April 11, 2011
USE OF STRETCHER VANS TO TRANSPORT DSS MEDICAL ASSISTANCE RECIPIENTS
By: Robin K. Cohen, Principal Analyst
You asked for an explanation of Governor Malloy's budget proposal, and the bill to implement it (SB 1013), which allow the Department of Social Services (DSS) to pay for stretcher vans instead of ambulances to transport certain individuals eligible for DSS medical assistance programs to medical appointments.
Governor Malloy's budget proposal reflects anticipated savings ($6.3 million in FY 12 and $7 million in FY 13) from allowing certain DSS medical assistance recipients to be transported to medical appointments in stretcher vans instead of an ambulance. A stretcher van is a vehicle, such as a modified van, that is capable of accommodating a stretcher for transporting individuals who cannot sit up.
Under the proposal, a recipient of DSS medical assistance would be transported in a stretcher van if (1) the trip is medically necessary and (2) the recipient must be transported in a prone position but does not need medical care during the trip. The bill to implement this provision (SB 1013) directs DSS to set payment rates for transporting patients in the vans and the Department of Transportation (DOT) to regulate the vans. It indirectly appears to permit the Department of Public Health (DPH) to license the vans as invalid coaches, but eliminates a requirement that vehicles, other than ambulances and other rescue vehicles, have DPH licenses to transport patients on stretchers. An “invalid coach” is defined as a vehicle used exclusively for transporting nonambulatory patients to or from either a medical facility or the patient's home.
The Human Services Committee held a public hearing on the bill on March 15. The Office of Policy and Management (OPM) and DSS supported the bill, but offered a few changes to ensure that DOT regulations include safety standards requiring more than one person besides the driver in the vans. The ambulance company trade group opposed the bill, citing safety concerns. The group's president also expressed concern that stretcher vans could have a negative impact on the state's ambulance ride capacity. The committee gave the bill a straight change of reference to the Appropriations Committee on March 23, 2011.
SB 1013—STRETCHER VANS FOR DSS MEDICAL ASSISTANCE RECIPIENTS
DSS—Medical Assistance Recipients
SB 1013 (§§ 10-12) directs the DSS commissioner to authorize payment only for the mode of transportation services that is medically necessary for a beneficiary of DSS medical assistance programs.
DSS, through its transportation brokers, currently pays for the mode of transportation that is the most appropriate and least expensive, including invalid coaches, liveries, and ambulances when a medical assistance recipient needs a ride to a medical appointment. When a DSS medical assistance recipient is stretcher bound (i.e., cannot sit up), DSS will authorize an ambulance to transport him or her to medical appointments. The “definitions” section of the DSS Medical Services Provider Manual provides that ambulance services are needed because a recipient may require medical care during transit, which an ambulance is equipped and staffed to provide (DSS Medical Services Provider Manual, § 175E.II.e, et seq.).
The bill permits these recipients to be transported by a stretcher van if they (1) require transportation for a medical appointment and (2) must be transported in a prone position but do not require medical services during transport. The bill requires the DSS commissioner to set payment rates for companies that provide these van rides, provided they have a DOT permit (see below).
The bill seems to assume that DPH will license stretcher vans as invalid coaches by eliminating the prohibition in law that these coaches not transport people who are stretcher bound. In general, DPH, through the Office of Emergency Management Services, regulates emergency medical services, including vehicles used to transport patients in an emergency. But it also regulates invalid coach services, which generally can be used only for nonemergency transportation. DPH issues licenses to companies that provide this service (CGS § 19a-175, et seq.).
The bill also eliminates a requirement that any vehicle other than an ambulance, rescue, or management service have a DPH license in order to transport patients on stretchers (§ 11).
As drafted, the bill does not specify safety standards that a stretcher van must meet. But it contemplates that at least some of the companies providing the transportation will be invalid coach services, and the licensure requirements for invalid coaches are less burdensome than those for ambulance services.
Invalid Coach Service Regulation. As they do for other modes of transportation, DPH regulations include minimum staffing standards and vehicle design requirements as a condition of licensure for invalid coach services. For example, they require that invalid coach services:
1. provide at least one person trained in CPR in accordance with standards of the American Heart Association or the American Red Cross, and who may also serve as the driver and
2. comply with DPH regulations governing minimum vehicle standards (Conn. Agency Regs. § 19a-179-10, et seq.).
Ambulance Regulation. DPH regulation requires ambulances, when responding to a service request, to have one medical response technician certified in accordance with the minimum standards set in regulation, and one certified emergency medical technician, who must be with the patient at all times in the patient compartment of the ambulance. The ambulances must meet minimum design and equipment requirements, including proper restraints, as a condition of licensure or certification (Conn. Agency Regs., §§ 19a-179-10, et. seq.).
The bill requires the DOT commissioner to adopt regulations to establish oversight of stretcher vans as a livery service that requires a permit to operate. If DPH has certified the van (presumably as an invalid coach), this certification alone is sufficient for the stretcher van to receive the DOT permit. (DPH generally only licenses, not certificates, invalid coaches so it is not clear what the effect of the provision would be, although the bill's intent appears to be to allow licensed stretcher van companies to get the livery permit without having to meet additional regulatory requirements.)
Current DOT regulations require only that livery permit holders ascertain that any drivers that they employ holds a public service operator's license and is fully instructed in the state's motor vehicle and livery laws. They do not address the number of personnel, the personnel's medical training, or vehicle design specific to stretchers (Conn. Agency Regs., § 16-325-6).
Public Hearing and Proposed Amendment
The Human Services Committee heard the bill on March 15, 2011. According to OPM and DSS testimony, the new stretcher van rate will be “roughly one-fifth” of the nonemergency ambulance rate, which has a base rate of $218 plus $2.88 per mile, per trip (approximately $275 for a 20-mile one-way trip). OPM testified that only “medically stable” individuals would ride in these vans. OPM and DSS also testified that the bill needed two “technical corrections.”
First, they asked to strike the language that required the DOT permit to allow DPH certification of stretcher vans as sufficient qualification for the DOT livery permit. Instead, the bill would require the DOT regulations to prescribe safety standards for the vans, including a requirement that an attendant in addition to the driver, accompany the patient. Presumably to conform with this, OPM and DSS recommended deleting the provision that modified the definition of invalid coach to apparently include stretcher vans (§ 12).
David Lowell, president of the Association of Connecticut Ambulance Providers, also testified on the proposal, which his association opposes. One of the concerns he expressed was that the vans, although apparently subject to the invalid coach regulations under the original bill, would present a health and safety concern in terms of inadequate equipment and personnel. Lowell also questioned how a patient requiring a stretcher van would not require medical services during transport.
Lowell also asserted that the Medicare program, which currently pays for nonemergency ambulance rides, will not pay for stretcher van rides to medical appointments, and that patients who are eligible for both Medicare and Medicaid could have their transportation costs shifted to the Medicaid program. This would potentially shift the cost of these rides from the federal government alone to a 50% state and 50% federal split.
Lowell also spoke of the state's capacity of ambulances that can respond to changing demands of both emergency and nonemergency call volumes, and how the bill could affect this balance and force some ambulances to sit idle. This could lead to a smaller ambulance capacity to respond to emergencies should some companies choose to reduce their ambulance fleet size.
The executive branch's proposed amendment could potentially address the ambulance lobby's safety concerns.
OLR report Payment Rates for Medical Transportation of Nursing Home Residents (2000-R-1067)