Commentary –

Considering Changes For State EMS Providers

By Julia Wasserman

The General Assembly’s Legislative Program Review and Investigations Committee is setting the stage for a thoughtful debate in the next legislative session on the provision of emergency medical services (i.e. ambulance service) in the State of Connecticut.

An EMS study was initiated at the outset of the 1999 legislative session in the wake of reported incidents in the Hartford area where ambulances were slow in responding to calls or did not respond at all. The program review committee proposed legislation during the 1999 session to address these concerns, but the bill was not enacted.

In the first phase, the committee concluded that the state should retain the existing regulatory scheme where a specific provider (commercial ambulance company, volunteer ambulance corps, fire department, etc.) is designated to respond to all 911 calls in a town or other geographic area. However, the committee recommended steps to improve state and local government oversight of the performance of these EMS providers.

The failure of the 1999 legislation can be attributed in part to opposition from municipalities. Local officials objected to proposals to require the development of local EMS plans that would be subject to review and approval by the state, and to a requirement that towns collect, compile and report data on the performance of EMS providers. Many towns viewed the reporting requirements as an unfunded state mandate.

The second phase of the study goes beyond the initial questions raised about ambulance response in the Hartford area. At the risk of oversimplification, the latest recommendations can be summarized as proposals to help control the cost of providing ambulance service while preserving the high quality of health care that we receive from these services.

Specifically, the committee staff report on the second phase of the study recommends:

*Streamlining the rate setting process so that only ambulance services that charge above a threshold amount and which want to raise their rates would be required to undergo the annual rate review by the state Department of Public Health.

The staff found that detailed annual rate review is not keeping costs down. Between 1994 and 1998, these costs rose at double the rate of increases in the Consumer Price Index (CPI) for health care and transportation. The staff report suggests that requiring ambulance services to go through this costly and cumbersome process each year in fact gives them an incentive to seek higher rates. It is important to note that the state sets only maximum rates, and that ambulance services do not, in fact, receive the maximum rate for most of the calls they handle. Medicare and Medicaid, which pay for roughly two-thirds of all calls, are not subject to state regulation. They set their own, lower rates. Many health maintenance organizations have negotiated discounted rates they pay for the patients they cover.

*Introducing controlled competition into the ambulance industry by allowing qualified not-for-profit services to provide and charge for non-emergency ambulance trips.

Only commercial services are now allowed to charge for non-emergency trips, such as the routine transport of a patient from a hospital to a nursing home. The staff estimates that some 40 percent of ambulance trips are non-emergency, yet only nine commercial operators can now charge for these calls. By contrast, there are 170 services that handle emergency calls, which include the volunteer ambulance corps, municipal and hospital-based groups that are responsible for answering emergency calls in the vast majority of Connecticut’s cities and towns. Again, the recommendation envisions introducing an element of controlled competition, with proper safeguards for patient health and safety. Non-commercial services would have to have at least two ambulances, handle at least 1,000 calls per year and have adequate staffing to maintain their emergency service before it could be approved for non-emergency work. Even then, they would be allowed to provide this additional service only in the area where they are designated or authorized to provide emergency service.

*Eliminating the state’s “determination of need” process that ambulance services must go through before they can add new vehicles or open branch offices.

This detailed review would remain, however, for those wishing to begin a new service or for a free service that wants to begin charging. The costs incurred by adding ambulances or opening branches would still be reviewed by the state, only as part of the detailed rate process when the ambulance service requested higher rates.

*Keeping better track of the performance of ambulance service throughout the state.

This is the thrust of one of the recommendations made in the first phase of the program review study of emergency medical services, and it has been revised to address many of the objections that helped to bring about the defeat of the 1999 session legislation.

Ongoing collection of statistics regarding the number and nature of all ambulance calls is critical to ongoing efforts to monitor the performance of emergency services in Connecticut. The first phase of the program review study was prompted by the media reports of situations where ambulances took too long to respond to calls or did not respond at all. The first phase recommendation placed much of the responsibility for collecting this data with the towns, which objected to what they considered an unfunded state mandate. The latest recommendation places the responsibility with the state. This would be financed with money already available in the account that was established to pay for the creation of the system that now allows anyone in Connecticut to reach emergency help by dialing 911.

*Requiring all 911 communications centers to provide emergency medical dispatch, where the dispatcher sending the ambulance would gather critical information and instruct the caller on how to assist the patient until the ambulance arrives or transfer the call to someone who can provide this assistance.

Again, the cost of training dispatchers to make this critical service available throughout Connecticut would be borne by the state. This funding, too, would come from the 911 emergency service account.

Emergency medical dispatch can save lives. All commercial ambulance services and many others already provide this service. The staff analysis found that on average this service adds less than two minutes to the length of a call for service, and that some providers already do so with dispatch centers staffed by a single person.

(Julia Wasserman is state representative in the 106th District and co-chairman of the General Assembly’s Legislative Program Review and Investigations Committee.)