Feedback Form for the Draft National Framework Document

The project team thanks those that have provided input through the public survey and the meetings in California, New York, and Washington, D.C. We also appreciate your continued participation and input on the recommendations for National Framework Document for Promoting Innovation in EMS. Please scroll down as you fill out the form and when you are finished, please click on the blue "DONE" button at the bottom.

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* 2.
States are encouraged to create a legislative and regulatory environment that both enables early adoption of evidence-based best practices and promotes innovative practices in EMS.   An ideal framework would adhere to the following priniciples:
 
a) State statutes and regulations should be silent about the practice locations where EMS may provide care and the transport destinations of patients assessed and managed by EMS providers (EMTs, AEMTs and paramedics).

b) Practitioner levels and services should be be based on the floors set by nationally recognized minimum standards for EMS. State regulatory bodies may build upon that framework while considering:

    i) The extent to which current provider levels provide the EMS provider with sufficient knowledge and skills to provide a minimally acceptable standard of care to all patients;

    ii) The unique needs of populations within their states that often do not have access to medical services due to income, transportation, location, or other needs;

     iii) The importance of ensuring patient safety and adequate physician oversight for EMS personnel and practice.

c) Scope of Practice ought not be strictly defined in statute so as to preserve flexibility of regulatory entities responding to emerging needs of the population being served.  Where scope of practice is already strictly defined, legislative and regulatory bodies should examine and address obstacles to innovation or unmet societal needs that result from current policy.

d) States should adopt a regulatory model that also allows communities to pilot and evaluate the success of innovations that stem from grassroots initiatives.  States should empower their regulators with the appropriate flexibility to investigate promising innovations.

e) Quality assurance activities and related communications should be protected from liability proceedings.

 
Rationale: As the traditional role of EMS providers evolves to meet the needs of local communities and the changes required by healthcare reform, legislative and regulatory barriers can prevent or delay the adoption of promising models of care delivery.  While innovation can and often does occur despite these limitations, the EMS community should seek to establish a more favorable legal and regulatory environment that enables and encourages both new innovation as well as implementation of new treatments and care models that have been proven elsewhere, all while maintaining the state’s duty to protect the public. 

Certainly, EMS agencies are encouraged to consider pursuing innovation within the realm of acute care services that are less likely to run afoul of current statute and regulation, and to think creatively about ways to implement new models of care into existing frameworks.  For inspiration or scientific evidence, one might look to academic journals, trade magazines, regional and national conferences, etc.  For assistance on understanding the limits of what is authorized in their state, one might refer to the HHS-ASPR sponsored study entitled “Expanding the Roles of Emergency Medical Services Providers: A Legal Analysis,” or to their state Office of EMS, or seek a determination from their Office of the Attorney General.

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* 3.
State entities and health plans should recognize that new and future EMS models may consist of both medical transportation and healthcare delivery services and should maintain favorable and flexible reimbursement practices for both types of services.

Rationale: One of the most fundamental barriers to innovation is the requirement of transportation, often to an ED, for an EMS claim to be paid.  This financial barrier, discussed in greater detail in the financial section, may in fact require a legal / regulatory solution.  At the federal level, CMS currently does not authorize payment due to language in Title 18 of the Social Services Act that describes an ambulance service benefit “where the use of other methods of transportation is contraindicated by the individual’s condition.”  This has been narrowly interpreted and codified in federal regulation 410.40.  Although Medicaid is administered by the states and have a great degree of flexibility, especially through the 1115 waiver process, states are not able to circumvent this narrow interpretation. 

However, there may be other ways in which state and local actors and encourage favorable and/or flexible reimbursement practices and thereby unleash innovation:

1) In the state’s power to regulate insurers, states should consider methods of promoting reimbursement for innovative models of EMS care.

a) health plans might be required to cover EMS assessment and treatment regardless of whether the patient is transported.

b) Regulators could require reimbursement for specific services such as paramedic home visits for specific types of patients

c) The state could use its convening power and bring health plans and EMS agencies together on a periodic basis to either exchange data or explore new service offerings.

2) Payment and reimbursement could be addressed in New or Revised Legislation as this will address revenue streams and sustainability.

a)  legislators / regulators could alter the definition of EMS providers to dissociate their services from the “ambulance” or the “transportation benefit” which may make them eligible for reimbursement from Medicaid.

3)  Increase the authority and possibly budgets of State EMS offices and enable them to play a more active role in the encouragement, vetting, authorization and direct funding of pilot programs.  Most state EMS Offices are not currently in a position to regulate healthcare payers nor to self-propose legislation for payment practices that embrace innovation.  While states have an obligation to protect the public they also have a responsibility to assure that public funds are expended wisely. By empowering these public officers, it would allow for both more rapid testing of Innovations and stronger ability to affect both public protection and wise spending

  Strongly Disagree Disagree Neutral Agree Strongly Agree
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* 4.
Hospitals that own and operate ambulance services subject to EMTALA should amend their bylaws to authorize EMS personnel in the field to perform or facilitate the necessary medical screening examination thereby enabling alternative destinations or treat and release protocols. Regional protocols should be amended to explicitly direct EMS to transport patients to non-emergency departments if they meet appropriate criteria or require medical contact with a physician not employed or affiliated with the hospital that owns the ambulance service.

Rationale: Either or both of the above approaches can help comply EMTALA requirements  and avoid liability and create a regulatory environment favorable for innovative models of care in which patients cared for by EMS could be either not transported or taken to destinations other than an emergency department.

  Strongly Disagree  Disagree Neutral Agree Strongly Agree
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* 5.
Portability: EMS personnel should have the ability to relocate and work in a new jurisdiction with only the minimal level of process necessary to assure the safety of the public.
 
Rationale: During large scale emergency situations, there is often a need to quickly move emergency personnel resources from one state to another (or one jurisdiction to another). As a consequence of our lack of standardization of education, licensure, and protocols across jurisdictions, it is difficult for EMS providers to migrate across borders. Independent of the variation between states, there seems to be excessive bureaucratic hurdles and insufficient planning on the part of many localities to consider how to rapidly integrate EMS providers across regions within the same state or across state borders.  All of this limits the flexibility of EMS resources both during disasters, as well as for more routine purposes such as maintaining a fluidity of our industry’s labor resources. 

It would therefore be prudent for states to take action to enable greater portability of EMS licensure.  Thankfully, the National Association of State EMS offices has developed model compact legislation known as REPLICA (Recognition of EMS Personnel Licensure Interstate CompAct).  By adopting this legislation, states can take a significant step forward to overcome this barrier to providing good quality care in times of crisis.    Of note, this requires the use of the National Registry of Emergency Medical Technicians examination as a condition of issuing initial licenses at the EMT and Paramedic levels.

NASEMSO should work to streamline mobility between the states and territories, and between the states and Canadian provinces. The various state exceptions to the scope of practice model should be catalogued. States should formally recognize EMS personnel currently licensed in another state as having already met entry level training standards and after completing a state-specific background investigation (if appropriate) issue a restricted license based on the national scope of practice model (or an unrestricted license in the case that the state’s scope of practice is limited to the national scope of practice model). Using the catalog of state variations, an unrestricted license should be issued when a medical director deems the licensee competent in the state’s individual variation. NASEMSO should work with the Canadian Organization of Paramedic Regulators (COPR) to create an interface that recognizes the differences between the various state scopes of practice and the provincial variations so that mobility between the two countries is similarly unimpeded.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
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* 6.
States or localities requiring a Certificate of Need, or with designated primary agencies should adopt a policy that allows secondary agencies to offer healthcare services that the primary agency is not willing or able to provide.
 
Rationale:  To our knowledge, approximately 12 states require a certificate of need (or similar) to provide EMS services, and a number of smaller jurisdictions designate a primary service area in which other EMS services may not enter or care for patients.  While this can be an important tool for accountability and protection of the public, it can also be a barrier to new entrants into a given market which thus has a negative impact on innovation.  By transforming to a model where the primary service has a “right of first refusal,” new entrants can potentially offer new services, such as non-emergent visits, telemedicine, or services integrated with home care, hospice  care, and others when the established service is not willing or lacks the capability to do so.  While, a new entrant would face efficiency barriers by not being able to flex resources, it would create some pressure on stagnant agencies to consider new collaborations or explore innovative models of care.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
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* 7.
EMS leaders should take concerted action to reduce or eliminate fraud within the industry thereby improving allocation of precious resources and enabling innovation.
 
Rationale:  While the EMS industry has long sought reimbursement reform to detach payment from transportation, one of the greatest fears among CMS and other payers is the potential for fraud and abuse in an industry already known for significant amounts of it.  Successive Office of the Inspector General reports have cited high degree of overpayments, particularly on the interfacility / non-emergency side. 

Undertaking this recommendation will serve two main goals.  First, to communicate the industry’s willingness to work collaboratively with CMS and AHIP to combat the fraud and abuse issues in the ambulance industry.  Second, working together, the ambulance industry, CMS and AHIP may be able to determine economic models for testing that alleviates the perverse incentive for payment based on transport, to a model that rewards quality service and program integrity.

· This is an impediment to reimbursement reform

-Actors should approach CMS and America’s Health Insurance Plans (AHIP) to establish a joint task force to design and implement anti-fraud and abuse initiatives.


· Must address fraud because the 1,2,3 of: decoupling, developing skills, and being able to innovate, won’t happen until this is addressed

  Strongly Disagree Disagree Neutral Agree Strongly Agree
Do you agree with this recommendation?

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