A Troubled State, Part 4: What Can We Learn from Iowa’s Experience?

Over the last few months, we’ve explored a number of significant concerns with EMS systems as they exist today. We’ve built on the issues raised by the investigative reporting of the Des Moines Register, but we’ve clearly seen that the issues raised in Iowa are national issues, ones that exist in pretty much every state in the country.

It is time for reform in EMS. Many of our EMS colleagues will jump right to a national solution and bemoan the lack of a “lead federal agency” for EMS, but those who do so will either not have studied, or not have an appreciation for, the notion of the limited roles of the federal government. Like most issues not specifically addressed in the Constitution of the United States, or inferred from it by the Supreme Court, EMS is a state issue.

Before I get too deep in to this discussion, I’d like to reiterate a point that I’ve made many times before. Emergency medical services, or EMS as we know it, is more than just “ambulance service.” While others have embraced broad definitions that include everybody from the telephone company to responders, from the trauma surgeon to the rehabilitation hospital, I take a bit narrower view. When I discuss EMS I’m talking about outside-the-hospital care provided to people who need it and who ask for it—pre-arrival “EMD” instruction; non-ambulance and ambulance response to requests for medical aid; the care provided, and (sometimes) ambulance transportation to a hospital. It also includes things like community paramedicine; prevention of 9-1-1 calls; reduction of injuries and control of illnesses; medical support to other public safety functions (law enforcement and fire); and planning and preparation for large community events, scheduled or unscheduled.

How We Got Here

It will soon be 50 years since the 1966 release of the white paper, Accidental Death and Disability: The Neglected Disease of Modern Society, by the National Academies of Science and the National Institutes of Health. This paper, plus early work in Ireland by Frank Patridge, MD, in New York City by William Grace, MD, of St. Vincent’s Hospital, in Miami by Gene Nagel, MD, in Honolulu by Livingston Wong, MD, and his colleagues, and in Seattle by Leonard Cobb, MD, set the stage for development of EMS systems as we know them today. These systems have evolved from experiments, novelties and a “hobby” for many, to evidence-based practices that have been well-documented to reduce morbidity and mortality, to reduce suffering and to serve as foundations for the next generation of out-of-hospital, advanced medical services.

Unfortunately, the legislative and societal structure in which modern EMS systems exist has not kept pace with the times. This is nothing new—the law lags behind social and technical developments in many ways. What exists today, in terms of laws, rules and state government involvement in EMS, is a product of days gone by.

While the early, pilot paramedic programs were being conducted, the white paper was being written and Jack Webb and Bob Cinader were working on the scripts for the first episodes of “Emergency!,” the concept of an EMS system was pretty much non-existent. Most of the United States was served by privately-operated ambulance services with little or no medical capabilities—far below even today’s basic life support standard. In 1960, only six states had standard courses for rescuers, only four states regulated ambulance design specifications and fewer than half of all EMS personnel had received even minimal training (e.g., American Red Cross first aid).^1,2 Carrying oxygen onboard an ambulance was a novel thing—“yellow pages” advertisements of the day proudly announced “Radio Dispatched, Oxygen Equipped.”

Into this environment sailed the federal government. Regional medical programs (RMPs), created in 1964 under the administration of President John F. Kennedy for other health promotion purposes, began to focus on the issues raised in the white paper. The Highway Safety Act of 1966 focused on EMS as a transportation-related issue and assigned responsibility to the U.S. Department of Transportation, but in 1973 the Emergency Medical Services Development Act moved the EMS focus to the U.S. Department of Health, Education and Welfare (now DHHS). Federal money flowed to the states and states created EMS offices, usually in their health departments, to receive and distribute the federal money and implement the federal mandates, which involved training EMS providers, developing communications systems and similar developmental efforts. While the federal funds dried up in 1984, the state EMS offices remained, usually operating under state law mandates and the same missions that were conceived and enacted prior to 1984.

Those state laws and EMS offices continue today, in many cases with only the slightest modifications to the laws that created them. However, their legal mandates, their structures and their funding streams in most part remain focused on developing systems that are already pretty much developed.

Today’s EMS Policy Environment

Since the pilot project days it’s been clear that EMS progress, and EMS service delivery, occurs at the local level. Today’s medical care models and developments suggest health services are best organized and coordinated at a regional level, but that theory has had limited success in America’s generally home-rule and often competitive environments. Every town, city and county has “its way,” and there is little political will to force top-down change on our communities. There may be a “better way,” but it’s not going to be forced upon us.

An EMS Environment for the 21^st Century

If EMS is going to undergo transformation at the state level, change will have to come from within—driven by EMS people who organize, lobby state legislatures for change and drag EMS in their states into the 21^st century by the scruff of its neck. If this movement should develop, here are some changes I would recommend:

• Most important of all, make the existence of an EMS system (9-1-1 EMD, medical first response and ambulance service) a mandatory function of county governments across the state, with a single standard of care for each county. In some states, where populations are sparse or small, multi-county systems should be encouraged. Along the way, remove the option for sub-county municipalities to opt in or opt out from the system. Require each county, by ordinance, to establish the standard of care and other requirements, such as response performance. Utilize a “certificate of need” or franchise process to regulate the proliferation of commercial ambulance services serving the non-EMS ambulance transportation needs of the county.
• Abolish the state EMS office as we know it today. If system development is still required (and it probably is in some states), place that responsibility squarely in the state’s health department, with necessary funding attached. Establish, instead, an independent board to license and provide professional oversight to paramedics (really, EMS practitioners at all levels), made up of paramedics with some “consumer” input. This board should have at its disposal a staff of trained investigators to conduct its work. What about licensing and inspecting ambulances, you say? Haven’t the states always done that? Yes, they have. While once upon a time it was perhaps a necessity, there are plenty of other forces at work out there—local medical direction, professional management, plaintiffs’ attorneys, you name it. The notion that a state inspector has to count the number of bandages on an ambulance or harm will come to the patients is simply no longer valid. This has been, for at least 20 years, a waste of energy and an exercise in micro-management, nothing else. If there is a need for oversight, vest it at the county level and be done with it.
• Require, as a condition of state licensure, graduation from a nationally accredited EMS educational program and passing of the National Registry of EMTs examination at the appropriate level. Perhaps at the same time we could raise our educational standards to the level of other developed nations, and include sufficient education so that providers are prepared for what is to come in EMS, not “what was” in the 1970s.
• Require EMS provider agencies to conduct complete pre-hire investigations for all personnel, including nationwide, fingerprint-based criminal records checks, psychological suitability evaluations, driving record checks and educational verification prior to allowing that individual to serve in a public contact capacity.

These steps are few, and they would fundamentally alter the face of EMS in the United States.

Are they likely to occur? Even for a perennial optimist like me, probably not. There are too many with a vested interest in maintaining the status quo. There are the hobbyists, a strong lobby against the raising of standards—any standards—that would make it more difficult to call themselves paramedics while devoting only a little time to EMS. There are commercial interests who see the town-by-town squabbling as business opportunities, hoping to find one more place to set up shop. There are large national labor organizations with heavy investment in the status quo. And there is the apathy of the paramedics themselves, and their unwillingness to contribute—financially or with personal effort—to organized activities that will, in the long run, improve both their own lot and the care in their communities. Too many people have too much “cheese” that they don’t want moved, no matter how bad that cheese may be!³

The Feds Could Help!

Although I mentioned earlier that EMS is primarily a state issue, the federal government remains the largest purchaser of healthcare services, including ambulance transportation, in the United States. Agree or disagree, the federal government has a long history of addressing topics not part of its enumerated constitutional powers through the use of its “spending power,” including the power to spend and not to spend.⁴ Many states have been persuaded to take legislative action in the face of federal action that would withhold money for non-compliance.

One of the features of many of today’s EMS delivery models is great inefficiency—usually manifested by having multiple agencies serve the same area, or having a patchwork of myriad very small agencies. Much of the federal healthcare reform effort is aimed at eliminating inefficiencies, so why not in EMS? How about using that “spending power” to bring about the changes recommended in the more recent white paper—Regionalizing Emergency Care: Workshop Summary, released in 2010 by the National Academies of Science and National Institutes of Health.⁵

Although the feds currently pay only for ambulance transportation, that model is changing. As non-transporting services increase, this paradigm is likely to change. The feds have started to punish inefficiency by refusing to pay for care of patients sent home too soon from hospitals, or sent home without adequate follow-up care (such as CHF patients). How about nudging states, through their EMS agencies, with a similar action? Want to see states get behind reform? Change the Medicare payment structure such that providers in states that don’t adopt system requirements such as those described here are paid 25% less than they are today. Encourage community paramedicine development by refusing to pay for transportation by ambulance of individuals whose condition, as assessed by responding paramedics, does not require the use of this most expensive form of transportation. If “the carrot”—the rewards of doing the right thing—is not enough to bring about change, perhaps a little bit of “the stick” will provide the necessary motivation.

I realize that these changes may not happen soon—perhaps not even in my lifetime. But things are going to change. The question is whether they will change in an organized fashion, in a way that will benefit the patients and communities we serve, or if they will change in a fragmented manner, benefitting only those special and organized interests that have the sense to stand out ahead of the train.

Where would you like to be?

References

1. Kelly J. Rescue squad. Am Heritage, 1996; 47:90–100.
2. Hampton OP Jr. Present status of ambulance services in the US. Bull Am Coll Surg, Jul–Aug 1965:55.
3. Johnson, S. Who moved my cheese? An amazing way to deal with change in your work and in your life. New York: Putnam, 2002.
4. The Federal Powers to Tax and to Spend (and other powers of Congress). Exploring Constitutional Conflicts. law2.umkc.edu/faculty/projects/ftrials/conlaw/tax&spendpowers.html.
5. National Research Council. Regionalizing Emergency Care: Workshop Summary. Washington, D.C.: The National Academies Press, 2010.

Skip Kirkwood, MS, JD, EMT-P, EFO, CEMSO, is drector of Durham County (NC) EMS, past president of the National EMS Management Association and an editorial advisory board member for EMS World. He previously served as Chief, Emergency Medical Services Division, Wake County, NC.