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In Chico, Calif.,
paramedics receive a daily list of patients discharged from Enloe Medical
Center with a diagnosis of heart attack or heart failure. Within 72 hours of a
patient’s arrival home, a paramedic is on the phone.
“They call to make sure
the patients understand their discharge instructions, that they have filled
their prescriptions, that they have their follow-up appointment, and that they
understand what the follow-up appointment is,” says Marty Marshall, managing
director of Butte County Emergency Medical Services (EMS). “If it sounds like
the patient is confused or would benefit from some help, they try to make an
Robbinsdale, Minn., paramedics are part of a multidisciplinary care team that
targets Medicaid patients who do not qualify for home healthcare services or
who refuse long-term care. Their goal is to help patients understand and follow
“We are going to be part
of this person’s life for 30 days,” says Pete Carlson, manager, community
paramedicine, North Memorial Health Care.
“Do they know how to follow their low-sodium diet? Where to grocery
shop? What to do when their insurance doesn’t cover the durable medical
In fact, the influence of
community paramedics does not end at 30 days. Care then transitions to
community-based providers, including those that provide nonclinical social
supports, with community paramedics visiting on an as-needed basis.
The two programs are part
of the fast-growing community paramedicine (CP) movement, in which specially
trained EMS personnel are deployed to help reduce avoidable emergency
department (ED) visits and inpatient admissions while improving patients’
health status and experiences of care.
Despite many barriers to
widespread adoption, community paramedicine holds great promise, says Kenneth
W. Kizer, MD, MPH, director of the Institute for Population Health Improvement at
the UC Davis Health System and a former state EMS director in California.
“CP is an important
component of population health management and the emerging value-based
healthcare economy because it fills gaps in the local healthcare delivery
infrastructure that are directly germane to value-based payment,” he says.
Still in its infancy,
community paramedicine is emerging around the country. Kizer estimates that at
least 150 programs are established or being piloted in nearly 20 states.
He is the author of a
2013 report, “Community Paramedicine: A Promising Model for Integrating
Emergency and Primary Care,” that assessed the feasibility of developing CP
programs in California. Commissioned by the California HealthCare Foundation
and California Emergency Medical Services Authority, the report said CP
programs may result in:
No comprehensive database
exists, but researchers at the University of Washington identified 86 CP
programs operating as of December 2014, including 49 serving urban areas, 27 in
rural communities, and 10 serving both rural and urban patients.a
Focusing only on the
rural programs, the researchers found that:
CP has developed most
quickly in Minnesota, courtesy of 2011 state legislation directing the
Minnesota Department of Human Services to determine CP services that should be
covered by Medicaid. The CP concept got another boost in 2013 when Minnesota
received a $45 million grant from the Center for Medicare & Medicaid
Innovation to test new healthcare ideas.
As of early 2016,
Minnesota had 16 CP programs in place, with another eight in development. One
of the first was launched in 2012 by North Memorial Health Care. Working as
part of a team that includes social workers, nurses, pharmacists, case managers,
and other professionals, North Memorial paramedics seek to provide better
primary care access for patients discharged from the hospital who are not
receiving home healthcare services and those with chronic conditions who need
Most of North Memorial’s
paramedics work as traditional 911 responders on some days each week and as
community paramedics making home visits on other days, Carlson says.
Since the program began
in 2014, North Memorial has documented that CP patients more frequently keep
their follow-up primary care appointments and report greater confidence in
their ability to manage their health problems. Moreover, Carlson says ED visits
and inpatient admissions for patients served by CP have been reduced by at least 40 percent since the program began.
Butte County EMS’s CP
program is one of 12 pilot projects authorized by the California state
legislature following recommendations by Kizer and his colleagues in their
feasibility study. State law regarding scope-of-practice for paramedics will
need to be changed to permit community paramedicine, and the pilots are
generating the safety, efficacy, and outcomes data that are needed before that
The goal of the Butte
County pilot is to determine whether readmission rates for patients discharged
after a diagnosis of acute myocardial infarction (AMI) or congestive heart
failure (CHF) would be reduced if paramedics provide follow-up calls and/or
Although the pilot is
still in progress, Marshall can see what is happening. The follow-up calls are
helping AMI patients—in 2016, AMI readmissions were 53 percent lower than the
baseline level in 2014. But a phone call is insufficient for CHF patients;
indeed, the readmission rate for that group actually increased during the
last half of 2016.
That’s because CHF
patients often have trouble complying with the lifestyle changes that are
required to control their condition, and they need considerable support to
consistently weigh themselves to monitor for fluid retention. Because no
additional paramedics were added to the EMS staff, the pilot is designed to
reveal whether the current staff has adequate time to provide the requisite
“What we’re going to find
in the end is that we need to have more dedicated resources to consistently make
home visits to those more difficult patients if we are going to make a positive
impact on the readmission rate,” Marshall says.
Based on his staff’s
experience to date, he thinks other diagnoses—chronic obstructive pulmonary
disease and pneumonia, in particular—might be better suited to CP follow-up than
are CHF cases. But he thinks the CP movement could have the most impact on
health care if paramedics were authorized to transport patients to the most
“So often, they don’t
need to come to the ER,” Marshall says. “If paramedics have the authority and
the latitude to redirect patients, they can make a real difference in the cost
and the outcomes of our patients.”
Some of the California CP
pilots are allowing paramedics to transport patients to urgent care or mental
health clinics, while others are providing hospice support, follow-up treatment
after a tuberculosis diagnosis, and other interventions.
As health systems pivot to population health management and value-based
contracts, CP offers a lot to like.
“There’s face validity for the
underlying concept of using an existing pool of healthcare workers who already
possess most of the needed skills and are an established and trusted part of
the community infrastructure to expand access to basic services,” Kizer says.
“And it fills a clear and demonstrated need to bridge primary care and
emergency care and fill gaps in the underlying healthcare delivery
infrastructure that exist in so many communities across the country.”
But two big barriers stand in the way
of rapid adoption. One is lack of evidence about which CP strategies truly add
value. While various programs have demonstrated that they reduce 911 calls, ED
visits, or emergency transport charges, the field is so new that almost every
program is an experiment and no standard protocols have been developed or
“The data are not as compelling as
either Medicare or other healthcare payers want to see before deciding whether
they are going to cover this as a service,” Kizer says.
Some programs are supported by grant
funding, which means their long-term viability is uncertain. Other programs
work only because of particular circumstances. For example, Butte County EMS is
a joint venture between Enloe Medical Center and a private EMS provider.
“In our case, if I can save the
hospital money, that makes this financially worthwhile,” Marshall says. “But
stand-alone ambulance providers aren’t going to get into this business if they
don’t get paid for it.”
In general, neither public insurers nor
health plans pay for CP services, with Minnesota as a notable exception. That
state’s Medicaid program has covered CP services since 2012.
Blue Cross and Blue Shield of
Minnesota thus reimburses community paramedics who serve its Blue Plus managed
Medicaid subscribers. In keeping with state regulations, CP services are
covered only if they are part of a patient care plan developed in coordination
with the patient’s primary physician and relevant local healthcare providers, according
to a Blue Cross spokesperson.
Carlson, a longtime CP leader in
Minnesota, expects CP will advance only in states in which widespread payment
reform forces health systems to develop new care delivery models. EMS
organizations cannot afford to provide CP without payment, and payers are
unwilling to cover CP because the value has not been quantified.
“The challenge right now is the traditional fee-for-service
structure,” he says. “Until bundled or value-based payments become more
entrenched, it’s going to be challenging for people to make that leap.”
writes about healthcare business and policy topics for several HFMA
Interviewed for this article: Peter Carlson, manager, community paramedicine, North Memorial Health
Care, Robbinsdale, Minn.; Kenneth W. Kizer, MD, MPH, director, Institute
for Population Health Improvement, UC Davis Health System, Sacramento, Calif.; Marty Marshall, director, Butte County Emergency Medical Services, Enloe
Medical Center, Chico, Calif.).
a. Patterson, D.G., et
al, “What is the Potential of Community
Paramedicine to Fill Rural Health Care Gaps?” Journal of
Health Care for the Poor and Underserved, November 2015.
HealthTrust: Solving Workforce Management Challenges
Two of HealthTrust’s senior leaders talk about strategies for optimizing the hospital workforce to improve productivity and reduce waste.
Grant Thornton: Optimizing the Ambulatory Workforce
One of Grant Thornton’s senior healthcare consultants addresses the topic of workforce management and the importance of a data-driven approach.
Cedar: Reimagining the Patient Financial Experience
Cedar’s CEO and co-founder tackles the topic of patient payment and the importance of having an innovative patient financial management system.
TRIMEDX: Moving Healthcare Providers Toward Mature Clinical Asset Management
This article includes a discussion by TRIMEDX leaders about the best ways to mature a clinical asset management program.
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
Does Your Budgeting Process Lack Accountability?
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.