A pilot program run by Commonwealth Care Alliance in Greater Boston has been experimenting with the use of at-home paramedic visits to keep patients out of emergency rooms.
A patient with anxiety, diabetes and congestive heart failure called a health clinician one evening complaining of low blood sugar. A nurse told the person to drink juice, but the person still felt sick. Paramedics arrived, did a blood test, determined the person was dehydrated and gave the patient saline solution with medication. When the paramedics left, the patient became anxious and called back. So the paramedics reassured the individual and instructed the patient to see a primary care doctor the next day, and that doctor treated the anxiety.
This case was documented in a report released last spring about a pilot program run by a Massachusetts insurer and health care provider. The program uses paramedics to treat patients at home in cases when they may otherwise go to the emergency room.
"You get to achieve a triple aim through one intervention -- you improve patient satisfaction and the quality of care they receive, as well as decrease the costs," said Dr. Toyin Ajayi, chief medical officer for the insurer, Commonwealth Care Alliance.
When a delegation of Massachusetts state senators traveled to Minnesota in December to learn about ways to lower health care costs, one program stood out to the trip's leaders: the use of paramedicine.
In Minnesota, if someone calls 911 with a non-acute problem, they may receive a visit from a paramedic, who is trained to treat certain symptoms and illnesses in a person's home.
State Sen. Jim Welch, D-West Springfield, chairman of the Joint Committee on Health Care Financing, and Senate President Stan Rosenberg, D-Amherst, both pointed to paramedicine as a program Massachusetts could potentially import as a way to cut back on unnecessary and expensive emergency room visits.
In fact, a similar pilot program already exists -- and preliminary results find it is saving money. The program is run by Commonwealth Care Alliance, a nonprofit health care system, which is now considering expanding the pilot from Greater Boston to Western and Central Massachusetts.
But health policy experts caution that analysis must still be done to determine if the program can and should be expanded. "It's one thing putting a program into a pilot, it's another thing transitioning to full implementation," Welch said. "We have more data to review and more information to review about the success."
Commonwealth Care Alliance provides care through community health centers to patients with complex medical needs who are eligible for both Medicare and Medicaid. These are low income and disabled or elderly patients, who generally have significant health care needs, often including behavioral health problems and chronic diseases. The organization, which functions as an insurer and provider, offers care through teams that include doctors, nurses and specialists for everything from urgent care to long-term care. It is trying to reduce unnecessary stays in hospitals and institutions. Services are paid for by Medicare and Medicaid.
In 2014, Commonwealth Care Alliance launched the pilot program with EasCare Ambulance, where EasCare would deploy paramedics for in-home treatment. The program covered 2,600 Commonwealth Care Alliance members around Boston. It offered care overnight, when there are fewer options.
The program is meant to reduce visits to emergency rooms, which are one of the most expensive places to provide care but are often used for needs that could be treated elsewhere.
Ajayi said patients may avoid medical care if they fear going to an emergency room. Those who go can face long waits, physical discomfort and potentially stigma for people with mental illness. Ajayi said paramedicine is a "high quality way of providing care to people in a setting they find to be acceptable."
In December, Mathematica Policy Research and the Center for Health Care Strategies, with support from Kaiser Permanente, released an evaluation of the pilot program. According to that report, in the program's first year, 126 patients received a home visit. Of those, 81 percent were treated at home, while 19 percent were taken to the emergency department. (Some patients were instructed to see a doctor the next day.) There were no adverse health outcomes reported.
The program resulted in estimated average per-patient savings of $791 over a week, $3,677 over a 15-day period and $538 over a 30-day period. This includes estimates not only of diverted hospitalization costs but, for example, costs that would have been incurred if someone waited longer for treatment.
The paramedics, who have specialized training, are able to handle calls for things like urinary tract infections, behavioral health conditions and end-of-life care. They can dispense medication, diagnose infections and draw blood.
Because Commonwealth Care Alliance is reimbursed by Medicare and Medicaid, any savings ultimately benefits taxpayers.
Over the program's first 18 months, paramedics have responded to nearly 600 dispatches for over 200 members. Surveys conducted by Commonwealth Care Alliance and EasCare reported that patients were happy with the care.
"They talk about how empowered they feel to get care in a home setting," Ajayi said.
Commonwealth Care Alliance currently contracts with Holyoke Hospital and Baystate Medical Center.
"There are a ton of opportunities to expand this for the benefit of patients, providers, payers and the commonwealth," Ajayi said.
Commonwealth Care Alliance still needs permission to expand from the Massachusetts Office of Health and Human Services. According to state health officials, an external review is underway of the pilot program's cost-effectiveness, and a separate multi-year study of patient outcomes is ongoing.
"MassHealth is committed to providing members with high quality health care and is pleased with the preliminary results of the pilot," said Health and Human Services spokeswoman Sharon Torgerson. "We look forward to reviewing the cost-effectiveness evaluation for the pilot once it's complete."
The Mathematica report warns that expanding the program will not necessarily result in identical savings. Factors including customer volume, emergency department diversion rates, operating costs and spending rates per episode all affect the cost.
Challenges that could face an expansion include how to share medical records between paramedics and the patient's doctors, how to ensure patients get follow-up care, how to ensure paramedics are properly trained and how to negotiate terms with paramedics and other health care providers.
"Any time you try and change the way health care is delivered, it's not as easy as just flicking a switch," Welch said. "Trying to work out all of those details can be complicated, and it can be difficult. I think we're in the infant stages of that, and we'll continue to move forward."
