MedStar by the Numbers:
1986: Established
15: Cities served
919,000: Population served
120,000: Annual responses
460: Employees
56: Ambulances
Fiscal Year 2015-16:
$143 million: Billable fees for service
$ 50.5 million: Deduction for Medicare/Medicaid contractual allowances
$ 48.7 million: Uncollectable fees/bad debt provision
$ 45 million: Annual operating budget
MedStar Mobile Integrated Healthcare program savings analysis:
9-1-1 Nurse Triage
1,346: Ambulance transports avoided
1,615: Hours of ambulance availability from not responding to these calls
$419: Health care expenditure per ambulance transport
$565,974: Ambulance transport expenditure savings
1,119: Emergency department visits avoided
6,714: Bed hours made available for other patients from not having these patients in the emergency room
$969: Health care expenditure per emergency room visit (facility fee only)
$1,084,311: Emergency room visit savings
$1,650,285: Health Care Expenditure Savings from the 9-1-1 Nurse Triage Program
High-Utilizer Program
2,481: Ambulance transports avoided
3,101: Hours of ambulance availability from not responding to these calls
$419: Health care expenditure per ambulance transport
$1,039,539: Ambulance transport expenditure savings
596: Emergency department visits avoided
14,886: Bed hours made available for other patients from not having these patients in the emergency room
$969: Health care expenditure per emergency room visit (facility fee only)
$577,524: Savings
115: Hospital admissions avoided
$10,550: Health care expenditure per hospital admission
$1,207,500: Health Care Expenditure Savings from the High-Utilizer Program
Readmission Prevention
76: Ambulance transports avoided
91: Hours of ambulance availability from not responding to these calls
$419: Health care expenditure per ambulance transport
$31,844: Ambulance transport expenditure savings
76: Emergency department visits avoided
456: Bed hours made available for other patients from not having these patients in the emergency room
$969: Health care expenditure per emergency room visit (facility fee only)
$73,644: Savings
86: Hospital admissions avoided
$10,550: Health care expenditure per hospital admission
$909,000: Health Care Expenditure Savings from the Readmission Prevention Program
14: FTEs in Mobile Healthcare Division
$1.4 million: Division annual budget
Totals:
$5,481,336: Health care expenditure savings
4,807: Hours of ambulance availability from not responding to these calls
22,056: Hours made available for other patients from not having these patients in the emergency room
The U.S. health care system is going through one of the most radical changes in history. The move is from traditional fee-for-service delivery models that encourage health care providers to do more, to a value-based, outcome-focused delivery system that financially rewards providers who improve patient outcomes, improve the patient’s experience of care and reduce costs.
In the macro view, this really had to happen. America has the most expensive health care system in the world, generating $9,695 in health care spending per capita, USAToday reported in late July. That is more than twice the cost of other economically developed nations. A 2014 report by the Commonwealth Fund also ranked the United States last in most health care outcomes by virtually every health measure, as it was in 2010, 2007, 2006 and 2004.
America’s health care system can be very difficult to navigate, especially for patients who lack access to appropriate primary care or have multiple medical conditions. These patients often end up using the emergency medical system – 9-1-1 and hospital emergency departments – for primary care for non-emergency conditions.
Other patient populations responsible for inappropriate trips to emergency rooms include those with chronic conditions, such as congestive heart failure, that can be managed in an outpatient setting, those who are admitted for “observation” but whose needs are social or environmental rather than medical,; and those with terminal illness who may prefer to die at home. These calls result in higher costs and divert valuable resources away from true emergencies.
Cutting edge thinking
MedStar Mobile Healthcare, the emergency medical service provider serving Fort Worth and 14 other cities in North Central Texas, has been on the cutting edge of managing high-user patients – those who call 9-1-1 with low-acuity medical conditions – as well as other patient populations who are at risk for preventable 9-1-1 calls, emergency department visits and hospital admissions.
The overall goals of the MedStar Mobile Integrated Healthcare programs are to improve patient outcomes, enhance the patient’s experience of care, reduce the cost of caring for these patients, and conserve valuable emergency resources for patients truly suffering from emergency medical conditions.
Working collaboratively with the rest of the health care system, specially trained MedStar paramedics conduct an in-depth medical assessment of patients when called and periodically visit or telephone the patient and family to support them in following the care plan established by their primary health care provider. Support generally continues until the patient can manage on his or her own.
MedStar has developed a number of groundbreaking programs since the inception of the concept in 2009.
The Programs
9-1-1 Nurse Triage: Low-acuity 9-1-1 callers are referred to a specially trained registered nurse in MedStar’s Call Center who helps the patient find appropriate resources for his medical issue. Since June 2012, 3,600 low-acuity 9-1-1 callers have been referred to this program, and 38 percent of these patients have had a disposition other than an ambulance trip to the emergency department. This reduction has saved $1,648,000 in health care spending for ambulance transport and emergency department costs – $1,225 per enrolled patient. It has also made more than 4,000 hours of ambulance time available to respond to other, more serious medical emergencies and made 21,000 bed-hours available in area emergency departments.
EMS Loyalty Program: Patients who use 9-1-1 15 or more times in 90 days, or who are referred into the program by emergency department case managers due to high usage, are enrolled in this program. MedStar’s Mobile Health providers conduct regular home visits, connect the patients to available resources and teach them how to better manage their own health care. Typical enrollment in the program is 30-90 days.
Since July 2009, 142 patients with one year pre-enrollment and one year post-enrollment data have reduced ambulance trips to the emergency department by 2,240 trips – 51.8 percent – and patients designated as “super utilizers” showed a 82.3 percent reduction in ambulance and emergency room use. This reduction has saved $8.2 million in health care spending for emergency departments and hospital admissions – $57,729 per enrolled patient. The program has also made over 13,000 emergency hours available for patients in the waiting rooms.
Readmission Avoidance: For the past three years, Medicare has imposed financial penalties on hospitals that have a higher than average readmission rate within 30 days for patients with conditions such as heart failure, pneumonia and emphysema. In an effort to improve patient transition to home, as well as to reduce the Medicare penalties, hospitals are experimenting with numerous options to reduce preventable readmissions. One such collaboration is between area Fort Worth hospitals and MedStar.
Under this arrangement, patients at risk for a 30-day readmission are referred to MedStar by the patient’s case manager or physician. MedStar conducts a series of home visits to educate the patient and family on appropriate care management and loops the patient to his or her primary care physician. If the patient needs intervention, MedStar personnel may coordinate in-home treatments in consultation with the patient’s physician, along with a follow-up doctor’s appointment.
Since October 2013, 119 patients who had a prior 30-day readmission and who the referring agency believed would have another 30-day readmission have been referred into the program. Of those, only 33 were readmitted within 30 days, a 72.3 percent reduction in readmissions for this high-risk readmission group. This reduction has saved the health care system $903,000 and has helped the patients avoid the inconvenience associated with a hospital admission.
Hospice Care Coordination: Patients on hospice care may desire to die peacefully and comfortably at home. Unfortunately, when the final moments near, families sometimes panic and call 9-1-1. Often, this results in an unplanned and emotionally traumatizing trip to the emergency department. Through a partnership between VITAS Health Care and MedStar, patients and families at risk for calling 9-1-1 as the patient nears the expected death at home are identified by the hospice agency. If the family calls 9-1-1, MedStar and VITAS coordinate efforts to reduce the possibility of the patient not having his or her wishes met regarding end of life care.
Through July 2015, 163 patients who VITAS believed were likely to call 9-1-1 were enrolled in the program. Of the 50 9-1-1 calls placed by these families, only 17 ended up with the patient transported to an emergency department – 14.7 percent of the calls. The rest of the patients died peacefully at home under the care of MedStar personnel and the VITAS nurse.
Home Health Partnership: Through an innovative partnership with Klarus Home Care, MedStar and Klarus collaborate to provide effective after-hours episodic care for the agency’s patients and to notify the Klarus on-call nurse in the event of a 9-1-1 call from a patient enrolled in this program. Working together, the Klarus staff and MedStar personnel determine the most appropriate care for the patient. Since program inception, 754 patients in the MedStar service area have been enrolled. Of these, 455 used the 9-1-1 system and MedStar had a specially trained provider on scene as a co-responder for 200 calls. With a MedStar health provider on scene, care was coordinated with the Klarus on-call nurse and only 74 patients – 37 percent – required transport to an emergency department.
A National Model
These programs have been so innovative that more than 160 communities from 40 states and five nations have visited MedStar during the past four years. MedStar has also created the only book on the subject, published by Jones and Bartlett publishing.
Representatives of MedStar, VITAS, Klarus Home Care and John Peter Smith Health Network have written numerous articles in national health care publications, have been featured in videos and national news media, and have been frequent presenters at national health care conferences detailing how Fort Worth has become the national model for health care integration using the EMS system.
It’s nice to know that “The Fort Worth Way” – the city’s culture of collaboration and innovation – is transforming the way our nation delivers health care.
Matt Zavadsky is the director of public affairs for MedStar Mobile Healthcare in Fort Worth and has helped guide the implementation of several innovative programs with health care partners that have transformed MedStar fully as a mobile integrated health care provider. He is an adjunct faculty member at the University of North Texas Health Science Center and chairs the National Association of EMTs Mobile Integrated Healthcare committee. He is also co-author of the book Mobile Integrated Healthcare – Approach to Implementation, published by Jones & Bartlett Publishing. He has a master’s degree in health care administration, with a graduate certificate in health care data management.