Lead Federal Agency for EMS? What should it do? What should it NOT do?

So.....at the JEMS/EMS TODAY conference, there were a number of sessions, forums, and side meetings where the role of the federal government in EMS and discussion of a "lead federal agency" for EMS were discussed.  There is a bill kicking around (in the draft stages) called the "Field EMS Act", and a white paper prepared by the National EMS Labor Alliance and the International Association of EMS Chiefs.

 

Right now, there is EMS activity spread across the Department of Transportation (NHTSA), the Department of Health and Human Services (HRSA, SAMSA, ASPR, CDC), the Department of Homeland Security (US Fire Administration), the Department of Defense, etc.  There is a "Federal Interagency Committee on EMS" (FICEMS) that is supposed to "coordinate."  Yet the efforts of the various federal agencies look like an uncoordinated, unprioritized, unfocused collection of satellites and space junk - no coordination visible.

 

So, what do you think?

 

What role(s) should the federal government play in EMS?  What roles should the federal government NOT be involved with? 

 

Do you favor EMS living in a particular EMS agency?  If so, why?

 

Or is it more important what the lead federal agency can DO for and with EMS than which cabinet agency EMS lives in?

 

I'd like your thoughts, well-reasoned and considered, so that I can use them as input in to the various policy forums where I have access.  Thanks.

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The "strength" of a federal agency comes from its statutory mandates and the amount of money provided to it.  I don't think that strength is an inherent characteristic of any particular federal agency - if it's statute were strong enough and it were provided with enough funds, the FDA or the IRS could be the lead agency for all that I care.  NHTSA has been the de facto lead agency for 40 years, but it has never been provided with a strong statute or much money (probably because we in EMS have not known what to ask for, or we haven't asked for it very effectively).

 

Rather than "who," how about some "what"?  What do we want our lead federal agency to DO that someone is not doing now?  [Do you have any idea what the various federal agencies are doing about EMS right now?  If not....]

 

What do we, as the EMS community, WANT in the way of federal leadership or federal services?

Do we really want a single bureaucracy controlling all aspects of EMS at the federal level?

A bureaucracy that conceivably have the intrusiveness of DHS, the efficiency of the Postal Service, the compassion of the IRS, and the resistance to special interests of the DoD or the DoAg?

 

The defacto fragmentation of EMS interests at the federal level mirrors the fragmentation of...well, EMS as a whole. 

 

What could be done to improve things - one agency could be a good start, but there would be an inevitable battle between DHS and DHHS to control it, due to the fact that EMS includes aspects of both public safety (DHS) and public health (DHHS).  

 

There is the possibility of creating an independent bureau with shared funding and oversight from two different cabinet-leved Departments (DHS/DHHS, again) but the problem with that type of bureau is that they are the favorite son when successful but they are orphans at budget time or when a problem that might involve distribution of blame "up food chain" occurs.

 

With the fact that it took a watershed national crisis like the 9/11 attack to create DHS and adding funding costs isn't a popular concept among a lot of the public and many legislators, I'm not sure we really have a shot at putting all of our eggs in one basket, even if a compelling and unified case for doing so could be agreed upon.

Ideal spot would be HHS; NHTSA (as the current Field EMS Bill text suggests) would be my second choice.

 

What it should be able to do:  act as a best-practices clearinghouse, develop upper-level courses akin to USFA courses (including leadership & management stuff), lobby CMS for payment standards (the quickest way to bring every state on board with a national education standard would be to quit paying for people who don't meet said standard--God knows the DOs wouldn't still exist if they didn't show their equivalency to the MDs, making them eligible for Medicare), write position statements, distribute grant money as available (for research, best-practices demonstration projects, etc), and handle all of the stuff that's currently spread everywhere else, lobby NIH for an Institute of Emergency, Out of Hospital, and Disaster Medicine.

 

What it shouldn't be able to do:  directly set education requirements, certify providers, write tests, make up static curricula that only change every decade or so, dictate local delivery models, be subject to Congress' whim.

Thanks, Doc....I think you're on the track I hope to see travelled -- except that EVERYBODY is subject to the whims of Congress.

 

Ben, my informal poll says that you are out-voted.  The EMS community wants a lead federal agency.  NOTE that nobody said "control" anything - everyone including the feds know that all EMS is local EMS - we're looking for a LEAD AGENCY instead of a potpourri or an interagency committee.  And we probably won't alter the fundamental structure of the federal government if/when we get one.  We are striving for something at the A level (agency, like HRSA, or administration, like NHTSA or HRSA), but it will be in one cabinet-level department.  And I submit that it doesn't much matter which one, provided that we have things well-specified in the creation/authorization bill.  So (since I think you're smart guy and can give me some good input), I'll ask again - what should such an agency DO (for us?) and what should it NOT do (to us?)?.

 

I'm hoping one piece will not be "lobby CMS" for anything - rather "direct CMS" to contribute financially to the EMS system in an appropriate manner on behalf of its beneficiaries.

 

Go ahead.....



dr-exmedic said:
God knows the DOs wouldn't still exist if they didn't show their equivalency to the MDs, making them eligible for Medicare

To be fair, California so did not help the MDs cause with the 1960s merger. There's nothing quite like saying another medical profession is not equivalent by giving them your degree for $60 and a weekend seminar.

I'd like to see a lead agency at the Federal level and I agree with most of what has been written about things that should (and should not) be part of the scope of that agency.

 

I hope this doesn't open any old wounds, but I worry about where the new agency, if created, will be located, and I worry about the makeup of the leadership.  The fire service, after decades of ignoring EMS, now wants to dictate the design, education, and funding of emergency medical services.  I think the fire service would bring many good qualities and ideas to the table, but I fear they'll work to change EMS so that the fire service with either become the sole provider of provide EMS in the community or they will exclusively monitor and control the third-service agency or private company that does.  The 'white paper' written a few years ago by the IAFF/IAFC wants that very much.  The American Ambulance Association, the primary industry representative and lobbying group for private providers, seems to be mainly interested in billing-related matters and getting third-party reimbursement issues addressed for their members.

 

We must reduce the fragmentation in EMS and one lead agency at the Federal level would be a great start.  But we need that new Federal agency to be able to synthesize the needs of the fire service, third service, and for-profit private providers (including the volunteer services) and get us all going in the same direction.  We also need to address and synthesize 9-1-1 emergency service with non-emergency medical transportation and the special needs of the aeromedical and hospital based MICU services. I'm not making a value decision on which type of 9-1-1 service model is best for a given area, but our new Federal agency shouldn't support the exclusive agenda of one type of provider and shoehorn the other guys into that mold or out of the business.  I think this will be one of the most difficult tasks that legislators will take on if they get serious about a lead agency for EMS.

 

Hope I didn't get the thread off track!

 

-Rick

I used to think this was important. Not sure I do anymore. I may be wrong, but I don't really see how the Federal government is even on the map as it is. NHSTA really isn't doing...::blink::...FICEMS...anything meaningful?

 

The reality is that EMS is a state thing. Travel this country and look at the variety of EMS systems, state regulations, etc and you'll see this right away. The practice of medicine tends to be regulated state to state. Drug regulation, medical devices (sometimes), and research are the purview of the federal government. It's only been recently that Dr. Collins (genome pioneer and current administrator for NIH) proposed a lead federal research center for drug development. Add in some special interest of law makers (abortion, stem cells) and there you go. The biggest reason that the federal government has as much say as it does is Medicare, the largest payer of health services. The power of the purse.

 

Could the federal government technically produce a lead federal agency with teeth, the right goals, and some money? Yeah. BUT how successful would they be? Too many special interest would make sure it was watered down or have ulterior motives.

 

If there was one, I think it should be under HHS. I think it should have the power to set a minimum standard for both education, practice, etc. It should consist of an advisory board of some sort, consisting of experts from across the country. It should be lead by professional EMS leaders, not physicians, but in consultation with physicians (obviously).

 

Good discussion and very interesting. Sorry if I seem pessimistic.

Skip,

 

I haven't forgotten this - I just don't have time to come up with something comprehensive and coherent due to a very busy week.  When I have some time, I'll stop mulling it over and post my ideas.

 



Skip Kirkwood said:

Thanks, Doc....I think you're on the track I hope to see travelled -- except that EVERYBODY is subject to the whims of Congress.

 

Ben, my informal poll says that you are out-voted.  The EMS community wants a lead federal agency.  NOTE that nobody said "control" anything - everyone including the feds know that all EMS is local EMS - we're looking for a LEAD AGENCY instead of a potpourri or an interagency committee.  And we probably won't alter the fundamental structure of the federal government if/when we get one.  We are striving for something at the A level (agency, like HRSA, or administration, like NHTSA or HRSA), but it will be in one cabinet-level department.  And I submit that it doesn't much matter which one, provided that we have things well-specified in the creation/authorization bill.  So (since I think you're smart guy and can give me some good input), I'll ask again - what should such an agency DO (for us?) and what should it NOT do (to us?)?.

 

I'm hoping one piece will not be "lobby CMS" for anything - rather "direct CMS" to contribute financially to the EMS system in an appropriate manner on behalf of its beneficiaries.

 

Go ahead.....

Nathan said:

Require Med radios in all ambulances in all states.

Don't most states already require ambulance-to-hospital communication in every ambulance? Or am I not understanding you?

I prefer a stand alone EMS agency.  To start and in addition to some of the other suggestions, I would expect this agency to establish standards for:

  • staffing including supervisory span of control;
  • training, education, and credentialing;
  • response times;
  • service coverage; 
  • quality improvement programs; 
  • technology; 
  • communications; 
  • ethics and codes of conduct; 
  • billing; 
  • multiple casualty, disaster and terrorism response and operations; 
  • ambulance and personnel safety; 
  • required equipment; 
  • types of ambulances;
  • continuity of operations.
Kathy
A federal agency to oversee EMS; an interesting topic. Let’s see. We have federal recommendations for the construction of ambulances so that we can display the Star of Life. And we have the NFPA (with the emphasis on the F) pushing it’s version of recommended standards for construction of ambulances. We have 51+ state and provincial statutes and codes that direct how, who and what is required for and of EMS with limited commonality of form and focus. We have real college based training programs, vo-tech based training programs, pseudo-college based training programs and certificate mill based training programs trying to provide a “standardized” training curriculum while seeking accreditation from groups and organizations with different criteria.

We have new equipment and tools at every seminar or meeting being marketed by a plethora of vendors that look cool but have little medical research or little evidence of best practices supporting their use on real people. We fill out trip tickets or “patient care reports” on either paper forms or in a vendor produced software program that differ in information and data gathered, where it goes or how it’s used. We still have EDs that smile, take our documentation and toss it in the circular file of what they view as unimportant and irrelevant.

We have a “white paper” from a transportation agency published over 40 years ago that alerted the consciousness of the country to the realization that some sort of standardization of treatment of the sick and injured outside of the hospital is needed. We have volunteer providers, private providers, third service providers and fire service providers still fighting amongst themselves over whom does it best, the quickest and the cheapest. We have a federal agency tightening reimbursement rules and regulations based on hospital, clinic and doctor office practices with little regard for the input from and the uniqueness of EMS providers. And still, almost 10 years after September 11th, we have disjointed and patchwork communications between emergency public service agencies and organizations.

Do we need a federal agency to oversee EMS? Interesting topic.

Skip's question continues to be relevant. In fact, those are the two points FICEMS Chair Alexander Garza, MD, asked stakeholders to answer during yesterday's teleconference.

 

Check out http://www.jems.com/article/administration-and-leadership/ficems-ho... to see what Skip and other stakeholders from various national and regional organizations said.

 

Then tell us, if you think EMS DOES need a lead federal agency, what do you think it should and shouldn't do?

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