In all the strategic planning discussions on how to move a provider organization from pay-for-volume to pay-for-value, one area, moving patients, has seemingly gotten detoured. While 15% of Medicare beneficiaries used an ambulance in 2011, this cost item has received much less attention than other healthcare services. In 2011, there was 15.2M Medicare ambulance claims(1) for totaling $5.3B.(2) This is over $9PMPM for the 47M Medicare beneficiaries.(3) To put this in perspective, ambulance costs to Medicare are almost half of that for Emergency Rooms.(4) To an ACO or at-risk provider attempting to remove costs one $1 PMPM at a time, this is too big a target to simply ignore.
Part of the reason for the under management of transportation spend is the high-risk nature of emergency response, and the seemingly incompressibility of the line item. However, when the utilization is properly segmented there are opportunities to safely reduce costs. The Fire Department of New York City reported that of their 1.5M ambulance runs in 2012, only 37% were for Life Threatening emergencies.(5) According to Medpac, from 2007 to 2011 non-emergency basic life support (BLS) transports grew at rate 11.4%, outpacing emergency BLS growth of 9.6%.(6) Contributing to this growth is more use of ambulances for Dialysis transports, especially from Skilled Nursing Facilities (SNFs) and dialysis centers. Net net, not all ambulance runs are emergent, and hence options may exist
The first set of transportation cost reduction opportunities are not specific to ambulance spending. Aggressive population management should reduce emergency and non-emergency transports alike through stabilizing or reversing disease progression. For example, tighter control of CHF, COPD, Diabetes, ESRD, Mental Illness, etc., should reduce ED and hospitalization rates, and their corresponding transport costs. Also, properly placing patients into the right step down facility—including steering patients to the highest performing providers, will reduce acute care readmission rates and transport costs alike.
However, there are additional, more specifically transportation cost reduction strategies to explore as well:
Bundle visits when possible. For non-emergency transports to out-patient visits, it may be possible to schedule multiple doctors’ appointments for the same day, especially when the providers operate out of the same clinic. While a bit of a headache for front-office staff, the saving of a $250-$400 ambulance bill is probably worth the hassle.
Flag high-utilizers for education, counseling, and logistics support. As with other compressible health metrics (e.g., use of branded pharmaceutical for which there is a reasonable alternative), bringing transportation utilization data to the physician and/or case manager is likely beneficial. Creating one or two metrics on transport costs, especially non-emergency transports, can help spur a dialog with the patient on ways to get to visits more cost-effectively. This may include working with volunteers and community resources to secure rides to routine office visits and or dialysis treatments as practical. Of course, the same metrics can be used at a patient panel- level as well as at a patient-level to identify outlying providers.
Improve triaging and telephonic access. In evaluating the “frequent flyer” EMT users, Matt Zavadsky, assistant director of operations for Fort Worth (Texas) Paramedics, found many patients just wanted to someone to talk to.(7) Improved use of nurse lines and after-hour telephonic support may give patients the comfort they need without the unwarranted ambulance trip.
Transport the treatment/providers to the patient. EMS in Wake County, North Carolina are exploring using specially trained EMS personnel to assess trip & falls at assisted living facilities, including working with the primary care group to develop a treatment plan. Thus, transport to the ER may not be necessary for all cases.(8) Further west, EMTs in Fort Worth, Texas have created “’community health paramedics’ who are specially trained to respond to non-emergency medical calls and regularly visit patients to check blood sugar, blood pressure, etc.”(9) In each of these examples, the care being moved to the patient, not the other way around. Another, more basic implementation of moving care to the patients is increasing physician presence at SNFs and LTACs, if practical, rather than having the patient come to clinic.
Find a cheaper ride. When transport is necessary, it is best to find the cheapest ride that meets the clinical need. Companies like Stat have created a dynamic marketplace for providers to source idle EMT assets. Encouraging use of Non-Emergency, Non-Ambulance Medical Transportation, either for- or not-for-profit, is another viable option. Of course, if safe and practical, non-medical transportation services (e.g., taxi vouchers, local volunteers), could be considered.
While transport costs may not be top of mind as health systems harvest the “low-hanging fruit” of readmissions and chronic disease management, a dollar saved on transport is just as green as in-patient stay dollar. Further, reducing use of transport services and emergency rooms not only removes the direct expense, but can eliminate significant potential unnecessary workups and follow-ups that the acute episodes generate.
1. Gaumer Z et. al. Powerpoint: “Mandated Report: Medicare Payment for Ambulance Services.” Sept. 6, 2012, P. 11, found online.
2. Medpac. Report to the Congress: Medicare and the Health Care Delivery System, June 2013. P. 168
3. KFF.org Web Site: http://kff.org/medicare/state-indicator/total-medicare-beneficiaries/, 2011.
4. Assume roughly $15 - $20 PMPM for ER Facility plus Professional Costs.
5. 2012 Citywide Yearly EMS Report at: http://www.nyc.gov/html/fdny/html/stats/citywide.shtml.
6. Gaumer Z et. al. p. 13.
7. Auge K. “911 Non-Emergencies a Growing Problem Nationwide.” The Denver Post. Dec 29, 2009.
8. Ferares S. “Wake Commission Roundup: Fewer Ambulance Rides for Non-Emergencies.” Jan 12, 2012. Raleigh Public Record.
9. Auge K. Dec. 29, 2009.