directly to them (or their insurers) for all costs. Either avenue has its risks associated with revenue.

The former's risks have to do with losing municipal contracts over time as municipalities are squeezed and endangered from an economic standpoint. With pensions at all-time highs and populations declining (the elderly population is climbing more rapidly than the younger population), the expectation that revenues can climb or be sustained simply as a result of the ACA is unfounded at best. The ACA has created an atmosphere in which new financial challenges are being felt on all fronts.

The poor business model of reimbursements described by Eckstein (2013) will directly impact the balance sheet of EMS providers. How to cope with that situation is what the Administrator must determine. For this reason, revenues will have to be generated in a way that is both in conformity with ACA legislation and with the provider's need to keep a balanced book. If expenditures are not being matched by income, the threat of closing doors and abandoning service becomes real.

The ideal outcome in the situation being faced by EMS is that insurance providers will cover costs -- but the reality is that this likelihood is looking slimmer. The upcoming presidential election may further throw a wrench into the works -- for if presidential hopeful Donald Trump is elected, the impact on the ACA and the role of the EMS could be overridden by Executive Order. Trump has already discussed publicly his disdain for the ACA and that he would repeal it.

Politics and business make for uncertain bedfellows and business models in such an environment have to be approached with careful consideration. The best avenue for the EMS Administrator at this point may be simply to wait and see what unfolds in the coming months and in the meantime maintain as much business as possible without causing the balance to dip into the red. Sustainability The sustainability of EMS in this environment is to be considered unlikely.

Various researchers have already pointed out the destabilizing effect on the market that the ACA will have as it pertains to EMS (Eckstein, 2013; Ludwig, 2013). The expansion of Medicare makes the situation even more untenable as individuals seek to find coverage for costs that health care providers do not want to cover and fear they will not be.