Legislative Program Review and Investigations Committee
Keypoints
Emergency Medical Services
Background
Key legislation establishing regulation of emergency medical services in Connecticut occurred in 1967, 1974, and 1980.
Ambulance services must be certified or licensed to operate. Commercial services are licensed and nonprofit providers are certified. There are currently 167 certified and 17 commercial providers. About 107 of these ambulance services charge for their services.
Connecticut’s regulation of EMS is comprehensive and involves territorial assignment of providers (into Primary Service Areas), rate setting, and determination of need.
Ambulance services that charge must have approval from DPH to offer new or expanded services. The purchase of an existing ambulance provider in its entirety is exempt from the DPH determination of need requirements.
Primary services areas (PSAs) were first designated in 1974 as a result of legislative action. For each town, DPH designates the PSA responder at three levels – first responder, basic life support (BLS), and advanced life support (ALS).
There are currently 187 designated first responders, and 183 BLS and 107 ALS responders.
DPH sets maximum allowable statewide rates that each provider may charge for different levels of ambulance service.
Government and private third party payers establish rates for what they will pay for ambulance transport service.
Medicare recipients comprise the largest portion -- 55 percent -- of both emergency and non-emergency ambulance call volume; Medicaid makes up 12 percent.
The top six commercial providers handle between 75 and 80 percent of all ambulance calls in Connecticut. The rates charged by these commercial providers have all exceeded the provider statewide average rate since 1994.
Findings and Recommendations
Proposed recommendations maintain the current system, but suggest policy enhancements to improve the ability of both local and state governments to perform oversight functions.
Reasons for the scope of recommendations include:
need for enhanced accountability;
unclear need for wholesale change;
recent significant changes just implemented or proposed; and
complexity of the current system.
Recommendation areas include:
local EMS plans need to be established;
mechanism to resolve EMS provider and municipal differences over performance agreement is required;
model guidelines for local EMS plans and agreements need to be developed;
municipalities’ ability to remove EMS providers for poor performance needs to be improved;
annual report on local EMS plan is necessary to track performance;
response time measurement is imprecise, and requires common definition;
sales of existing ambulance companies holding PSAs shall include adoption of existing performance agreements; and
outcome measures need to be developed to assess EMS system.
The committee authorized a Phase II of the study examining further refinements needed in the system
The committee took no action on alternative approaches to evaluate other changes to the system that would alter the fundamental regulatory structure of EMS
The chart that follows summarizes the proposed changes to the EMS system. It provides an overview comparing the current regulatory structure to the proposed changes for each of the main participants in the system.
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Proposed Changes Regarding Accountability in the EMS System |
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| Current Regulation | Proposed Change |
|
Department of Public Health |
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| Planning for EMS is disconnected with municipalities | Municipalities become a planning partner with the state |
| May inspect response time records | Required to receive and publish uniform information on response times |
| Has minimal performance standards in regulation | Will provide guidance documents on performance agreements and oversee system of locally determined performance standards |
| In most cases, the only entity providing oversight of providers that could lead to corrective action or negative consequences | Municipalities have greater role in providing oversight and in developing corrective action plans |
| May remove a provider if it determines that it is in the best interest of patient care to do so | This standard is maintained |
| Extent of subcontracting by PSA holders is unknown | Subcontracting and mutual aid agreements must be disclosed in EMS plan and agreements |
|
Municipalities |
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| Participate in initial sign-off for indefinite PSA assignment – no reconsideration of PSA | PSA assignment can be reconsidered every three years if previously agreed to performance standards are not met |
| Have attenuated role in EMS planning | Have a direct and active role in determining the level and quality of service provided in own community |
| May contract for services | Must have an enforceable agreement with providers |
| May develop performance standards. Municipalities that have developed standards, in most cases, only have standards for basic ambulance service | Must develop performance standards based on local conditions and resources for the continuum of EMS providers from dispatch to advanced life support |
| May monitor performance standards | Must monitor the performance of providers |
| Residents may receive information on the performance of their municipality’s EMS provider | Must report publicly on the performance of providers on at least an annual basis and will be publicized by DPH |
| May petition DPH for removal if an emergency exists and if the actions of the PSA holder jeopardize the safety, health, and welfare of the citizens | May petition DPH for removal of a PSA responder based on poor performance as defined by the municipality as well as existing standard |
| No assurances about provider performance, if the current provider changes ownership | New owner must abide by existing performance contracts |
|
Providers |
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| May enter into an agreement with municipality | Required to enter into an agreement with municipality |
| May be subject to performance standards | Required to adhere to locally determined performance standards |
Local Emergency Medical Service Plans (p. 23 – refers to page number in full report)
The local legislative body of each town shall establish a local Emergency Medical Services (EMS) plan that would include, but not be limited to:
identification of who will carry out each level of service – dispatch; first response; basic life support (ambulance transport) and advanced life support (paramedic);
establishment of performance measures for each segment of the system;
establishment of a monitoring system that will identify who will receive information necessary for monitoring, who will provide the information, how frequently the information will be monitored, and what will require corrective action on the part of any service providers, including provisions for progressive sanctions; and
any written agreements or contracts developed between the town and its providers (including any subcontracts, written agreements, and/or mutual aid agreements providers may have with other entities to provide service).
All plans shall be filed with the Department of Public Health by January 1, 2000, and be updated and refiled with DPH every three years. Towns are encouraged to consult their Regional EMS Council, their regional coordinator for EMS, the regional EMS medical advisory committees and the sponsor hospital(s) in their area for assistance in development of the plan, and shall submit the plans to their Regional EMS Council for review and comment. DPH may reject a plan if the department deems it in the best interest of patient care to do so.
Mechanism to Resolve Differences Between Primary Service Area Responder and Municipality About Performance Agreement Terms (p. 25)
The Department of Public Health shall monitor receipt of written agreements or contracts that must be submitted with a local EMS plan. If no written agreements are submitted by January 1, 2000, DPH shall notify the town and the PSA responder no later than March 1, 2000, that a hearing will be held within 60 days of the notice, if agreements are not submitted by that date. DPH could prioritize the holding of hearings based on its categories of urban, suburban, and rural, with areas of greatest population scheduled first.
The hearing would be held to determine if the standards adopted in a local EMS plan were reasonable based on criteria that DPH uses including the state EMS plan, model guidelines developed, and standards, contracts and written agreements in use by towns of similar population and characteristics.
If the standards were determined reasonable by DPH, the PSA responder would have 30 days to sign the agreement or lose the PSA. If DPH found the standards were unreasonable it would establish standards considered reasonable given the criteria used above. If a town refused to agree to the standards established by DPH, the PSA holder would have to meet the minimum state regulatory standards in place.
Model Guidelines for Local EMS Plans and Agreements (p. 26)
The Office of Emergency Medical Services shall, with the advice and assistance of the EMS Advisory Board and Regional Councils, develop model local EMS plans and performance agreements, recognizing the differences in the delivery of EMS services in urban, suburban, and rural settings, to guide municipalities in the development of these documents.
Municipality-Initiated Process to Remove PSA Responder for Poor Performance (p. 27)
Grant municipalities the ability to petition DPH every three years for the removal of a basic life support or advanced life support PSA responder based on unsatisfactory performance of that responder as outlined in the local EMS plan and associated agreements.
Policy Option: Pilot study (p. 27)
A pilot study shall be considered to assess the effect of PSA holder selection based on the periodic issuance of a RFP with right of first refusal for the current PSA holder. The pilot would involve three to six towns in urban, rural, and suburban contexts that contract with commercial providers. Phase II of the current program review study would identify the details for implementing the pilot program including: feasibility of such a pilot project, its design and measurement, identification of elements to be assessed, time frame, selection of pilot municipalities, impact on service delivery and market, and who would conduct the evaluation of the pilot.
Annual Performance Report On Local EMS Plans (p. 28)
Each town will be required to annually report by March 31, on a form furnished by the Department of Public Health, on the implementation of its plan for the previous calendar year, including:
total number of EMS calls;
number of calls requiring each level of service;
number of refused calls and number of calls requiring mutual aid response;
name of service provider for each level of service;
using the common definitions of response times established by the Department of Public Health submit fractile response times for each levels of the EMS system – dispatch; first response; basic life support, and advanced life support; and
the monitoring and compliance of the providers with locally developed performance standards, and if non-compliance has been identified what steps the town has taken, or will take, to enforce provisions of the contract.
The Department of Public Health shall compile the information – grouping towns according to urban, suburban and rural categories-- and make the information available to the public in a report card format by July 1 of each year. The department shall make the report card available on its web site, and shall submit a copy to the Public Health Committee of the General Assembly.
Establish Common Definition for Response Time Measurement (p. 29)
DPH shall establish and reinforce a common definition for response time to include the time a call is received by a Public Safety Answering Point to the time each dispatched responder (i.e., first responder, supplemental responder, BLS, ALS) arrives on scene and every significant point in between for reporting purposes.
Purchases of Ambulance Companies Require Acceptance of Existing Performance Agreements (p. 29)
An express condition of the purchase of a business holding a PSA, subject to the determination of need exemption, is that the purchaser must abide by the performance standards to which the purchased business was obligated pursuant to its agreement with the municipality.
Outcome Measure Development to Assess EMS System (p. 30)
DPH shall research and develop appropriate outcome measures for the emergency medical services system and shall submit to the Public Health Committee of the General Assembly, by January 1, 2001, and annually thereafter, a report on the progress toward development of such measures. After outcome measures are implemented, DPH shall include in its annual report an analysis of system outcomes.
Continue Study to Examine Further Refinements to the Current System