A Squirrels Perspective
Legislation Affecting EMS and Good Decision Making
By Alan Perry
July 24, 2013
I have been trying to understand the recent pushes in EMS toward Mobile Integrated Healthcare Practice (MIHP), Community Paramedicine and the function of Accountable Care Organizations (ACO’s). It appears I have been looking at it from the wrong perspective assuming that it has been driven internally by the healthcare community delivering on recommendations made by the National Highway Traffic Safety Administration (NHTSA), the Institutes of Medicine (IOM) and others which have spelled out clearly what steps need to be taken to integrate our healthcare system and move pre-hospital EMS into full partnership with other healthcare fields. While the power of these recommendations has moved many organizations and systems forward, they have failed to garner widespread adoption in the years since they were written. What is pushing the change now, at this late hour?
So I proceeded to work backward studying applicable portions of various programs, exploring the contents of pending legislation and recently enacted healthcare law. I will admit here that this process was not very methodical; I focused my attention on pieces that were overtly related to EMS and limited that material to what was most applicable to daily operations, financing and coordination with other healthcare organizations. I compare my actions, and that of many EMS systems, to that of the squirrel finding itself in the middle of the road and not being able to decide which way to run, therefore my focus has jumped around quite a bit and I still see the vehicle of healthcare system reform coming at me. I hope I can illustrate for my own benefit and others what the options and potential consequences are before we simply get plowed over by the changes before we can react. My opinions here are by no means “expert” and I encourage everyone to read the actual documents before taking any action or embarking on a substantial project.
The Patient Protection and Affordable Care Act
Enter Obamacare; Section 5101(d)(2) of the Patient Protection and Affordable Care Act (Affordable Care act) Titles III & V provide the impetus for change in payment strategies, development of ACO’s, community healthcare teams and coordinated care. The mandates are very broad and do not specify the “how” or “who” just the desired outcome, leaving the whole process up to substantial interpretation, funding is achieved through costs savings to successful participants. The intended effects of the Affordable Care Act are sweeping change to business as usual in the healthcare arena; Emergency Medical Services (EMS) is no exception. The mandated changes will occur by adoption of new and more effective delivery methods by the existing providers within each region or their replacement by new ones. This is not a suggestion; it is a flat out requirement. The federal government is using a carrot/stick approach, with financial rewards for performers and penalties for failure, such an approach will be game changing, spelling financial ruin for those who cannot adapt and creating much more competition, EMS systems will be no exception. This has created renewed interest in the ancient texts written by NHTSA and IOM, leaving me personally wondering if we may have waited too long. I can see control of EMS systems and organizations being slowly taken away and replaced with something we will have no hand in developing, unless we act quickly, deliberately and intelligently.
Current Legislation, House Bill 809
As I dug further I found there is more legislation in the pipeline which could help reduce some of the chaos created by the Affordable Care Act if it can be passed successfully. The apparent goal of House Bill 809 (HB809) is to the define the changes in EMS that will occur because of the Affordable Care Act, using existing studies and recommendations already prepared for this purpose by the EMS community. If it can pass, it will give EMS systems a framework, funding and protection, allowing EMS to evolve in the ways described in the EMS Agenda for the Future, EMS at the Crossroads and others. This legislation provides a much more specific, controlled, and funded way for systems to study and implement meaningful change that adheres to the requirements of the Affordable Care Act. The Bill is currently in committee, and according to GovTrack, has only a 2% chance of leaving there with a 0% chance of enactment. I am mystified that every EMS & Fire Chief out there is not beating down the doors of their congressman to get this bill through, could it be that they are unaware of the coming storm? I suspect that EMS system development has been placed on the back burner by many chiefs because of more immediate issues like shrinking budgets and meeting service obligations, both of which are important, but won’t matter when you are no longer in control of your system. You should realize that if this bill does not pass we don’t just go back to business as usual; it will be the chopping block. Perhaps we are waiting for Obamacare to be repealed, that has been attempted several times and has failed, and after examining the legislation, the reformation of our healthcare delivery system is necessary, but I still doubt mandatory healthcare will work.
Which way do we run?
So, can we act now? HB809 not only provides the specifics to bring field EMS up speed and integrate with the greater healthcare system, it provides funding, around $325,000,000 in grants for research, education, staffing, innovation, communications, integration and quality improvement, and keeps established high quality EMS organizations in control of the process. This legislation will do what no other has been able to; mandate a nationally recognized standard for education, certification and scope of practice. It will bring EMS professionals to a career milestone; national recognition of our healthcare credentials. It also places EMS under Health and Human Services instead of the NHTSA. As things are today, this is just a dream, it appears to be more prudent to start in our own backyard and start working on building some alliances and cooperative agreements with the rest of the healthcare community. I really hate reality TV, but the series “Survivor” brings to mind the type of politicking and ruthless deal making that may need to be done at this late hour to preserve the stability of current EMS systems. There are a few EMS systems out there that will surely avoid being road kill, they acted on the early warnings and recommendations for changes in EMS and pre-hospital healthcare delivery, sought and built alliances and made meaningful changes while maintaining control. These systems now serve as models for the rest of us who find ourselves on that yellow line with no clear direction to turn.
HR 3590, Patient Protection and Affordable Care Act
HR 809, Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013
National Academies Press, Best Healthcare at Lower Cost
National Academies Press, EMS at the crossroads
National Highway Traffic Safety Administration, EMS Agenda for the Future: A Systems Approach
University of Exeter School of Psychology, Animal Cognition