Lower-cost alternative to paramedic care put to test

James David Dickson
The Detroit News

The state is allowing an Ann Arbor-based ambulance company operating in parts of Metro Detroit to try delivering care for its flood of non-emergency calls at a quarter of the cost of emergency runs.

Huron Valley Ambulance has been permitted to test a program in Livingston and Washtenaw counties that changes who cares for people who place distress calls, but don’t have life-threatening health issues.

The three-year program, already in operation, is intended to let regular paramedics focus on people in mortal danger and direct the estimated half of all calls that are non-emergencies to “community paramedics,” who can take the time to treat the health issues at a lower price.

Community paramedic Jennifer DeVoe responds to calls for assistance in the Metro area.

Community paramedics, who complete state-approved training, can administer blood and urine tests, dispense medication, care for wounds, replace feeding tubes, start IVs and replace catheters. They also video-conference with emergency room doctors at St. Joseph Mercy and the University of Michigan Health System, and, depending on the needs of the patient, contact the patient’s primary care physician or help patients find doctors if they don’t have one.

“A 911 response, ambulance transport and emergency room visit is a very costly way to take care of a minor, non-acute illness,” said Huron Valley Ambulance CEO Dale Berry, whose company serves Washtenaw County as well as parts of western Wayne County, Wixom and the southeast corner of Livingston County.

“We have people who call 911 50 times a year,” Berry said.

It’s an experiment Michigan’s largest insurer is watching.

“Blue Cross Blue Shield of Michigan would consider evaluating the results of the study and any potential opportunity for our members with non-emergency situations to avoid the emergency department while receiving appropriate care,” said Helen Stojic, a company spokeswoman, in a statement.

“The benefits and risks need to be studied to avoid situations where patients aren’t transported to the ER when they should be.”

The pilot program was born in part because the 911 system was overtaxed by emergency phone calls that were growing faster than Washtenaw County’s population, ambulance officials said. Many of the calls weren’t emergencies and about a third did not result in transporting someone to the hospital.

“An emergency is in the eye of the beholder,” said Dr. Michael Mikhail, regional director of emergency medicine for the St. Joseph Mercy Health System.

Patients have learned to work the 911 system, mentioning trigger phrases like “tightness in the chest” and “abdominal pain” that ensure immediate service because emergency medical workers don’t want to take chances, Berry said.

Huron Valley Ambulance lobbied the Michigan Department of Health and Human Services and got permission in the spring to start a three-year community paramedic program. A state task force of emergency physicians and other emergency medical personnel reviewed and approved the study.

It helped that 20 years ago the company became a pioneer in mobile intensive care units under a similar three-year special study.

Huron Valley’s $1.2 million pilot program is being financed by its parent company, Emergent Health. It employs 14 full-time community paramedics and four part-timers compared with 117 paramedics in Washtenaw County. It is a collaboration among Huron Valley, the St. Joseph Mercy Health System, Livingston County EMS and the University of Michigan Health System.

The two health systems helped develop the program and write its protocols, and both supply the emergency room physicians who video-conference with community paramedics, said Huron Valley spokeswoman Joyce Williams.

Huron Valley affiliates report that the ambulance system is accommodating people who might have otherwise gone untreated.

The dispatch center is integral to making community experiment work. Its call screeners decide whose calls get funneled to emergency paramedics and whose merit a community paramedic visit, said Kristin Kasten, a supervisor at Huron Valley’s dispatch center, the epicenter of the pilot program.

Huron Valley Ambulance gives many examples of how community paramedics have saved money and helped patients in need.

In one case, a bed-bound obese woman had difficulty breathing and her lifeline alarm sounded because her breathing tube came out and fell to the floor, according to the company’s records, which don’t identify the patient for privacy reasons. The tube was contaminated, and she couldn’t reach the new tube in her cabinet.

Huron Valley Ambulance said it dispatched a community paramedic, who connected a new tube.

“Patient’s condition went back to normal almost immediately,” according to the ambulance firm’s report. “... Community paramedic is gone within 40 minutes, saving a trip to the ER for the same reinsertion accomplished at home.”

Huron Valley ambulance runs typically cost $700, the company said, not including the cost of an emergency room visit and a possible overnight stay. A community paramedic visit costs closer to $180.

“We get outcomes just as good, but at less cost,” said Dr. Keenan Bora, an emergency room physician at St. Joseph Mercy and supervisor for the community paramedic program.

A community paramedic visit sometimes requires consultation with a doctor — either at the scene or in a follow-up appointment.

What sets a community paramedic visit apart from normal home health care is the video consultation with a doctor, Bora said. Dr. Keenan Bora, an emergency room physician at St. Joseph Mercy and supervisor for the community paramedic program.

In the video consultation, the community paramedic acts as a doctor’s hands, eyes and ears and ensures a high level of care, Bora said..

Rob Foster, who worked in emergency medicine since 2001, sees the difference the program has made. The former senior-level paramedic became one of Huron Valley Ambulance’s community paramedics.

“When I was a paramedic, I focused on the event,” he said. “I made a quick assessment and jumped into action to save someone’s life.”

By contrast, follow-up calls require more coordination with primary care doctors — something an emergency paramedic never does, Foster said. The community paramedic also needs more people skills, works at a slower pace and deals with much more paperwork, he said.

In Foster’s experience, most non-emergency 911 calls come from people who should be working with their doctor.

A key challenge is convincing insurance companies to pay for community paramedics. Huron Valley officials said they need to show money is being saved and patients are being adequately treated.

Although the Medicaid health program for the poor is the only insurer that would pay for community paramedics, Huron Valley isn’t yet billing the government. Huron Valley officials said they fear being accused of fraud if Medicaid pays for patients, but other providers and insurers don’t.

Huron Valley isn’t being paid for community paramedic services by anyone — a situation that needs to change to ensure the pilot program’s long-term future, Mikhail said.

“The program has potential, but it could also go away,” Mikhail said.