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Call 911 with no emergency? Mesa might send you a bill

Maria Polletta, The Republic | azcentral.com 12:10 p.m. MST May 13, 2016

For a decade, Mesa has been piloting alternative emergency-response units designed to more efficiently tackle increasing numbers medical calls

Fire officials are now gearing up to test a series of billing models that will determine whether the program is viable long term Both federal health officials and fire departments throughout the country are watching to see if Mesa can financially sustain its program For nearly a decade, medical professionals across the nation have watched as Mesa developed and honed alternative emergency-response units designed to more efficiently tackle increasing numbers of medical calls and curtail unnecessary emergency-room visits.

Now, the city is looking to charge people for those lower-level medical services, testing a series of billing models that will determine whether the program is viable for the long term.

"As a municipality, we’re not in the business of making money. We’re in the business of offsetting our costs," said Tony LoGiudice, Mesa firefighter and the pilot program's grant administrator. "Can we get reimbursed enough to continue these services moving forward? I think there are a lot of people kind of sitting back and thinking, 'If they can sustain and make this happen, possibly we’ll be able to do the same thing.' "

LoGiudice said it costs Mesa officials roughly half the price of a typical ambulance transport and emergency-room visit — $1,500 — to provide non-emergency medical care. Fire officials are working with insurers to determine how much of that $500 to $700 they would be willing to reimburse under a traditional "fee for service" model, and how much of that cost they'd pass along to patients.

Mesa also will pilot several "value based" models, considered community medicine's new frontier. Under those billing structures, providers negotiate contracts with insurance companies or hospitals in advance, agreeing to administer preventative care and minimize costly emergency-room trips if they can have a cut of the resulting savings.

"The idea is pretty simple: We’re keeping people out of the EDs (emergency departments) that don’t need to be there. We’re keeping people off the ambulances. We’re getting them to the right care," LoGiudice said. "We're saving insurance providers, hospitals, community partners money by doing that, and we want them to share those savings with us."

The billing models will be piloted in stages, he said, with the first implemented in June or July.

Until now, the department has only sent mock bills to insurance providers, asking them to respond with an explanation of what they would or would not reimburse. Patients have not been charged.

How does the program work?

Mesa's Community Medicine units have come a long way since their start as two-paramedic trucks in 2006. The original units freed up larger engines and first responders to handle more serious situations, but they still had to transport patients to emergency rooms for straightforward procedures and tests, since paramedics are limited in what they're allowed to do on scene.

The department responded by collaborating with Mountain Vista Medical Center to turn one of the trucks into what was called a "PA unit" in 2012, replacing one paramedic with a physician assistant or nurse practitioner. Those professionals can suture wounds, test for urinary-tract infections, provide slings, administer flu and tetanus shots and write prescriptions on site, essentially converting the unit into an urgent care on wheels.

In spring 2013, the Fire and Medical Department modified another unit to help address mounting numbers of behavioral-health calls related to substance abuse, psychiatric issues and anxiety. It paired paramedics with a crisis counselor who could directly determine whether patients needed to go to a behavioral facility, rather than meeting and evaluating patients at emergency rooms.

Thanks to a $12.5 million federal grant awarded in 2014, the department now operates three Community Medicine medical units — the latest version of the PA unit — around the clock, with 12 physician assistants and nurse practitioners staffing them. It also operates two Community Medicine behavioral units 40 hours a week.

"Our diversion rates have really gone through the roof," Mesa Deputy Chief Steve Ward said. Of the roughly 6,000 calls the Community Medicine units responded to last year, they were able to handle about 4,000 without taking patients to emergency rooms, fire officials said — twice the diversion rate they initially expected.

The grant funding also has allowed the department to staff a nurse triage line to handle simple cases requiring no immediate medical care, such as a parent unsure of how much Tylenol to give his or her feverish child. And officials have stepped up preventive measures, such as administering flu vaccines, conducting home-safety inspections to minimize repeat calls by identifying fall risks and fire hazards, and teaching patients how to manage chronic conditions such as diabetes.

What are the implications?

Both federal health officials and fire departments throughout the country are watching to see if Mesa can financially sustain its program. The Centers for Medicare & Medicaid Services, the federal agency behind Mesa's $12.5 million grant, has said it hopes Mesa's concept eventually revolutionizes the efficiency of emergency-response systems nationwide.

The city will have to overcome several deep-rooted roadblocks to do so.

For instance, local and national officials report that certain insurers continue to incentivize emergency personnel to use the highest-cost resources available — ambulances and emergency rooms — because there's typically no payout if a patient isn't taken to the emergency room.

And when officials categorized as emergency-service providers administer non-emergency services, the insurance claims often get rejected.

"If we try to submit a claim for a physician-assistant or a nurse-practitioner type of service, the insurance company is going to say, 'No, you’re classified as a EMS organization, we’re not going to pay it,' " LoGiudice said. "We’re really operating outside of the box, so for the last year, we've been trying to establish who we are so we have the appropriate codes to bill under."

The department is in talks with roughly 10 insurance companies to create billing models, LoGiudice said, though he declined to share specific names given the status of the negotiations. The department has been collecting scores of demographic, medical and customer-satisfaction data in order to quantify results and make its case for reimbursement.

"Make no mistake — for insurers and hospitals, it's about the patient, but it's also about the money," said Matt Zavadsky, a national paramedicine expert and the director of public affairs for Fort Worth-based MedStar Mobile Healthcare.

"If Mesa Fire can reduce the cost of health care in Mesa, then there’s the potential that the taxpayer will have less of a tax burden funding those uncompensated costs. There's potential for Medicaid to spend less and thus put less pressure on the state budget. There's the opportunity for insurance companies who are no longer having to write these huge checks for medically unnecessary care to slow down the rate of premium increases. There's the potential for emergency rooms to have more beds available for those who really need them," he said. "The benefits can't be overestimated."

Given Mesa’s success pioneering its alternative emergency-response model, other southeast Valley municipalities have begun following suit — or at least considering doing so. Here’s a look at where comparable programs stand in those cities and towns.

Tempe: For two years, Tempe has staffed a Patient Advocate Services, or “PAS”, unit with registered nurses in partnership with Tempe St. Luke’s Hospital. It also has a “CARE7” unit to address social-service crises. Patients have not been billed for the non-emergency services. While a future expansion is possible, according to the city, no concrete plans for one exist now.

Gilbert: The town does not currently operate alternative units, but it plans to implement a one-unit pilot program in 2017, pending final budget approval. The unit, staffed by paramedics, will respond to low-level medical calls but be equipped to transport patients to an emergency room if needed.