While the concept of community paramedicine and expanded roles for EMS has been around for well over a decade, little progress had been made in the United States largely due to a combination of regulatory and financial barriers. Most notably, current Medicare and private payer reimbursement policies require an EMS agency to transport a patient to an emergency department (ED) for a service claim to be paid.7 This fee-for-service model creates a perverse incentive for agencies to transport patients to the hospital ED, even if this is not what a patient needs or wants, and even if other alternatives might be better, less expensive, or more patient centered.8 As the 2007 Institute of Medicine Report points out, changes to the current system are urgently needed due to ED overcrowding and increasing rates of utilization by people seeking treatment for nonurgent conditions.
In the last few years, health care is beginning to move away from fee-for-service medicine and toward the triple aims of improving access, improving quality, and lowering costs through a realignment of incentives with value and efficiency.9 These recent trends have been facilitated and accelerated by the passage of the American Recovery and Reinvestment Act (ARRA) of 2009 which incentivized hospitals and physicians to adopt electronic medical records, and the Patient Protection and Affordable Care Act (ACA) of 2010 which authorized numerous demonstration projects within Medicare including the accountable care organization (ACO). The culmination of these changes and innovations in the health care system is an environment less focused on inhospital care and more conducive to experimentation with new approaches to patient care and population health management. Community Paramedicine, an innovative model in which existing health care resources are being redeployed to better meet patient needs, is thus very much in line with the goals of the ACA and is now beginning to attract the attention from health care systems, payers, and providers beyond the EMS community.
Some of the more recent pioneers in the current, ever-changing health care environment include the MedStar Mobile Integrated Health Care program in Texas, the Transitional Response Vehicle program in Arizona, the Supporting Public Health with Emergency Responders (SPHERE) program in Seattle and Wake County, NC, and the well-established CP program at Western Eagle County Ambulance District in Colorado.2 Some pilot programs are being funded internally, others through governmental grants and in some cases by insurance companies. Three programs involving community paramedicine were funded during the initial offering of Health Care Innovation Challenge Awards offered through the Center for Medicare and Medicaid Innovation.
One CP program is already getting reimbursed for their services. North Memorial Medical Center in Minneapolis, Minnesota, was successful in getting state legislation passed that allows reimbursement for CP home services such as health assessments, immunizations and vaccinations, collection of lab specimens, follow-up after hospital discharge, monitoring/educating patients with chronic disease, minor medical procedures approved by the medical director, and medication compliance checks.
As this health care model gains momentum and popularity, new programs are being created faster and faster. The success of these programs, the current era of change in the health care laws, and the need to fill the gaps in our health care delivery model indicate that CP will only grow in the future.