News & Updates

Insider analysis: ‘What truly matters in EMS systems’

A coalition of EMS organizations advocates for new performance indicators that prioritize effectiveness, safety, satisfaction, equity and efficiency over traditional response times

August 08, 2024

The Overrun Podcast & Blog

What happened: On July 31st, a significant shift in evaluating EMS performance metrics was heralded by the publication of a joint statement from 16 prominent EMS organizations. This initiative involves key players like the American Ambulance Association, the American College of Emergency Physicians and the International Association of EMS Chiefs.

This diverse coalition seeks to redefine the key performance indicators (KPIs) for EMS systems, emphasizing metrics that are effective, safe, satisfying, equitable and efficient.

16 EMS groups publish joint statement on EMS performance metrics

Highlights

Watch as Ed Bauter, MBA, MHL, NRP, FP-C, CCP-C; and Daniel Schwester, MICP, highlight the significance of this development, including:

• A move away from response times. Historically, response times have dominated as the primary measure of EMS system quality. However, growing evidence suggests that response times alone do not correlate with improved patient outcomes. The joint statement challenges the long-held belief that faster response times equate to better patient care.
• Reduced red lights and sirens. The statement draws attention to the inherent risks associated with the use of red lights and sirens, which have been shown to increase the likelihood of collisions by up to 60%. These incidents not only endanger patients and providers but also civilians. The focus now is on using lights and sirens only when they provide a direct, demonstrable benefit to patient outcomes.
• A nuanced approach to performance metrics. This shift represents a fundamental change in EMS practice, advocating for performance indicators that reflect the quality of care provided, rather than the speed of response. The coalition’s unified stance marks a critical step towards a more comprehensive and patient-centered approach to EMS evaluation.

As EMS systems nationwide begin to adopt these new metrics, the focus will likely shift towards improving the overall quality and safety of patient care.

This evolution in performance measurement promises to enhance the effectiveness and reliability of EMS services, ultimately benefiting patients, providers, and communities alike.

EMS is the subject of many current legislative proposals, all of these very favorable for EMS agencies, and the communities they serve. 

If you would like to support any of these initiatives with a letter to your members of congress, visit: https://naemt.org/advocacy/online-legislative-service#/ 

Current EMS Economic Legislation

Treatment In Place (EMS ROCS Act): S.3236 and H.R.6257

Improving Access to Emergency Medical Services Act: H.R. 8977

Community Paramedicine Act of 2024: H.R. 8042

SIREN Reauthorization: S.265 and H.R. 4646

Medicare Extenders: S.1673 and H.R. 1666

EMS Counts: S.1115 and H.R. 2574

VA Emergency Transportation Access Act: S.2757

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Medicare patients could get emergency treatment at home under new bill

The proposal could give 67.2 million Medicare enrollees more flexible treatment choices

By Jessica Hall

July 31, 2024

https://www.marketwatch.com/story/medicare-patients-could-get-emergency-treatment-at-home-under-new-bill-aa394ca3

A new proposal in Congress would allow older Medicare recipients to receive emergency medical services at home rather than having to be transported to a hospital for care, which could help them avert potential health and financial consequences resulting from a hospital visit.

The proposal, called the Improving Access to Emergency Medical Services for Seniors Act, would allow people to receive care at home for minor but urgent medical incidents instead of being sent to a hospital, where they risk long waits, hospital-acquired infections and higher costs.

Under the proposal, a pilot project would be created to demonstrate the financial and medical impact to Medicare of reimbursing paramedics and emergency medical technicians for treating patients in place.

The bill was introduced by a bipartisan group of representatives, including New York Democrat Pat Ryan, Ohio Republican Mike Carey, Texas Democrat Lloyd Doggett, West Virginia Republican Carol Miller and Michigan Democrat Debbie Dingell.

"Not every patient is best served by an emergency room visit," Carey said in a joint statement from the lawmakers. "In fact, for many seniors, a trip to the hospital can mean long wait times, increased costs and potentially life-threatening complications."

The proposal would end a requirement that Medicare patients be transported to emergency healthcare facilities in order for providers to receive reimbursement, thus allowing emergency responders to receive compensation for in-home care they provide. Patients would still be taken to a hospital's emergency department if needed, but under the proposal, they could, when possible, be treated at home.

People 60 and older account for nearly 20% of all emergency-room visits, according to the Centers for Disease Control and Prevention.

Patients who received care through treatment-in-place programs had experiences similar to or better than those treated in a hospital, according to a study published in JAMA in 2021. They faced similar mortality risk, a 26% lower hospital readmission risk and a lower risk for admission into a long-term care facility compared with their counterparts treated in hospitals, the study found.

Medicare is federal health insurance that covers people age 65 and older, as well as some people under 65 who have certain disabilities or medical conditions. As of March 2024, more than 67.2 million people were covered by Medicare or Medicare Advantage programs, according to the Centers for Medicare and Medicaid.

"Treating patients immediately at home and preventing an emergency room trip is sometimes both the best way to help the patient and the taxpayer," Doggett said in the statement.

In rural areas, some older people live hours from an emergency room and would benefit from being treated at home by emergency personnel, Miller said.

"Allowing EMTs to be reimbursed for this care and preventing unnecessary hospital visits would be an immense cost-saver for Medicare, free up emergency room space for those who really need critical care, and improve quality of life for our seniors," Dingell said in the statement.

The bill has received support from the National Rural Health Association, International Association of Fire Chiefs, International Association of Firefighters, American Ambulance Association, Congressional Fire Service Institute, National Association of Towns and Townships and the National Association of Emergency Medical Technicians.

COMMUNITY RELEASE: Top EMS Groups Publish Joint Statement on EMS Performance Metrics – Beyond Response Times

Sixteen national and international EMS, patient safety and public policy associations have partnered on the release of a Joint Statement on EMS Performance Metrics – Beyond Response Times.

The joint statement encourages EMS systems and community leaders to implement an approach to EMS system performance that prioritizes patient-centered care and uses a broad, balanced set of clinical, safety, experiential, equity, operational, and financial measures to evaluate the effectiveness of EMS systems.

The endorsing associations include:

• Academy of International Mobile Healthcare Integration

• American Ambulance Association
• American College of Emergency Physicians
• American College of Surgeons – Committee on Trauma
• American Paramedic Association
• Center for Patient Safety
• International Academies of Emergency Dispatch
• International Association of EMS Chiefs
• International City/County Management Association
• National Association of EMS Physicians
• National Association of Emergency Medical Technicians
• National Association of State EMS Officials
• National EMS Management Association
• National EMS Quality Alliance
• National Volunteer Fire Council
• Paramedic Chiefs of Canada

These associations recommend that local communities and governments modernize the assessment of the performance of their EMS systems/agencies by evaluating a broad array of domains with key performance indicators (KPIs) that can be measured and trended over time, and whenever possible, benchmarked with comparable EMS systems, or other national data, and published to local community stakeholders on a regular basis.

“Historically, response time performance has been the primary measure used to assess the quality of an EMS system. However, response times have not generally been associated with improved patient outcomes in the growing body of EMS evidence and research, and the reliance on response time performance prevents communities from evaluating other EMS system quality measures that have greater significance for patient care and outcomes”, states Dr. Doug Kupas, the primary author of the Joint Statement.

Matt Zavadsky, one of the contributing authors of the statement adds “This Joint Statement is the second major collaboration for most of these national and international associations, representing a significant coalescence of these associations, including public policy makers, to help assure that evidence-based clinical, operational, experiential and financial measures are used to more appropriately evaluate system performance.” 

The prior Joint Position Statement from these groups encouraged EMS agencies to reduce lights and siren responses to improve community and patient safety.

The Joint Statement includes the domains that should be used when evaluating an EMS system/agency including:

• Effective:  Is the health care provided clinically appropriate and high quality?

• Safe: Are services being provided in a way that is clinically and operationally safe for patients, responders, and the community?
• Satisfying: How do patients and EMS clinicians feel about the service being provided?
• Equitable:  Is the system providing care that is equitable based on patient demographics and service area geography?
• Efficient:  Is this service being provided in a way that maximizes the use of economic and operational resources?

The participating associations emphasize that it is essential for government and community leaders and decision-makers to consider all elements of the EMS system from the moment a 9-1-1 call is made to the conclusion of care by the EMS system/agency. 

By considering these additional performance measures, local communities can gain a more comprehensive understanding of the effectiveness of their EMS system/agency, identify areas for improvement in patient care, system efficiency, and overall emergency response capabilities.

The Joint Statement on EMS Performance Metrics – Beyond Response Times can be found here: https://doi.org/10.1080/10903127.2024.2375739

A PDF of the document can be downloaded here:

Kupas - Zavadsky - with Logos - Joint Statement on EMS Performance Measures Beyond Response Times - FINAL Approved by Named Associations CLEAN 4-30-24.pdf

A resource guide for effective evaluation of EMS systems can be downloaded here:

References-Resources on EMS Performance Measures _ Beyond Response Times FINAL 2-15-24.pdf

 

Interesting insight from a former elected official in Manitoba, Canada. 

Although the context is Canadian, the issue is very similar in many U.S. communities.

Thankfully, elected and appointed officials, and brave EMS agency leaders, are appropriately driving EMS delivery changes, using evidence-based research to 'right-size' response plans for low-acuity calls, deploying ALS, BLS, CIT and community paramedic units to low-acuity calls, and preserving valuable medical first response resources for high-acuity calls by assuring they are NOT on low-acuity calls.

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Firefighters need to focus on core jobs

By: Rochelle Squires

Jul. 30, 2024

https://www.winnipegfreepress.com/opinion/analysis/2024/07/30/firefighters-need-to-focus-on-core-jobs

It takes an average of six minutes for a house to become engulfed in flames. Not every house, of course. Depending on the building materials and contents inside, it may burn slower or faster, with newer builds typically experiencing structural failure quicker than a house made of traditional lumber. In those instances, especially, if firefighters aren’t on the scene immediately, it takes almost no time for it to collapse and burn to the ground.

Thankfully, there’s a fire department nearby. Not just in my south St. Vital neighbourhood where I am three minutes away from a station, but in every community throughout the city.

I’ve had to call 911 exactly two times in my life, both for a loved one’s emergent medical crisis that was thankfully rectified, one with a hospital visit and one without. Of course, as anyone who has ever called 911 knows, it’s not usually the paramedics in an ambulance that arrive first, but a fire engine and four firefighters with at least one dually trained as a paramedic.

Yet having a fire hall close by does not always guarantee a fast response for a fire or medical emergency.

Consider this: the Winnipeg Fire Paramedic Services is one of the busiest departments in North America on a per capita basis, surpassing cities like Detroit, Chicago and Los Angeles, yet resources have not kept pace.

In the Canadian context, the WFPS nearly quadruples fire calls in places like Toronto and Calgary. Further, Winnipeg’s firefighters battle more fires of significance than any other jurisdiction, meaning Winnipeg has a greater frequency of big fires that take more than an hour to fight and require multiple apparatus on scene.

This alone should be a substantial part of any firefighter’s job. Yet ask anyone working in the department today and they’ll undoubtedly tell you that a significant part of the job nowadays is also doing things they weren’t trained to do and don’t always have the capacity for, causing incredible strain on the service and its members.

Put bluntly, today’s firefighters spend countless hours attending non-emergent calls where there is no fire or safety hazard present.

Almost a daily occurrence now, firefighters provide well-being checks for people who are not experiencing medical emergencies and respond to mental health crises. It’s also not uncommon for them to get sent to scenes because someone is acting aggressively or belligerent, are expected to intervene in incidents of vandalism and other criminal activity, and even get involved in domestic violence situations.

Undoubtedly, in most of the above-mentioned cases, intervention is necessary. But surely there’s got to be a better response to non-emergent situations than sending fire apparatus and a team of firefighters. Not only is it creating workload issues, fatigue and burnout, it’s putting us in danger.

That’s because non-emergent calls routinely tie up emergency resources to the point of creating vulnerabilities or gaps in service. It is a growing concern that in any given week, there are moments when resources are unavailable, and if a catastrophe or a major blaze erupts, there’ll be a delay in the arrival of life-saving resources.

In other words, if my house caught on fire and there was six minutes on the clock before it became fully engulfed, even though I’m only three minutes from a fire hall, resources may not arrive in time.

So what needs to be done?

The province has stepped up in a few ways, including a $20 million boost to ambulance funding by my former government, and the current government deserves kudos for providing new funding for 40 more firefighters.

Yet additional cash isn’t the sole answer when the system needs a reboot.

For starters, empowering dispatch resources to find alternate responses for non-emergent situations is worth looking at. Yes, it’s complex. People calling 911 deserve to be treated first with an assumption there is an emergency. But when it is clear that there is no emergency, what then? Alternatives to sending a battalion of fire resources should be considered, including an expansion of the community paramedic program where personnel are trained to handle some of the aforementioned calls.

Firefighters also spend countless hours sitting with stable patients waiting to go to hospital. Expanding transportation options would also go a long way in ensuring life-saving resources are available when most needed, and firefighters should have the ability to disengage and be made available for prioritized emergencies.

As stated before, it’s a complex problem needing a comprehensive solution. But nothing is more complex than waiting on help in a time of emergency.

Rochelle Squires is a recovering politician after 7 1/2 years in the Manitoba legislature. She is a political and social commentator whose column appears Tuesdays. rochelle@rochellesquires.ca

For a list of the 15 recommendations voted on by the Advisory Committee on Ground Ambulance and Patient Billing (GAPB), and the voting history, click on the file links below:

04_GAPB_ PPT_Mtg3_D1_ Recommendations_V4_11.08.2023_508.pdf   

Ground Ambulance and Patient Billing -Third Meeting Voting Summary_V03_508.pdf

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Plan to end exorbitant ‘surprise’ ambulance bills heads to Congress

Committee to recommend patients should pay no more than $100 or 10% of a bill, depending on which is less

By Jessica Glenza

July 21, 2024

https://www.theguardian.com/us-news/article/2024/jul/21/ambulance-surprise-bills-congress

A committee chartered to find ways to stop ambulances from sending patients exorbitant bills is set to tell Congress that patients should pay no more than $100 or 10% of a bill, depending on which is less.

The recommendation, which still relies on the convoluted private insurance industry, comes as nearly half of all ambulance rides in the US result in a “surprise bill” of often hundreds of dollars.

“America has decided to use an insurance system to spread the risk among many,” said Patricia Kelmar, senior director of healthcare campaigns at US Pirg, a consumer advocacy group.

“But when it comes to ambulances, without a surprise billing protection, that risk isn’t spread – the person who needs the ambulance is paying a lot more than anyone else who has that insurance.”

Kelmar was the lone consumer spokesperson on the committee formally known as the Advisory Committee on Ground Ambulance and Patient Billing. Other committee members included emergency service providers, ambulance companies, insurance industry insiders and representatives of federal agencies.

The committee was chartered when the former president Donald Trump signed the No Surprises Act in 2020 – a bipartisan bill to stop patients from receiving “surprise bills”. Although the legislation stops an estimated 10m surprise bills a year from reaching patients, ground ambulances are conspicuously excluded.

Surprise bills are in effect a dispute between insurance companies and healthcare providers. When a person takes an ambulance that is not directly contracted with an insurance company, they can bill insurance any amount they please. The remainder of the bill is then the patient’s responsibility. Hence, surprise bills are often called “balance bills”. And they can cost thousands.

For instance, Theo is a Washington state infant who arrived earlier than expected and needed to be transferred between hospitals for specialized care. The hospital ordered the ambulance, and the family was grateful for the good care.

Then the family received a $7,000 bill.

Insurance paid only a small portion – $1,000. The family tried to negotiate with both the ambulance and insurance companies, but were rebuffed. Now, they are now on a 30-month payment plan. Theo will be nearly three years old by the time the balance is satisfied.

“The hospital arranged the transportation, we didn’t have a say,” the parents said, in a presentation by Pirg. “We are grateful for the care, but surprised that even though we have good insurance we owe so much because the ambulance was out-of-network.”

Part of the reason Congress has found it difficult to regulate ground ambulances is because there are so many parties to please. Ambulances were once considered a public good and were funded by the federal government. But in 1981, the Reagan administration transformed funding for emergency medical transportation into limited block grants which states could then spend as they wish.

With federal funding diminished and states facing varying political and budget pressures, localities closed some public facilities, contracted with private companies and both began to seek payment from health insurance companies.

Now, a hodge-podge of private and public entities provide emergency medical transport, and stick patients with surprise bills as much as half of the time, according to Pirg. Privately insured Americans paid an average of $129m in surprise ambulance bills between 2013 and 2017, according to an article examining the problem in the journal Health Affairs.

Private equity has also prospered. Two of the three largest ground and air ambulance companies are now owned by private equity, which in some places has resulted in aggressive billing and collections.

“There was no discussion of whether or not we were going to ban balance billing,” said Dr Ritu Sahni, an emergency medicine doctor and a committee member at a panel discussion on their findings. “Balance billing created a barrier to good healthcare. But it was the ‘yes and’ component – how do we ensure the safety and survival of our community by making sure the future of the EMS service was secure?”

The committee coalesced around a set of recommendations to Congress that continue to rely on private insurance. They said patients with private insurance should be covered when they call 911 or are transferred between hospitals, like Theo’s family. A patient should pay no more than the lesser of 10% of a bill or $100. And, insurance should pay ambulances in a timely manner.

Although the committee published its top-line findings, the full report will not be available until it is sent to Congress, which is expected in the coming weeks. Whether Congress will act on the recommendations is unclear. Eighteen states offer some kind of consumer protection from surprise ambulance bills.

“In many ways we’re locked into the system we have and we’re trying to solve for the system we have,” said Kelmar. “But it’s a really important public policy question to know: should we keep this system? Is this the way we want to pay for emergency transportation service? Do we want private equity running ambulance services in communities?”

EMS agency and community leaders should monitor developments like this to assure logical public policy that modernizes EMS reimbursement to include reasonable reimbursement rates and coverage for valuable Treatment in Place (TIP) and Transport to Alternate Destinations (TAD) remain in place.

It's also a good reminder that during legislative processes, all stakeholders should be engaged in the process.

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Health insurance advocacy group seeks to block ambulance reimbursement bill
By Anthony Warren
Jul. 12, 2024
 
https://www.wlbt.com/2024/07/12/health-insurance-advocacy-group-seeks-block-ambulance-reimbursement-bill/
 
JACKSON, Miss. (WLBT) - An advocacy group for health insurance providers in the state wants to block a new law that would increase how much its members would have to pay ambulance companies for certain services.
 
The Mississippi Association of Health Plans (MAHP) recently filed for an injunction to block the State Insurance Commissioner from implementing H.B. 1489.
 
The petition was filed on June 28 in U.S. District Court for the Southern District of Mississippi, just days before the new law was set to take effect.
 
The bill, which was signed by Gov. Tate Reeves on May 2 after passing both the House and Senate on unanimous votes, requires insurance providers to compensate ambulance companies for certain services they previously were not paid for.
 
That compensation would be what is charged under the ambulance’s contract with a city or county, or 350 percent of the reimbursement rate of Medicare, whichever is larger.
 
Among concerns, MAHP argues the law is too vague to understand, and that provisions of the measure could drive up healthcare costs for customers. Additionally, the group is concerned about what impact the new law has on health insurance policies already in place.
 
“The vague language will create uncertainty for MAHP’s member plans, leaving plans without direction as to what claims may require coverage and what claims may not,” the suit states. “Furthermore, the significant lack of clarity will leave the interpretation and enforcement of these provisions to the sole discretion of the Commissioner [of Insurance]... or to courts deciding whether a denied claim is required to be covered as a matter of law.”
 
H.B. 1489, the “Mississippi Triage, Treat and Transport to Alternate Destination Act,” was passed during the 2024 legislative session and signed into law by Gov. Tate Reeves. The measure took effect on July 1.
 
The bill, in part, increases how much insurance companies must pay ambulance firms for services provided.
 
H.B. 1489
 
The measure also mandates insurance providers reimburse EMTs for services that they were previously not reimbursable, such as instances where individuals are treated in place or are transported to “alternative destinations” other than emergency rooms.
 
 
1489 defines those destinations as federally qualified health centers, urgent care centers, physician’s offices or medical clinics, and behavioral health facilities.
 
Currently, EMTs can transport individuals to those locations but are not reimbursed by insurance companies for doing so.
 
Rep. Stacey Hobgood-Wilkes rejects the lawsuit, saying ambulances shouldn’t have to provide services for free. “If you provide a service, you should be compensated for it,” she said. “Without adequate reimbursement for these services, the citizens of Mississippi will not receive the reliable, high-quality care they deserve and pay for.”
 
Figures provided by the Ambulance Alliance show EMS providers in the state charge between $988 and $1,224.82 for a basic life support emergency response in urban areas. Medicare reimburses those companies just $398.56.
 
MAHP takes issue with the bill’s use of the phrase, “including but not limited to” endlessly expands the list of destinations insurance companies now must pay for.
 
“As written, it is substantially unclear what constitutes an ‘alternative destination’ and if an ‘alternative destination’ includes medical providers who do not provide any degree of emergency medical services, such as a dermatologist, pharmacist, chiropractor, and the like,” the suit states.
 
MAHP members include Amerigroup, CareSource, Cigna Healthcare, CVS Health, Magnolia Health, Molina Healthcare, TrueCare, United Healthcare, and others. A list of members can be found here.
 
The group also takes umbrage with the bill’s requirement that insurance providers reimburse ambulances for “encounters” between EMTs and those seeking medical help.
 
Under the act, third-party payers would be required to pay for treatment in place when a patient is not transported to an emergency room. Before the passage of the bill, EMTs were only reimbursed if a patient was taken to the hospital.
 
That amount of the reimbursements would be the local fees set by a city or county contract or 325 percent of Medicare, whichever is greater. In the absence of a local rate, the ambulance provider would be paid their billed charges or 325 percent of Medicare, whichever is greater, the bill states.
 
However, MAHP says the law does not say what level of service would have to be provided, only that the service must be initiated by a 911 call.
 
The group also is unsure whether companies are required to pay the reimbursements under current insurance plans, or if they would only be required to do so under plans issued after the law took effect.
 
“These unintelligible provisions create no standard at all and/or cause House Bill 1489, Section 1 to be substantially incomprehensible,” the suit states. “Section 1 does not give a person of ordinary intelligence a reasonable opportunity to know what is prohibited, and increases the risk of arbitrary application and enforcement.”
 
MAHP is asking the court for a summary judgment ruling that Section 1 of H.B. 1489 violates the due process clause of the Fourteenth Amendment to the Constitution; it also is asking the court to void Section 2 of the bill, saying it violates the Constitution’s Contract Clause.
 
The group is also asking the court to prevent the state to implement or take any action to enforce provisions of the bill being challenged.

Special thanks to Rep. Carey for introducing H.R. 8977 the 'Improving Access to Emergency Medical Services Act of 2024' yesterday.  This marks the 3rd active bill in Congress to change the economic model for EMS from a transport-based reimbursement model to a 'response-based' model; in essence, reimbursing for the CARE we provide vs. the transport we supply. The 2 other bills are S. 3236 & H.R. 6257, the Emergency Medical Services Reimbursement for On-scene Care and Support Act (EMS ROCS). Congress has been very engaged with the EMS economic model for the past year. In March, 2024, the House Ways and Means Committee recently held a field hearing on access to emergency care with Dr. Ed Racht and Matt Zavadsky as invited experts to provide testimony and participate in a 3-hour Q & A session with the committee members.  You can watch the EMS-related testimony and the Q & A with the Committee members here. Carey Leads Effort to Expand Emergency Medical Treatment Options for Seniors  July 11, 2024   WASHINGTON, D.C. - Today, Representatives Mike Carey (OH-15), Lloyd Doggett (TX-35), Carol Miller (WV-01), Pat Ryan (NY-18) and Debbie Dingell (MI-12) introduced the bipartisan Improving Access to Emergency Medical Services for Seniors Act. The bill would allow seniors on Medicare to receive at-home emergency medical services to treat minor medical incidents.   “Not every patient is best served by an emergency room visit,” said Congressman Carey. “In fact, for many seniors, a trip to the hospital can mean long wait times, increased costs and potentially life-threatening complications. We’re proud to lead this bill to give our seniors access to the highest caliber of care.”  Treatment-in-place options for emergency medical reduces costs, increases convenience and protects seniors from potentially life-threatening infections.   Adults aged 65 and older account for nearly 20 percent of all ER visits. This population contributes to the backlog in waiting rooms, even when they might not have an issue requiring inpatient treatment. In a 2021 study, patients who received at-home care had a lower risk for readmission by 26 percent and a lower risk for long-term care admission as compared to patients who received in-hospital treatment.   “Treating patients immediately at home and preventing an emergency room trip is sometimes both the best way to help the patient and the taxpayer. Our legislation to establish a Medicare pilot program is designed to show the effectiveness of fair pay to first responders for such services. Thereby we hope to encourage a permanent payment system for treatment in place,” said Rep. Doggett.   Emergency Medical Services (EMS) providers are at the frontline of delivering care and transportation in rural America. In West Virginia, many patients live hours from a hospital and must consistently rely on EMS for treatment. Our EMS personnel are equipped to provide care to patients that may not be in a dire medical situation, rather than spend precious time and resources on transporting non-emergency patients to a hospital emergency department. This commonsense legislation builds upon the Treatment-in-Place Model to provide timely care to our rural patients and empower EMS providers, and I will continue to work to improve access to quality health care for patients in West Virginia and across the U.S.” said Congresswoman Miller.   “Our grandparents, neighbors, and friends are safer and healthier because of the dedicated care paramedics and EMTs provide to our community,” said Congressman Pat Ryan. “They deserve to be compensated – no matter where they administer care. That’s why I’m proud to co-lead the Improving Access to Emergency Medical Services Act to ensure that our highly trained first responders are fully supported in continuing to save lives and serve our seniors. I will keep fighting for the resources that our first responders need and deserve.”   Rep Dingell said, “We should be making it easier for seniors to live and receive the care they need at home and in their communities. The Improving Access to Emergency Ambulance Services Act will allow seniors to receive this care that can easily be provided at home by EMT professionals rather than paying for a hospital visit. Allowing EMTs to be reimbursed for this care and preventing unnecessary hospital visits would be an immense cost-saver for Medicare, free up emergency room space for those who really need critical care, and improve quality of life for our seniors.”   The bill has received support from the National Rural Health Association, International Association of Fire Chiefs, International Association of Firefighters, American Ambulance Association, Congressional Fire Service Institute, National Association of Towns and Townships and the National Association of Emergency Medical Technicians.    Randy Strozyk, President of the American Ambulance Association said, "We greatly appreciate the leadership of Representatives Mike Carey, Lloyd Doggett, Carol Miller, Debbie Dingell and Pat Ryan in laying the foundation for future Medicare reimbursement of vital ambulance services provided at the scene of a patient in need of medical care but doesn't require a transport to a health care facility. The Improving Access to Emergency Ambulance Services Act will establish a pilot project that will demonstrate the financial and medical benefits to the Medicare program of reimbursing for treatment in place of patients by paramedics and emergency medical technicians."   Susan Bailey, MSEM, NRP, President of NAEMT, remarked: "EMS is an integral part of our nation’s healthcare system and has been proven effective in the health continuum. EMS Practitioners are now providing medical care in a variety of settings. Our role has become much broader than ambulance transport. NAEMT has long advocated for providing EMS agencies the flexibility to navigate patients to the right care in the right setting through federal and state reimbursement of Treatment in Place (TIP). We applaud Rep. Mike Carey, Rep. Lloyd Doggett, Rep. Carol Miller, Rep. Pat Ryan and Rep. Debbie Dingell for their leadership and introduction of the Improving Access to Emergency Medical Services Act of 2024.   Reimbursing EMS agencies for TIP will save Medicare billions of dollars on unnecessary emergency department visits, enhance patient experience, shorten task times for EMS agencies struggling with workforce shortages, help decompress overcrowded hospitals and emergency departments, and meet patients’ needs without long waits at the hospital.”   “EMS is a fundamental, core service that fire departments provide in their communities. Fire fighters are among the most skilled and experienced pre-hospital emergency care providers in the nation, and it is long past time that we reimburse them for the full range of care that they give to ill and injured patients. Updating Medicare’s reimbursement policies is a common-sense way to drive EMS innovation and improve the patients’ experiences during medical emergencies. The IAFF applauds Reps. Carey, Doggett, Miller, Ryan, and Dingell for their bipartisan leadership in developing this bill, and we urge Congress to answer our call to bring EMS into the 21st century,” said IAFF General President Edward A. Kelly   “I thank Representatives Carey, Doggett, Miller, Ryan, and Dingell for introducing this legislation to reimburse fire and EMS departments for treating Medicare patients in places like their homes,” said Fire Chief John S. Butler, Fairfax County, VA and International Association of Fire Chiefs President and Board Chair. “This legislation will allow some of our nation’s most vulnerable citizens to receive necessary care without the trauma and expense of being transported to the hospital. It also ensures that fire and EMS departments only must transport patients if it is medically necessary, which frees up vital EMS and hospital resources. This program will be a win-win for both Medicare patients and emergency response agencies.”   Full text of the bill is available here.

A very well done summary of the public policy issues related to ambulance deserts, looming system failures, and the challenges with 'essential service' designation. Note the wages quoted in the article, likely related to the funding challenge, which leads to the staffing crisis.

Although this report focuses on rural challenges, the same issues are occurring in urban and suburban communities all across the country!

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Wyoming’s Emergency Medical Services ‘in limbo’

By Marit Gookin

July 9, 2024

https://www.wyomingnews.com/laramieboomerang/news/wyoming-s-emergency-medical-services-in-limbo/article_e099fe14-3d58-11ef-97ea-579add73226c.html

LANDER — In Wyoming, emergency medical care is non-essential. While people may feel that the ability to reach the hospital after a heart attack or a life-threatening car crash is vital to the health and well-being of themselves and their loved ones, legally speaking, the state of Wyoming does not consider it essential.

No one — at any level of Wyoming government — is required to provide ambulance service.

That leaves one glaring question: Who should provide ambulance service, and how should it be paid for?

After struggles with ambulance service last year, the Fremont County Commission appointed an ambulance task force including Commissioner Mike Jones to consider future funding options.

This task force met once, Jones said, and decided it had a variety of potential options to explore.

“We figured we had a couple of good options on the table,” he commented. “Things are kind of in limbo.”

Among the options considered are a sales tax, forming a special EMS district, and repurposing part of the existing half-percent economic development tax.

Some Fremont County commissioners are opposed to this last option, Commissioner Jenny McCarty explained, because they feel it stands on dubious legal ground: How does an ambulance constitute economic development?

Some Wyoming counties have no ambulance service at all — but McCarty said those counties are much smaller than Fremont County.

“We’re bigger than eight states,” she pointed out. “That’s a lot of dirt — and people are spread out all across it.”

A $2M price tag

Ambulance service in Fremont County has evolved over the years, at various points being entirely private-run, all-volunteer, fully county-operated and eventually winding up where it is today: a service provided through the county via a contract with a private company.

The county contracts with Frontier Ambulance to provide its emergency medical services.

But after its union workers voted to strike last fall, Frontier Ambulance and its parent company, Priority Ambulance, asked the county commissioners for an additional $386,796 to help cover the cost of the increased wages the workers were asking for.

In September, United Steelworkers Wyoming Union leader Will Wilkinson told this paper that low wages were leaving ambulance services short-staffed, leading to slower response times and EMTs working longer and longer shifts. The workers asked for an increase from a base rate of $12.58 an hour (for the lowest-paid EMTs) to $15 an hour.

The commissioners eventually voted in favor of the increase, bringing the county’s total ambulance expenditure up to about $1.8 million annually.

“It’s paid for this year out of the budget — but it’s unsustainable,” McCarty said.

She explained that the county had to dip into emergency reserve funds to cover the cost increase; with the county facing budget difficulties this year, that isn’t a long-term solution.

Unlike some of the other services provided through the county, Frontier Ambulance doesn’t necessarily bring the commission information about its budget or operations; as a private entity that the county contracts with, it is under no legal obligation to do so.

It used to provide periodic reports to the commissioners on how many people it had transported, but, said McCarty, it hasn’t done so for some time now.

And even if the county wanted to, shopping around isn’t much of an option.

There aren’t many organizations providing ground ambulance service in Wyoming, and if it intends to continue contracting for private ambulance service, the county doesn’t have a wealth of other companies from which to choose.

“They can walk away today; they can walk away tomorrow,” McCarty pointed out.

Although the county owns the ambulances and medical equipment and has worked out a memorandum of understanding that allows it to use these to provide services in emergencies, long term “there is no back up.”

Property tax, sales tax

The 2023 bill that allows for the formation of emergency medical districts, sponsored by Sen. Cale Case, R-Lander, and co-sponsored by Rep. Lloyd Larsen, R-Lander, outlines a specific process by which such a district can be formed.

The county commission must create a board of directors, which will then be responsible for evaluating the financial needs of emergency medical service and collecting payment from private insurance, Medicare and Medicaid.

The county can then levy a tax of up to two mills if the district was formed by a group petitioning the commission, and up to four mills if established directly by the county commission via a resolution, based on the assessed funding needs of the district after it has collected payment.

Districts are a more sustainable source of funding than sales taxes, which have to be reapproved by voters every few years.

But property taxes are often unpopular, and some feel unfair; Jones and McCarty said that several members of the public have communicated to the commission that they feel that funding the ambulance with a mill levy wouldn’t be equitable, not least because some of the areas that the ambulance currently provides service to don’t pay county property taxes.

On the other hand, the EMS district — and therefore the area it services — doesn’t necessarily have to correlate with the county’s boundaries.

An EMS district does have to consist of a specific, bounded geographic area, but the group forming the district, whether it’s a group of citizens or the county commissioners, can select any area that they want to within the county.

The idea of changing the memorandum of understanding (MOU) regarding the current half-percent sales tax has been strongly supported by some and met with opposition from others.

The half-percent tax cannot pay for the full nearly $2 million cost of the county’s contract; across the various entities that receive half-percent funding in the county, a total of $854,376 would be repurposed to help cover ambulance costs under the new MOU.

Opponents of the changes have included those who feel their legality is questionable and those who wonder what would happen to ambulance service if the half-percent tax failed to pass the ballots this November.

Lander City Council’s lone “no” vote on the new MOU, Missy White, objected to the altered MOU because she said the percentages of funds being taken from municipalities versus the county were out of balance. The question isn’t whether there’s a plan B, said White. She’s sure the county has a plan B, C and D — but she wants to know what those plans are.

“Bottom line, there has to be a funding mechanism — and it should be the people who use it who pay for it,” Larsen said.

Statewide challenges

“Our system is not working. We’ve got challenges, and people are falling through the cracks,” Gov. Mark Gordon remarked during the Wyoming Press Association convention this past January.

Around the state, he said, ambulance services are struggling; when you call 911, he pointed out, people have a reasonable expectation that someone will show up. But when it comes to medical emergencies, there are parts of Wyoming where that simply isn’t the case.

Fremont County isn’t alone in its ambulance woes — and part of the problem, Gordon said, comes back to whether it is legally considered essential.

“How do we make it an essential service?” he asked.

Some people believe the state of Wyoming should play a larger role in helping counties and municipalities fund ambulance services.

“Ultimately the question is … whose responsibility is ambulance service?” Larsen remarked. “Is it the responsibility of the state, or should it be more local?”

The county commission may be under no legal obligation to provide emergency medical services — but, McCarty said, she at least feels a moral and ethical obligation to make sure the people of Fremont County have access to life-saving health care when they need it.

“My number one job is to make sure that everybody is safe and sound in this county,” she commented.

For now, the county commission’s ambulance task force has made no reportable further progress since its first meeting. If it’s hoping to add a new potential tax to the ballot, it still has a little time to put it together; the deadline for adding measures to the November ballot is Aug. 25.

Another example of EMS agencies struggling under the current economic model. Skyrocketing costs and stagnant revenues are taxing current service levels. Municipal funding could be key to keeping the McCandless-Franklin Park Ambulance Authority afloat 2022 was the first year the authority didn't operate in the red, due to contributions from McCandless LAURA ESPOSITO AND CIARA MCENEANY June 30, 2024   https://www.post-gazette.com/news/social-services/2024/06/30/ems-mccandless-franklin-park-ambulance/stories/202406270110   Fiscally, the sole ambulance authority that covers five municipalities and 64 square miles of Allegheny County walks on soft cement.   At least, that's how Chief Chris Dell describes it. He took the helm at McCandless-Franklin Park Ambulance Authority, or MFPAA, in 2022, when the threat of disbandment was looming even more prominently over the EMS system than it is now.    Since then, Chief Dell has implemented cost-cutting measures, applied for numerous grants, and the ambulance authority has even earned national accreditation, the gold standard for first responders that less than 1% of EMS agencies earn nationwide.   From the outside, it all seems to be paying off for the MFPAA — 2022 was the first year in roughly half a decade it operated above the red line, making a modest gain of less than $5,000. While they've yet to receive their 2023 audit, Chief Dell said that internal reports indicate another year of financial gain for the organization.   But there's another factor, one out of Chief Dell's control, that now determines both profitability and the capabilities of the ambulance authority: municipal funding.    Like a growing number of EMS systems nationwide, the MFPAA, which answers about 9,000 calls annually, now relies on leaders from the areas it serves to keep it afloat. And while local municipalities acknowledge the need for ambulances, they don't necessarily want to pay for them.    "You can't blame them. They were able to get the service for free for so many years," Chief Dell said. "But municipalities are going to have to support their EMS agencies as they expect them to survive."   According to the Center for Rural Pennsylvania's 2022 survey of Pennsylvania EMS agencies, 32% of urban and mixed EMS agencies that serve urban and rural counties said they did not receive municipal funding.   And nearly two-thirds of urban and mixed EMS agencies also reported one or more budget deficits from 2018 to 2022.   Chief Dell said community members are often surprised to know that, unlike police departments, many EMS agencies, such as the MFPAA, aren’t funded by their municipalities.    Since its creation four decades ago, the ambulance authority's revenue has accrued from three sources: fees for services, a subscription program and community donations.    "[But now] everything that we do costs a lot more money than it used to," Chief Dell said.    For example, Chief Dell said, the recent purchase of an ambulance without equipment costs upward of $300,000 — more than double what it was a decade ago. The EMS system has five ambulances, and because of their robust volume of calls, they are on pace to purchase a new one every year, he said.   This year, McCandless officials set aside a $110,000 contribution to the MFPAA, the first time money for EMS was included in the town's budget. McCandless spokesman John Bojarski wrote in an email to the Post-Gazette that the town allocated the funds to "ensure that this crucial service continues to be provided to our residents."   "The town is aware of recent funding challenges facing the McCandless-Franklin Park Ambulance Authority and other ambulance providers throughout the region,” he wrote.    "We acknowledge the importance of providing professional ambulance coverage for our residents."  Franklin Park was already making contributions to the MFPAA but increased its funding, according to council meeting minutes from March.   However, the remaining municipalities — Pine, Marshall, and Bradford Woods — weren’t as quick to dole out funding.   “Pine has requested additional information regarding the cost of idle time before they make any further commitment. Marshall and Bradford Woods do not have any interest in paying or having a board seat,” according to council minutes.   After lengthy debate, $277,000 was allocated to the MFPAA for 2024 from all five towns. The agency originally asked for $350,000, but Chief Dell said he could work with that number.    "Had we not had the municipal support fund that we've gotten so far for the year, we would be operating at a loss or right around break-even," he said.   While the three municipalities committed to making only a one-time contribution, Chief Dell said he’s optimistic that once MPFAA leadership is modified, that will change.    The board consists of five representatives from McCandless and two from Franklin Park.    "The one-time contribution is dependent on having representation and having a say in the municipal MFPAA budgeting process in 2024, which makes sense," he said. "We believe that's a fair thing."   He's optimistic the one-time contributions will turn into annual payments as the MFPAA continues to meet and address concerns from unrepresented municipalities.    Nationwide Problem While disbandment and consolidation of EMS services are common nationwide, they have hit the Pittsburgh region especially hard.    Last July, Jeannette EMS shut down all operations primarily due to "financial issues," according to a Facebook post.   It urged people throughout the region to contact their government representatives to work to save EMS services, cautioning that more emergency services are also at risk of disbandment.   "We are sadly not the first service to have this happen to us, and we will unfortunately not be the last," the statement reads.   "The biggest hit to not only us but to any ambulance service is the poor reimbursement rates the insurance companies pay out, and with that, we can unfortunately no longer provide services to the City of Jeannette."    Aside from municipal funding, advocates have argued that additional funding from the state could curb the closures.   But many organizations have trouble securing funding because they are trained to provide emergency care, not fundraise, said Ralph Serphe, president and CEO of the Adams County Community Foundation, which created the WellSpan Emergency Services Fund to support Adams County nonprofit EMS agencies with professional services, start-up funding and project developments.   And a lack of secure funding ripples throughout an organization, leading to high employee turnover.   According to the National EMS Advisory Council 2023 report, EMT’s are paid almost a third less than most working Americans, with agencies seeing turnover rates of 20% to 30% annually.    Agencies that participated in the Center for Rural Pennsylvania’s 2022 survey said that pay and benefits, combined with the demands of the job, were major reasons providers left their posts.   “EMS services are a public good, and they should be supported by tax dollars,” Mr. Serphe said. “The business model of small, independent, all-volunteer EMS providers just doesn’t work anymore. We’re asking a shrinking pool of dedicated volunteers to do more and more.    “That time pressure, along with the increased cost of regulation, training and equipment, demands a workable solution.”   Chief Dell echoed his concern and said there are only so many grants ambulance authorities are eligible for and have time to apply for. Nearly 90% of a $30 million grant program from the state is allocated for fire departments, the rest is reserved for EMS.   "They get a much larger share of all grant money, but when you look at actual call volume, ambulance services do a lot more calls than fire departments," Chief Dell said.   Nationally, the EMS Advisory Council urged federal departments in its 2023 report to address pay gaps and limited funding opportunities that exist among the EMS industry compared to other public services, such as law enforcement and fire services.    The council wrote in the report that it is essential that EMS agencies have their own grant and funding opportunities that are available to “all EMS service delivery models,” along with being considered essential services on a national, state and local level.    "In reality, agencies have worked hard to do everything they can to reduce costs and to come up with unique or better funding streams and we're coming up with a shortfall — we're asking for municipal support,” Chief Dell said.

What’s most interesting about this report is that it uses response times as a measure of system performance. The reality is that according to recently published, peer-reviewed study of over 1.7 million EMS patient encounters, only 6% involved a time-critical EMS intervention.

Additionally, virtually every peer-reviewed study since 2002 evaluating response times and patient outcomes has demonstrated that any response time greater than 5 minutes, has no impact on patient outcomes; and only about 5% of 911 EMS calls could be impacted by a response time 5 minutes or less.

There are much more important, evidence-based measures that can be used to evaluate the performance of an EMS system; such as, compliance with medical director approved clinical bundles of care, EMS vehicle crashes, and patient experience scores. 

Domains for system performance and potential metrics, approved by 16 national and international EMS, Fire, city manager, and patient safety associations can be found here:

Kupas - Zavadsky - with Logos - Joint Statement on EMS Performance Measures Beyond Response Times - FINAL Approved by Named Associations CLEAN 4-30-24.pdf

A compendium of research related to response times and patient outcomes used to develop these potential metrics can be found here: 

References-Resources on EMS Performance Measures _ Beyond Response Times FINAL 2-15-24.pdf   

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Ambulance response times in NYC hit pandemic-era highs

By Linda Schmidt and edited by Amanda Geffner

July 1, 2024

https://www.fox5ny.com/news/ambulance-response-times-nyc-hit-pandemic-era-highs

New data shows it's taking longer for ambulances to arrive at the scene of emergencies here in the city.

The union president says city records show the city is on pace to break last year's record number of emergency calls. 

Last year it was 1.6 million, and the union says response times to those emergencies are putting the public in danger.

During the week of Memorial Day, the union says it took an average of nearly 13 minutes for ambulances to respond to life-threatening emergencies and an average of 28 minutes for non-life-threatening emergencies.  

These are the longest response times since the beginning of the pandemic.

"We're talking about people's lives here.  We're not talking about making an appointment with a plumber, or an electrician. We're talking about somebody's loved one who stopped breathing has to wait 11 to 16 minutes for an ambulance to get to their house," Barzilary said.

The union president says the city is equipped to handle about 4,000 calls a day but is receiving about 5,000. In addition to needing more ambulances, the union explains other factors contributing to the slower response times.

"With the lowering of the speed limits in New York City, lowering the lanes that are available for traffic to go through.  All the bike lanes that are added. All the street closures that are added. It's impossible to get through," Barzilay said.

The FDNY responded with a statement apparently agreeing with the union that more ambulances are needed:

"We saw a spike in EMS activity during the pandemic where we required additional resources. We have returned to pre-pandemic levels for our ambulances, but calls have not declined."