Administration and Leadership, Patient Care

Organizations Meet & Prioritize IOM Recommendations

EMS reimbursement revamp & boarding/diversion among top six to pursue

The American College of Emergency Physicians convened a meeting of emergency care organizations in Washington, D.C., on March 6 to consider the recommendations made by the Institute of Medicine for improving emergency medical care in the United States.

Only three prehospital organizations ƒ the National Association of Emergency Physicians, National Association of EMTs and National Association of State EMS Officials ƒ were among the 18 groups invited to the meeting.

“The IOM came out with 63 different recommendations,” said ACEP President Brian Keaton, MD, an attending physician in the department of emergency medicine at Summa Health Systems, Akron, Ohio. “At the IOM workshops around the country, the question was asked again and again: What can we actually get done?”

ACEP volunteered to convene a meeting to determine the top priorities of emergency care groups and seek consensus on which to pursue. “This doesn’t mean different groups can’t support additional activities,” he said.

Before the meeting, each organization was asked to choose its top two priorities in each of five topic areas: hospitals, EMS, pediatrics, trauma and research. ACEP compiled those votes into 10-12 top IOM recommendations, which were discussed and voted on at the meeting, ultimately agreeing on six priorities.

“When I first got there, I went around and asked the three [prehospital] organizations [what their priorities were], and we were all on the same sheet of music,” said Maryland EMS Director and NASEMSO Immediate-Past President Bob Bass, MD, who sat on the main IOM committee and the IOM EMS committee and represented NASEMSO at the meeting.

For all three prehospital groups participating, the top priority was to implement recommendation 3.7 from the EMS IOM report: “that the Centers for Medicare & Medicaid Services convene an ad hoc workgroup with expertise in emergency care, trauma and EMS systems to evaluate the reimbursement of EMS and make recommendations regarding inclusion of readiness costs and permitting payment without transport.”

NAEMT President Jerry Johnston, EMS director at Henry County Health Center, Mt. Pleasant, Iowa, who led the NAEMT delegation, said that organization’s second priority was to implement the IOM’s recommendation that EMS receive parity with fire and police in preparedness funding. “That didn’t make the cut,” he said.

Although ACEP has yet to compile the priorities into a report, according to prehospital participants in the meeting, the other five priorities were to seek:

Î Federal support for research on emergency-care and trauma issues and the development of evidence-based national standards for emergencyprovider core competencies;

Î Demonstration programs to promote regionalized, coordinated and accountable emergency care systems nationwide and the categorization of emergency care resources;

Î Federal funding to reimburse hospitals for the losses they incur in providing emergency and trauma care to uninsured patients;

Î At least $37 million annually for the EMS for Children program; and

Î An end to emergency department patient boarding and ambulance diversion.

The group planned to come up with only five priorities, but decided to add a sixth when ED patient boarding and ambulance diversion received too few votes to make the top five.

“Ambulance diversion is a huge issue for us,” said Paul Maniscalco of George Washington University’s Homeland Security Policy Institute and chair of the NAEMT Administrators Division, who attended with the NAEMT delegation. “Hopefully, we’re now going to have some high-level attention looking at boarding of patients and diversion.”

Maniscalco is a strong advocate for a lead EMS agency within the federal government ƒ one of the IOM’s recommendations, but one that reportedly didn’t generate much support at this meeting.

“You don’t get a sense that this is as important as the other issues raised,” Bass said. “And a lot of people want to wait and see what FICEMS [the Federal Interagency Committee on EMS] will do.”

Keaton said it now will be up to the “advocacy arms” of participating organizations to “turn the recommendations into strategies.”

Meeting participation Before the meeting, ACEP stipulated that every participating organization must agree in advance to support the priorities agreed to by the group.

Every organization agreed to do so, except the hospital association, which consequently sent only a non-voting observer to the meeting. (Organizations that agreed to this stipulation could bring three representatives but had only one vote.)

According to Kurt Krumperman, Rural/Metro’s senior vice president for government affairs, an NAEMT liaison to Advocates for EMS and a member of the NAEMT delegation, the hospital association “resisted efforts to say hospitals need to be responsible for ending boarding and diversion. They said, ÂIt’s a systems problem, and no one can be responsible for a systems problem; don’t single us out.’ But we must get the hospitals to the table.”

He noted that organizations represented at the meeting were “mostly physician groups ƒ emergency physicians, neurosurgeons, trauma surgeons ƒ and groups like the American Public Health Association and the American Hospital Association.”

ACEP did not invite the American Ambulance Association or any fire service organizations to the meeting.

When asked about this omission, Keaton said, “The fire service has multiple organizations that would have had to be represented, and the EMS issues seemed adequately covered by the three organizations invited. We tried to bring together the organizations that focus on the medicine side.”

Johnston said the meeting “gave us the opportunity to provide some education on issues affecting prehospital care and allowed us to educate some physician specialty groups. At the end of the day, I think the EMS folks who were there all agreed it was a good meeting.”

According to Keaton, “The take-home message is that a large and diverse group of emergency care organizations managed to reach consensus on things that were in the IOM report and need to happen.”

According to Rick Murray, EMT-P, director of ACEP’s EMS and Disaster Preparedness Department, “ACEP, NAEMSP, NASEMSO and NAEMT are planning to host an EMS Issues Forum during late May or early June to look at the top issues facing EMS and what has been accomplished in the year since the IOM EMS report was released.” He said representatives from all national EMS organizations and federal agencies involved in EMS will be invited.

For more information, contact ACEP EMS Manager Rick Murray at„[email protected].