Each state, to some degree, is preparing for widescale changes to its health care system under the Affordable Care Act. But some, including California, are pursuing smaller efforts, separate from the health reform law, that could help bridge gaps in care and reduce spending.
Beginning as early as summer 2014, California's Emergency Medical Services Authority and the Office of Statewide Health Planning and Development plan to oversee the launch of pilot programs that would expand EMS workers' responsibilities.
They are following the lead of several other states -- including Colorado and North Carolina -- that have launched similar initiatives and reported favorable outcomes. Yet some observers wonder if the Golden State has enough funding for such an undertaking, or if a recent scope-of-practice controversy forecast trouble for efforts to make EMS workers responsible for a greater portion of treatment.
A Look at EMS Pilots Around the Nation
One community agency finding success with such efforts is Western Eagle County Ambulance District in Colorado, which has piloted a program to expand paramedicine.
Christopher Montera -- assistant CEO of the district -- said that area paramedics' responsibilities under the program include administering blood tests, conducting neonate visits and reconciling medications. Montera said that in its first year, the program saved $1,250 per visit in health care costs for each of its 29 patients.
Another region experiencing similar success is New Hanover County in North Carolina.
Donnie Sides, operations manager at the North Carolina Office of EMS, told California Healthline that the county reported in July that hospital readmissions had dropped significantly since adopting a program that gives EMS workers 300 hours of training on advanced patient assessment and management.
According to Sides, the programs allow EMS workers who complete the course to visit patients who recently were discharged from a hospital but are at a high risk of readmission. They help those individuals with follow-up care tasks, such as taking prescription drugs, to aid recovery and prevent readmission.
Sides said that a half dozen such programs have launched across North Carolina, including one in Wake County, where officials are "ecstatic" about the results.
He added that although Wake County is one of the state's most populous counties, "rural counties also are reporting back that they are having success." He said state officials are "getting calls from various counties, asking how they can implement these programs. We're just referring them to current programs to learn the best ways to do this."
California Trying To Follow Suit
"It comes down to dealing with transporting patients to places other than emergency departments, determining, under tight protocols, whether that would be appropriate," said Lou Meyer, project manager of community paramedicine at California Emergency Medical Services Authority.
According to Meyer, another goal for the pilot programs is similar to the North Carolina initiatives: filling care gaps after a patient has been discharged from the hospital.
He said, "If a patient is discharged on Friday, they typically aren't engaged into a home health care provider until Monday or Tuesday of the following week. Under the pilot programs, paramedics will be trained to assess and assist patients during that period, making sure prescriptions are taken correctly, helping set up clinic appointments, that sort of thing."
Meyer noted, "More and more, hospitals will be penalized for readmissions. We see the paramedic as someone who would be able to fill that void."
He said that state officials solicited proposals for launching the pilot programs from various counties through the end of September. Once officials evaluate the proposals, they will select 10 to 12 sites to launch the initiatives, which likely will begin next summer.
Despite the potential to improve care efforts to implement and expand these programs could face numerous barriers. Here are three in particular for California and other states.
Lack of funding. Some observers argue that the state lacks proper funding to implement the pilot programs, which would include costs for providing additional education for EMS workers and other expenses. In California, Meyer said that the EMS Authority is seeking grant funding through the California HealthCare Foundation. (CHCF publishes California Healthline.) He said that he hopes California can prove the pilot programs are worth the money by showing that expanded EMS practices "are a more cost effective way of taking care of patients."
Scope-of-practice concerns. Another potential barrier is opposition by other health care providers who are not willing to accept a wider scope of practice for EMS workers. While there has been little criticism thus far, recent efforts in the California Legislature to expand nurse practitioners' scope of practice were met with swift rejection by the California Medical Association. According to HealthyCal, if the pilot programs go well and the state decides to implement the programs on a larger scale, the Legislature must pass more regulatory changes to standardize the programs.
Meyer said, "I would be naïve to think that we could get through that process without some discussions." However, he said that community paramedics "have never been independent practitioners of that sort, and they still would not be under these programs."
In North Carolina, EMS overseers have not encountered any resistance from other health care providers. "No, absolutely not. We haven't had those fights," Sides said, adding, "Before we even started the process, we had already worked out any differences with other providers. This is so any rule-writing goes right through."
Securing reimbursement. Another important barrier facing states who seek to expand EMS services is to have their programs reimbursed by CMS. Sides said, "The reimbursements are the problem. We have no mechanism for them under the new programs. Reimbursement for EMS still is based on transport, not for care. That's what we need to change."
What Lies Ahead
Meyer -- who spent 15 years as a paramedic -- is optimistic about overcoming the challenges in California.
"The point of these pilot programs is to have data to show CMS that say this works," he said, adding, "We need to be prepared to demonstrate that we can do things in a more cost-effective way so that governments and payers realize that they should be reimbursing for these types of services rather than thinking these patients should be transported through expensive means for expensive care."
And impending health reforms make a perfect storm for change, according to Meyer.
He said, "This is the time. Health reform is coming, reimbursement reform is coming. I know we can do it better."
Here's a look at other health care-related news:
Think of the researchers: Aaron Carroll at The Incidental Economist notes that medical researchers are "completely screwed up" by the lack of an organized NIH under the federal government shutdown.
Christmas in October: Chris Wheelahan at Project Millennial explores the complexities of launching the exchanges over the course of one night, which is a lot more difficult than "flipping on the Christmas lights."