Remarks
Informational Meeting
Initiatives and Legislative Goals
House Veterans Affairs and Emergency Preparedness Committee
March 7, 2017
Chairman Barrar, Chairman Sainato and members of the House Veterans Affairs and Emergency Preparedness Committee,thank you for this opportunity to come before you today to discuss initiatives and legislative goalsof the Emergency Medical Services (EMS) provider community of this Commonwealth.
My name is Dean Bollendorf and I am the President of the Ambulance Association of Pennsylvania (AAP). I am also the Vice President of Healthfleet Ambulance. Accompanying me today is Don DeReamus, Board Member and Legislative Chair.
Merriam-Webster defines a “crisis” as an unstable or crucial time or state of affairs in which a decisive change is impending; especially one with the distinct possibility of a highly undesirable outcome. The AAP has been privileged to come before this Committee, members of the General Assembly and the Administration countless times over the last decade. We have repeatedly forewarned that the EMS System in this Commonwealth is in crisis.
Once again, we are telling you that the EMS System; comprised of YOUR municipal or community ambulance service, aero-medical ambulance service and non-emergency ambulance service hasno sustainable funding mechanism to prevent a public safety crisis! Without a significant change in funding and reimbursement this impending crisis will deteriorate into a system collapse.
There is no perfect business model for the EMS System in this Commonwealth. The System, predominately volunteer in the 1980s and one that relied solely on donations, has transitioned to combination volunteer/career, fire-based or municipal services due to theincreasingstatutory and regulatory burden and decline of the volunteer workforce.
Services seek and rely on an adequate billable emergency call volume or a combination of emergency and non-emergency billable transports to fund the cost of readiness, personnel, equipment and supplies to sustain operations. The volunteer President and EMS Captain have been supplanted by full time administrators employed to run a business with capabilities to include human resources, marketing, compliance, quality assurance and accounts receivable and payable. Few services receive municipal financial support or tax revenues to subsidize these life saving operations.
The EMS provider community has been victimized by misconceptions that ambulance services bill and receive full payment for all services. Overall reimbursement from every payor mix for service has not increased nor offset the cost of regulatory requirementand the fixed costs associated with running a medical treatment and transportation company.
Specifically:
1.Medicaid reimbursement has not changed since 2004 and the mileage reimbursement has been essentially eliminated reimbursing less than 30% of the cost of providing the service
2.Medicare rates are based on a fee schedule instituted in 2002, are 6-17% below the cost of service and also carry a yearly deductible and 20% co-pay
3.Private insurance carriers now reflectAffordable Care Act allowed charges or in-network provider rates, a percentage of the Medicare rate, or the Usual, Customary and Reasonable (UCR) charges in your local area. Under the ACA, they have cost shifted reimbursement to the beneficiaries with high deductibles and high co-pays.
4.Reimbursement for automobile insurance and Worker’s Compensation is 106% and 113% of Medicare respectively and does not supply relief to support the System
When you review the payor mix for most EMS Agency emergency responses you find that 50-70% of all reimbursement they receive come from either Medicare, Medicaid or a government contracted Managed Care Organization.
From a business model perspective when 40-60% of all patient encounters come from a payor who remits 6-17% below the cost to provide the service, 10-30% of all encounters come from a payor who remits 30% of the cost of providing the service and the remaining encounters pay the same of slightly more; how is a ambulance service expected to sustain itself? At least 42% of the Commonwealth’s population has either Medicare or a Medicaid as their health insurer.
The EMS system has come to a point where escalating costs have met declining reimbursement head on. Consistent complex and inadequate funding is creating a cascading failure of ambulance services of all sizes and corporate structure. The result of this failure will be limited access to care resulting in increased response time withrelated increases in morbidity and mortality.
The EMS System must be seen as what is has become – Mobile Integrated Health Care – the emergency room on wheels and in the air, the original healthcare safety net. EMS must not and should not be treated as a transportation service. Unlike other healthcare professionals we are required by statute to respond when dispatched by public safety answering point. We are required by statute, Commonwealth protocol, standards of care and ethics to provide emergency care and transportation without regard for payment.
The EMS System is also the carrier by ground and air for the movement of critically ill and injured, rehabilitating and convalescing patient between hospitals, specialty hospitals, clinics and other healthcare facilities. The collapse of the EMS System would strand patients needing rapid movement to higher levels of care and just simple transportation to basic procedures and treatments.
Finally, EMS like a hospital emergency room, is a 24/7/365 service and must be staffed accordingly whether answering 2 calls per day or 50 calls per day. We do not receive payment when we assess and/or treat a patient who refuses transportation to an acute care facility. This does not occur anywhere else in healthcare.
The AAP participated in the development of the Senate Resolution 60 reboot and Senate Resolution 6 release this Session. The result of this effort produced the selection of sixteen priorities for Fire and EMS. Of these sixteen priorities, four are specific to the EMS provider community and listed by importance to include:
- Medical Assistance reimbursement rate increase and restoration of the mileage payment
- Reimbursement for treatment and/or assessment without a transportation component
- EMSOF fine increases to fund the EMSOF program and provide direct and targeted training in underserved and struggling rural areas
- Parity of funding in the Fire Company and EMS Grant program as EMS receives 12% vs. Fire receiving 88% of available funds
The AAP realizes that the Commonwealth is under tremendous budgetary constraint with a reported loomingdeficit. We have respectfully requested assistance with Medicaid reimbursement for twelve years, each year being told now is not a good time. The EMS System has run out of “a good time”. If another budget passes without an increase in the Medical Assistance rate and the return of a fee for “loaded mileage” as the federal government intended, many of our services will not be here next year to be told now is not a good time.
Thank you for the opportunity to offer these remarks. We will answer any questions at such time deemed appropriate by the Committee Chairs.
“When you reach the end of your rope, tie a knot and hang on.”
Abraham Lincoln
The AAP is a member organization that advocates the highest quality patient care through ethical and sound business practices, advancing the interests of our members in important legislative, educational, regulatory and reimbursement issues. Through the development of positive relationships with interested stakeholders, the AAP works for the advancement of emergency and non-emergency medical services delivery and transportation and the development and realization of mobile integrated healthcare in this evolving healthcare delivery environment.
Our nearly 250 members are based throughout the Commonwealth and include all delivery models of EMS including not-for-profit, for-profit, municipal based, fire based, hospital-based, volunteer and air medical. Our members perform a large majority of the patient contacts reported to the Department of Health.