Realigning reimbursement policy and financial incentives to support patient-centered out-of-hospital care.

INNOVATIVE MODELS OF PAYMENT AND CARE DELIVERY are increasingly being used to expand access, improve quality, and reduce medical costs. Although traditional fee-for-service medicine favors doing more than is necessary, newer payment models aim to realign incentives to decrease utilization and increase efficiency. However, little consideration has been given to how fee-for-service reimbursement in out-of-hospital care limits the ability of emergency medical services (EMS) to provide more patient-centered care and reduce downstream health care costs. Retrospective studies estimate that between 7% and 34% of Medicare patients transported by ambulance to an emergency department could have been safely treated in an alternate environment. However, Medicare and other payers provide no reimbursement for out-of-hospital care including response, triage, and patient assessment and treatment unless the patient is transported to an emergency department. The Medicare ambulance billing guide states, “The Medicare ambulance benefit is a transportation benefit and without a transport there is no benefit.” With most private insurers mimicking Medicare, this payment policy significantly affects the behavior of EMS agencies contributing to an inefficient use of out-of-hospital care resources.