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NEMSAC Takes Position on EMS in Health-Care Reform

At its June 2-3 meeting, the National EMS Advisory Council (NEMSAC) drafted and approved a position statement stating that EMS is "essential" and health-care reform must ensure "an accountable and sustained community-level EMS system." NEMSAC, created by Congress to advise NHTSA (which subsequently passes recommendations along to other federal EMS "partners" via the Federal Interagency Committee on EMS), also approved the first two "products" to come from its five committees and provided input on work by the three other committees.

Health-Care Reform
"The rallying cry that every EMS system and person can get behind is: Don't even begin reforming health care in this country unless the integrity and capacity of the EMS system is assured," said NEMSAC Chair Dia Gainor, Idaho's EMS director. "Any changes to the health-care system are likely to be disruptive and EMS is the safety net during that process, so you can't tamper with health care without ensuring that safety net is ready to deal with unexpected outcomes." She said NEMSAC drafted the document at the June meeting because "the awful and haunting realization that another train was about to leave the station without EMS on it gave us a sense of urgency."

The NEMSAC statement includes 10 "guiding principles," which state in essence that health-care reform must:
1. Ensure the stability and performance of a viable, funded EMS system;
2. Include investment in a ready EMS workforce;
3. Provide permanent funding for the National EMS Information System;
4. Fund EMS research;
5. Implement the Institute of Medicine recommendations for regional, accountable, evidence-based emergency care systems;
6. Ensure sufficient funding to maintain EMS readiness;
7. Provide "core-funding" for EMS "regardless of delivery model" to ensure the necessary "surge" capacity;
8. Include EMS in the minimum benefits set;
9. Ensure the inclusion of EMS as a partner with public health in home-health or "medical-home" models; and
10. Ensure the health-care system integrates 9-1-1 pre-arrival instructions and medical prioritization systems.

Gainor presented the statement to the Federal Committee on EMS, which met right after the NEMSAC meeting, "to be sure that every federal partner who is asked for input [on health-care reform] would be armed with this input."

NHTSA EMS Chief Drew Dawson said, "NEMSAC didn't task us with anything specific, but we'll make efforts to disseminate this to the appropriate people and there are multiple venues in which this can be used."

Committee Products
NEMSAC approved a report and recommendations on "Standardization, Certification, Licensure and Credentialing" from the Education and Workforce Committee. The committee concluded that the EMS Education Agenda for the Future and National EMS Scope of Practice Model "appropriately satisfy the concerns surrounding standardization, certification, licensure and credentialing and all should be addressed with widespread adoption and implementation."

The committee recommended NHTSA continue to support full adoption and implementation of the education agenda; continue to help draft model legislation to enable states to adopt all its components; publish a regular implementation report card; convene a "stakeholders group" to consider how to incorporate new developments (e.g., evidence-based practice and new learning technologies) into the education agenda; and support research on the agenda and on the effectiveness of EMS education systems.

NEMSAC also approved the Safety Committee's report and recommendations on "EMS Injury and Safety Data." That committee recommended that it create a standing subcommittee on EMS Safety Data "to ensure future development of information processing systems, processes or services capable of providing the analytical tools needed for the mitigation of illnesses and injuries and deaths to EMS providers, patients and the public."

It also recommended that NHTSA review current data definitions related to EMS illnesses, injuries and deaths in any databases that record such information; encourage and develop relations between federal and non-federal partners with reporting systems to improve terminology consistency and access to data sources on EMS illness, injuries and death; and work with FICEMS to insure the integration and utilization of any federal databases that include such information.

"These tasks were the committees' highest priorities, but there's no shortage of other tasks and activities for them to do," Dawson said. "The other three committees are very close to having final reports and will for sure [have them ready] for the next NEMSAC meeting."

The Systems Committee is working on an ambitious project. After establishing 16 "guiding principles" for EMS system design, the committee is now developing a list of "core issues" for each principle. "It's a big task, but a lot of the work has already been done in Oklahoma, so they didn't start from scratch," Dawson said. Committee Member John Sacra, MD, medical director the Tulsa and Oklahoma City EMS Authority did most of that work, he added.

NEMSAC charged its Oversight, Analysis and Research Committee with researching, discussing and developing recommendations for reducing medical errors in EMS. The committee presented a draft of its report, which included a 35-page bibliography and numerous recommendations for "creating an EMS culture of safety." That report should be ready for approval at the next NEMSAC meeting, which should take place in December or January.

"This is the first do-no-harm project in EMS," Gainor said.

Reimbursement Recommendations
The NEMSAC Finance Committee presented a draft and report and recommendations, but the council made some suggestions and asked for a revision before giving its approval. Most of the committee's report recommendations center on promoting changes to the Medicare ambulance fee schedule.

The committee recommends that baseline reimbursement be raised to "end the discrepancy between cost and reimbursement as identified in the GAO report"; several EMS interventions be upgraded to ALS-2 in the fee schedule; NHTSA convene an expert panel to develop national guidelines for EMS treat and refer and transport to alternative destinations; and the Centers for Medicare and Medicaid Services convene a negotiated rulemaking committee to develop a reimbursement scheme for treat and refer and transport to alternative destinations.

However, the committee noted that when NHTSA and FICEMS asked CMS to implement the "IOM recommendation calling for CMS to assemble an ad hoc working group ... to evaluate the reimbursement of EMS and make recommendations with regard to including readiness costs and permitting payment without transport ... CMS issued a position statement indicating they would not support the formation of such a working group." CMS said the fee schedule adequately addresses the cost of readiness and only Congress could allow Medicare to reimburse for anything other than ambulance transport.

"The Finance Committee really has its work cut out for them considering the CMS affront in refusing to convene a work group," Gainor said.

Finance Commitee Chair Kurt Krumperman, MS, who is also president of Advocates for EMS, said, "We might need to go to Congress for treat and release, but there may be ways around that because there are other examples of non-transport Medicare reimbursement, for example for paramedic intercept or if a patient is deceased. But we'll recommend that NHTSA look for the proper venue."

NEMSAC Progress
"We're working hard and making progress. Our discussions are getting meatier and there's a sense we're being listened to and our recommendations are being addressed," Krumperman said.

"NEMSAC members have done an incredible job of donating their time, and we should be seeing more and more fruits of their labor," Dawson said. "Not every recommendation can be implemented immediately but we've committed to reporting the status on each recommendation at the beginning of every meeting."

NEMSAC member Gary Wingrove, president of the National EMS Management Association, said, "It may not seem like it to the average EMS watcher, but lots of good work is being done in a careful manner that will soon be actionable, with things people can actually start to do."


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