States Using Emergency Medical Techs to Expand Health Care Services
States are increasingly turning to community paramedicine to help fill the gap in the health care workforce. States have been experimenting with community paramedicine programs for the last five years or more. Expanding the role of licensed or certified emergency medical technicians—or EMTs—and paramedics to provide non-emergency preventive health care services directly to patients in their communities can be cost-effective and make up for health care work force shortages.
Nevada Assemblyman James Oscarson said he was motivated to sponsor a community paramedicine law in 2015 because of the number of runs made by ambulances to pick up individuals who didn’t need to go to emergency rooms or be admitted to the hospital. Oscarson is a nurse and currently works as director of community relations at his hometown hospital.
In many rural areas of Nevada, doctors and nurses are in too short supply to provide the primary care services community residents need to stay healthy. But with the help of paramedics, according to Oscarson, patients with chronic diseases and other health needs may be better able to access the services required to manage their diseases, and prevent complications and admissions to the emergency room or hospital.
“Community paramedics offer extensive background experience and will provide for better access to health care,” Oscarson said. “Nevada now has an opportunity to fill unmet or unrealized community primary care and health needs. Using EMS providers in an expanded role will increase patient access to primary and preventive care, save health care dollars and improve patient outcomes.”
Nevada Gov. Brian Sandoval signed the bill into law on May 25, 2015. The bill allowed the state to write necessary rules for implementation on Jan. 1, 2016.
In late August, Nevada received approval of a state plan amendment from the Centers for Medicare and Medicaid to provide Medicaid reimbursement for medically necessary community paramedicine. Services must be part of the care plan ordered by the patient’s primary care provider and may include evaluation and health assessments; chronic disease prevention, monitoring and education; medication compliance; and immunizations.
“With approval of Medicaid reimbursement, I see tremendous opportunities opening up for Nevada,” said Oscarson.
Starting with Minnesota in 2011, 16 states and the District of Columbia have passed laws on community paramedicine. North Dakota dipped its toes in the water in 2013 with a feasibility study and by 2015 adopted statewide rules. In 2016, the West Virginia legislature authorized six demonstration sites. North Carolina and Maine provide some state funding to support community paramedicine efforts and Minnesota also has secured Medicaid reimbursement.
Janet Haebler, senior associate director of state government affairs for the American Nurses Association, said community paramedicine “strives to fill in gaps in services that previously had been provided by public health and home care nurses but were lost with funding cuts.”
Haebler underscored the necessity of a clear definition of the community paramedic role with patients, as well as the roles of all health team members who deliver such care. For that reason, in states with new community paramedicine laws, nurses have come to the table with EMTs and others to ensure that every patient has access to high-quality care from all health care providers.
In some communities and states, community paramedicine is part of a larger reform called mobile integrated health care. Mobile integrated health care includes services such as providing telephone advice to 911 callers instead of ambulance dispatch; providing community paramedicine care, chronic disease management, preventive care or post-discharge follow-up visits; and transport or referral to an array of health care settings beyond hospital emergency departments.
“We use a nurse to triage calls that come into our 911 number,” said Matt Zavadsky, director of public affairs for MedStar Mobile Healthcare, the ambulance service for Forth Worth, Texas, and 14 nearby cities that serve nearly a million people. “If you have twisted your ankle, for instance, our nurse may suggest that you go directly to an orthopedic clinic. We can even send a taxi to transport you.”
Zavadsky said Texas’ Section 1115 Medicaid waiver provides for reimbursement of the full array of mobile integrated health care services, including community paramedicine. But the waiver doesn’t eliminate the dilemma that ambulances are paid as transportation services, not health care services, under both Medicaid and Medicare. Transportation by the ambulance to a setting other than a hospital emergency room is not reimbursable, neither is providing medical treatment without accompanying transportation service.
“It doesn’t make sense that our ambulance can arrive and provide glucose for a diabetic who has forgotten to eat and is unconscious, treat the patient effectively and arrange for a follow-up visit to the patient’s physician, but not get paid unless the ambulance takes the patient to the hospital emergency department,” said Zavadsky.
Zavadsky and other members of the EMT community are working to change federal policy to make ambulance assessment and referral a reimbursable Medicaid and Medicare service, something they hope can make a significant impact on many individuals who need more accessible care and save money for the health care system overall.