Administration and Leadership, EMS Insider

The Role of the Federal Government in EMS: An Interview with Gregg Margolis, PhD

When Gregg Margolis, PhD, signed up for an EMT class while studying as an undergraduate at the University of Pittsburgh, he had no idea that it would lead him on the path he’s taken. Soon after, he became a paramedic and spent several years in the field, including 12 as a flight medic. He later worked in academia at his alma mater and then the George Washington University before a stint at the National Registry of EMTs (NREMT) as an associate director.

In 2009, Margolis began a year of service on Capitol Hill as a Robert Wood Johnson Health Policy fellow—the first EMS professional to receive that honor. That led to a position with the U.S. Department of Health and Human Services in the Office of the Assistant Secretary for Preparedness and Response (ASPR), where he led the Division of Health System Policy.

During his decades in emergency medicine, education and health policy, Margolis worked on numerous projects of national importance, from the EMS Education Agenda for the Future to the federal response to the Ebola outbreak.

Last fall, after seven years at ASPR, Margolis returned to the private sector as director of health policy fellowships and leadership programs at the National Academy of Medicine (formerly known as the Institute of Medicine). We spoke with Dr. Margolis about the role of the federal government in EMS, the future of EMS education and how to enact policy change—a topic he will be addressing in greater length at the Pinnacle EMS Leadership Forum in Phoenix, Arizona, this July.

Q: How did your years on Capitol Hill and at ASPR change your perceptions of the federal government?

A: First, I loved being a federal civil servant. I really did. I was really impressed as a government official at the commitment and dedication and competence of many of the people in the Federal Government. And I think the reality is that government employees sometimes get a bad rap and aren’t quite as valued by the people they serve. And maybe, at some level, I fell a bit into that trap in the past. But one of the joys of serving in the Federal Government was to realize how dedicated and committed most people that work there are, and how they get up every single day to try to make the country a better place.

One of the challenges is how difficult it is to navigate the legitimate competing interests of such a big country and, as a result, how hard it is to affect change at a federal level. You have to become satisfied with really, really, really incremental change in the right direction, because moving any policy initiative, even just a tiny amount, requires an extraordinary amount of effort.

Q: At ASPR, you worked on many issues both directly and indirectly related to EMS. What do people not understand about the role of the Federal Government in EMS?

A: Like many people, I used to be frustrated with the apparent lack of federal resources to support EMS compared to other disciplines. But one thing I realized is the Federal Government supports EMS to a very large extent, with about $5 billion a year through fee-for-service reimbursement. And as a result, the Federal Government is a big purchaser of EMS services, and few EMS agencies would be able to survive if it weren’t for Medicare reimbursement. So I think I failed to recognize—because EMS doesn’t have a big grant program or some of the other things that some other disciplines have—that the Federal Government does have a role in EMS. The main role that it has, like many other healthcare entities, is through its role as a purchaser of services, rather than through administering grants.

The other thing that I came to recognize is the true interdisciplinary nature of EMS: there are communications issues, there are transportation issues, there are healthcare issues, there are national security issues, military and veterans issues, Indian health issues, substance abuse and mental health, to name a few.

EMS crosses all of these disciplines, and the nature of the Federal Government is that those issues reside in different departments and agencies. I really do think that we need some mechanism to coordinate and bring together these different entities and different perspectives on EMS is essential. FICEMS [the Federal Interagency Committee on EMS] is a good start. And if FICEMS actually had resources and staff to allocate, could be a powerful coordination role. The problem is we’re in an environment where it’s very, very difficult to get new resources for initiatives that aren’t a crisis.

Q: Speaking of reimbursement—for years, EMS leaders have been hearing that fee-for-service is going away and EMS can’t just be a transport service. And there are a lot of innovative things going on in EMS, innovative ways of looking at changing the funding model. Yet many of them are struggling to become sustainable. Both from within the federal government and CMS, and in general, why has it been so difficult to make that change?

A: I still believe in my heart that there is enormous opportunity for people who are creative and innovative. Too often, I underestimate the rate of change and the difficulty of making that change. It just takes longer than you think it’s going to, and it’s harder than you think it’s going to be. But that doesn’t mean it isn’t worth it. Change is nonlinear, and you frequently have long, long periods of preparation that are necessary for rapid change when the timing is right. And sometimes people—myself included—get frustrated at those long periods of waiting.

I don’t think the idea that we should pay providers for the value they add, rather than the volume of services they provide, is going away. But I don’t think that the transition is going to be rapid, and I predict it will be uneven. And, frankly, emergency services overall —emergency departments, EMS agencies, ambulance service and medical transportation service — may be some of the last parts of the healthcare system to experience these changes, because it’s really hard to think through how you do value-based purchasing or bundled payment models for these episodic services. So, I think fee-for-service is still going to be here for a while. But eventually, once they figure out how to do those things for larger parts of the healthcare system—chronic disease management and pharmaceuticals—it’ll find its way into all of the healthcare system, and eventually EMS. But I don’t think it’s going to happen quickly.

Q: At Pinnacle, your talk is titled “Be the Change You Seek: Lessons in Persistence and Persuasion.” Is your experience with the slow pace of policy change a reason you chose to address this topic with EMS leaders?

A: Yes—I look back on some of my earlier career attempts to influence policy at the agency, region, state and federal level, and realize how many mistakes I made in trying to influence the direction of organizations and a profession that I cared about. And now, having the privilege of being able to have served in policy roles at each of those levels, I’ve developed a framework that I wish I would’ve had earlier in my career, because I would’ve been more effective. And I’m excited about sharing those experiences with others so that they can be more effective in influencing the direction of organizations that they care about.

Q: Switching gears to another topic that I know you certainly spent a lot of time thinking about during your career: education. What are your thoughts on the future of EMS education and specifically whether degree requirements should be part of that discussion or not?

A: I’m conflicted. I believe that a broad-based education is the best way to prepare for success in an unclear future, and that having a workforce that is well-prepared for whatever the future holds is very important. I think the nursing profession and other health professions have benefited from that, and the relatively narrow focus of EMS education on resuscitation and essentially acute life-threatening emergencies does limit our ability to take advantage of opportunities that may present themselves in the future.

So, I think the real challenge is how do we take advantage of the education and experience and talent that so many EMS people have and provide them with the education necessary to be successful in providing broader services in the future. I don’t think that degrees in and of themselves are the answer, but figuring out how to take our super-talented and dedicated and experienced workforce and help them transition for an evolving healthcare system is important.

Or the other alternative is that EMS remains very focused on resuscitation and emergency care, and other professions take advantage of the opportunities that present themselves. For 30 years, I’ve been hearing EMS providers and professionals wanting more professional recognition, more growth opportunities, more respect among their healthcare and public safety colleagues, and I think that some of these opportunities provide the chance to get the things that the profession has been asking for.

Q: In September you left federal service to run the fellowship programs at the National Academy of Medicine. How did your career in EMS lead to where you are now, and what can people in EMS who want to become involved in related fields like healthcare policy learn from your experience?

A: EMS experience brings to the policy conversation a level of experience and credibility that not a lot of other people have. Every single day, EMS professionals see the results of the failures of our healthcare system and policy decisions in a way that few other professions do. So, having that real-life, on-the-ground, one-on-one patient and community experience adds an element of realism to the policy conversations that not a lot of other people bring. So, I’d love to see more EMS professionals involved in policy. And I think there’s a lot of ways to do that to make sure that the EMS perspective is heard.