Various CP initiatives are underway across the globe, generally funded with grant dollars. In parts of Canada, Australia, New Zealand and elsewhere, these experienced individuals are essential to the well-being of large segments of the population.
In the U.S., a number of pilot projects that fill certain voids in the healthcare delivery system. Efforts in Fort Worth, Texas, and Colorado’s Eagle County not only offer care, but they also help reduce unnecessary ambulance transports and hospital emergency department (ED) visits.
In fact, the idea of arming experienced paramedics with expanded skills not traditionally taught in paramedic training programs has been discussed in Minnesota for more than a decade. However, due to tight budgets and the need for a clearly articulated mission, EMS providers have been reluctant to implement a formal CP program.
With this in mind, the Minnesota Ambulance Association (MAA) pursued state legislation to clearly define a community paramedic in law; outline their mission, purpose and role in the healthcare delivery system; and secure reimbursement under the Medical Assistance Program.
During the 2010 session of the Minnesota legislature, we informally broached the idea of pursuing a bill to place CPs in statute. After meeting with Republican and Democrat leadership in both the House and Senate, it became clear that the timing wasn’t right. We lacked a specific proposal and were, frankly, unprepared for the broad opposition from the healthcare provider community once news of our proposal spread.
We dropped pursuit of 2010 legislation and focused efforts on drafting a detailed plan, which included supportive documentation and a legislative proposal. Additionally, we arranged to meet with the variety of organizations that had expressed reservations about the CP initiative.
We hit the ground running in 2011. Despite a great deal of preparation and interest to move forward with legislation, specific language was elusive. Fellow MAA lobbyist Buck McAlpin and I were faced with the fact that no other state had yet to pass CP legislation, necessitating that we draft a bill without a template. Over the course of four months, we drafted roughly 19 versions which, for myriad reasons, didn’t work.
Attempts to include CP under the statutory definition of other seemingly similar healthcare providers resulted in increased push back from other provider organizations. With each successive draft, another interest group would emerge expressing serious reservations–if not downright opposition–to our proposal. It became evident that we were in a full-blown turf battle with nearly a dozen healthcare provider groups.
The effort can be compared to sprinting through a dense forest while blindfolded. Ultimately, overcoming the challenges compelled us to craft a very good piece of legislation. Among the groups engaged were public health officials, nursing home administrators, respiratory therapists, physicians, home health agencies, registered nurses, sports trainers and physical therapists. Consequently, we found we were able to address most of the opponent’s concerns. However, we were still unable to satisfy the objections of the nurses.
An important lesson we learned from the numerous meetings is that we had mistakenly assumed that other healthcare providers, as well as a large segment of the legislature, had a clear understanding of a paramedic’s work. In many people’s minds, paramedics were simply members of that amorphous group of “ambulance drivers.” There was little understanding of the significant training we undergo and the extensive list of treatment interventions that paramedics perform.
Once all parties involved understood that the community paramedic training represented a logical progression of our roles, much of the overt opposition ebbed and the legislative effort succeeded.
CP legislation was ultimately signed by the governor as Chapter 12 (Senate File 119) of 2011. The new law does the following:
- Defines a community paramedic;
- Establishes criteria for admission to a CP program;
- Requires that the CP curriculum must be approved by the Minnesota State College and University Systems (MNSCU);
- Requires regulatory oversight and certification by the Minnesota EMS Regulatory Board (EMSRB);
- Mandates that CP programs may only be established by ambulance services licensed in Minnesota and function under their physician medical director’s authority; and
- Mandates that CP services be reimbursed under the state’s Medical Assistance Program.
This last provision will not take effect until the legislature acts on recommendations put forth by the Department of Human Services. The Department’s report, due shortly before the session commenced in January, is to include the treatments covered and a fee schedule.
Lastly, we included language that requires a retrospective assessment of the CP program’s effectiveness in reducing unnecessary ambulance transports and hospital ED use.
Tips for future lobbying efforts
Even with more than 40 years of combined experience lobbying on behalf of EMS, McAlpin and I found that securing enactment of the community paramedic law was a particularly unique challenge. Based on our experience with this law, as well as previous legislative successes, we have a few suggestions that may help others pass similar legislation without developing ulcers.
- Your association needs to have a presence at your state capitol in order to navigate through the system. In Minnesota, only 5% to 7% of all bills introduced are signed into law. The legislative system is intentionally designed to assure that bills fail. It’s an overwhelmingly difficult endeavor to move potentially controversial legislation forward, and knowledge of the process is essential.
- Don’t assume that healthcare organizations, elected officials (or the public, for that matter) know what a paramedic is, the extent of a paramedic’s training or the services provided. As several registered nurses (RN) told me, all they knew is that we are “cowboys.” One of those nurses happens to be my wife.
- Before your legislation is introduced, you should meet with any organizations that may potentially oppose or support you legislation. Sell the concept.
- Clearly establish the utility of your CP proposal. Explain how CP availability will enhance patient care, fill unmet needs and reduce the cost to the healthcare system, and share that you don’t intend to compete with already financially brittle healthcare services available in the area. Emphasize that CPs are part of the healthcare team and not independent actors.
- Identify strong, influential legislators to carry your bill. Generally, your primary sponsors should be members of the majority caucus, but securing bipartisan support is also essential. It’s also very helpful to have a solid strategy for committee testimony and floor debate to help move your CP bill forward. Senator Julie Rosen (R) and Rep. Tara Mack (R) carried our bill. In addition, Rep. Erin Murphy (D-Fla.) spoke in favor of the bill, which helped counter opposition from the Minnesota Nurses Association (MNA). She is an RN as well as the former executive director of the MNA. Her efforts were key to the bill’s eventual success.
- Identify a single curriculum that must be approved by a widely accepted organization. The more specifics offered in your bill regarding training, certification and regulatory oversight, the more credibility it will add to your efforts.
- Count your votes before any committee hearings and floor debate. Don’t take any vote for granted, and remember that you need bipartisan support. One vote more than 50% in each body will get your bill to the governor’s desk. We had some traditionally solid EMS supporters in the House who, for political reasons, had to vote “no.” We understood and thanked them for their record of support for EMS over the years. Thank everyone who made your initiative a reality.
- Lobby the governor, too. Nothing is more frustrating than to secure legislative approval of a difficult piece of legislation only to have it vetoed.
- Finally, be patient! It often takes several attempts to turn a bill into a law.
Based on our experience in Minnesota, the concept of CP into state law goes a long way to spark interest in the EMS community, as well as among third- party payers. With reliable sources of revenue, CP can become a sustainable means of filling unmet patient needs and securing another revenue stream for your ambulance service.
