Community paramedicine is one of the most promising trends in American healthcare. More and more cities have implemented CP and mobile integrated healthcare (MIH) programs to provide residents the support and healthcare they need—all while lowering the costs of delivering it.
As more communities start community paramedicine programs, it’s natural to wonder about the role private insurance might play in funding them. Most programs are not yet reimbursable through Medicaid. New techniques for reducing ER visits and costs might not yet be an established norm, but it’s often in a private insurer’s best interest to fund local community paramedicine. Why? Here are several reasons.
Local community paramedicine helps lower all costs for the payer.
Every community has its EMS “frequent flyers.” In Alameda County, Calif., for example, the same 25 people collectively called 9-1-1 nearly 4,300 times in two years. In Fort Worth, Tex., 21 patients were transported to local EDs a total of 800 times over 12 months. Superutilizers like this rack up millions in costs for needs that are often nonemergency, increasing the burden on both commercial and public payers.
But if a patient calls 9-1-1 repeatedly for the same concern, they are not getting what they need.
Why does this happen? MIH-CP programs have identified several causes and aim to tackle each one at its root. On the reimbursement front, the current financial incentivization structure is outdated. Historically insurance companies have paid EMS only to transport patients to EDs—incentivizing taking patients to hospitals. This incurs not only the transport expense for the payer but, more important, additional downstream costs.
Community paramedicine works to nip those cycles in the bud and prevent not only unnecessary transports but also the associated ED visits and expenses for problems that are better fixed by other organizations.
Even most current commercial setups are still inadequate.
While payers have become reliable in identifying superutilizers, methods to solve their underlying issues have been lacking. As a result, these patients continue using the ER, their primary care provider (PCP), and the 9-1-1 system excessively even for nonemergency needs.
The standard method for tackling this problem is for the insurance company to call, e-mail, and/or mail the individual, offering them a free appointment at their PCP. However, the response rate to such attempts is only about 13%. And when the superutilizers do respond, their PCPs often can’t permanently fix their problems. Most doctors look only at what’s physically wrong—which is what they’re trained to do. But a multitude of social determinants also factor into health—things like substance abuse, mental health issues, and lifestyle behaviors. Even if doctors refer these patients to other organizations that can help alleviate their problems, no one knows whether the patient followed through or even arrived for treatment. This situation drastically increases payers’ costs.
Community paramedicine steps in and helps these superutilizers fix the underlying causes of their system usage. These programs educate, redirect, and account for the different social determinants that can affect the patient’s health.
The system needs to change, and private payers have the ability to make that happen by funding community paramedicine.
The trend has already begun.
Community paramedicine has an incredible potential to bend the cost curve. But without adequate funding, these well-intentioned programs won’t get off the ground.
Some states have seen that Medicaid reimbursement of community paramedicine services can change the game. Community paramedicine teams in Indiana, for example, can support many more people but also have become a potentially profitable enterprise as a result.
But for states that are not as fast-moving (most other states), it’s the commercial payers who have begun stepping up to the challenge. Commercial payers like UnitedHealthcare in Milwaukee have reengineered their initiatives to pay for MIH measures like post-acute follow-up visits, enrollment fees for high utilizers, and response fees that aren’t tied to whether patients are transported to the hospital. They have reaped the benefits.
In the Albuquerque area Blue Cross Blue Shield’s MIH-CP has reduced emergency room visits by nearly 62%, decreased ambulance use by 63%, and saved the insurer about $1.7 million within a year. Especially when these private insurance companies are contracted by the government to provide for underserved populations, MIH-CP is among the cost-reducing measures private insurers can fund that are proven to work.
Where government funding can be frustratingly slow to change, commercial payers are agile and nimble enough to innovate in this area. When private insurance companies fund community paramedicine programs, it sets a critical precedent for payers both public and private. The ball is beginning to roll.
Technology has made it easier.
Funding these programs means nothing if there isn’t good support for implementation. That’s where Julota comes in, helping an entire community’s health system, EMS, law enforcement, social services, mental health, and other care organizations work together effectively and, of course, lower payer costs. As a completely compliant (HIPAA, 42 CFR part 2 [mental health and substance abuse], Criminal Justice Information System) software system that manages secure multidirectional sharing of consented information, Julota facilitates getting patients needed help they might otherwise lack.
Julota can help insurers track patients and verify they’re receiving help from resources suitable for their needs. With the ability to pull and centralize health records from multiple sources (EMS, hospital systems, PCPs, mental health, etc.), Julota automates MIH-CP programs to help their patients. If the patient has a food insecurity issue, for example, community paramedicine teams can visit their home and link them to food pantries.
Instead of spending company resources on trying to contact the individual, private payers can fund city and county MIH-CP programs to task CP teams to do what they do best: follow up on superutilizers and connect them to the local community network of partners. Already insurance companies have seen the benefits as the rate of healthcare use dramatically drops, resulting in cost savings for the insurer.
Funding MIH-CP is a win-win for everyone, and Julota is here to make the transitions easier.