Regulation of Emergency Medical Services:II Ch 5

Legislative Program Review and Investigations Committee

Regulation of Emergency Medical Services: Phase 2
Chapter V

Chapter V: Management Controls

DPH Has Inadequate Management Controls

During the course of this study, the program review committee noted a number of areas where DPH is not in compliance with certain legal requirements or has not discharged its administrative and oversight duties in an appropriate manner. This includes the following examples:

· Not all Primary Service Areas (PSAs) are assigned as required by regulation

DPH has the responsibility to assign a primary service area responder (PSAR) to each municipality at each level of emergency service (first responder, basic life support and advanced life support). The committee found in its 1997 report the department was unsure what percent of the state was actually assigned coverage at each of the three levels. Under this current review, the committee continues to find the department has not assigned or does not know all the PSA assignments for all levels. There are three principal reasons for this:

First, members of the EMS community interviewed during the study indicated that in some instances local indecision about who the first responder should be has prevented one from being assigned. Further, in at least six towns no basic life support provider has been assigned. In a few areas, responders may be functioning but are not known to the department. The committee found that PSAs as large as the city of Norwalk, for example, had no designated first responder.

Secondly, in some cases, DPH has lost the documentation for PSA assignments. At least two BLS providers claim entitlement to two different areas where no documentation exists to prove who is the rightful PSA holder.

Finally, it has been stated that due to cost considerations, ALS level of service cannot be provided to each area of the state. Nonetheless, the legal requirement remains. The department could try to encourage more ALS development (such as the regionalization of ALS services), or try to remove this requirement from regulation.

Evaluation of the system is difficult when the number of providers and extent of coverage is unknown. In addition, legal disputes arise when the regulatory agency does not know which provider is the rightful PSA holder. The committee recognizes recent efforts by the department to inventory current providers. Nonetheless, even after the system is inventoried, the issue with first responders and ALS levels of service will remain. Assignment of first responders is especially important in the delivery of time-critical emergency medical services and should be a top priority of the department.

· PSA oversight is lacking

Program review found a provider being utilized who is not the legal PSA holder. A town refuses to use the assigned provider. The purpose of having PSAs is to assign a territory to a specific provider to ensure coverage and accountability. Other towns are also experiencing difficulties with a provider, and the ability of some towns to ignore the law sets a bad precedent.

· Certified providers charging for non-emergency transport services

Current state law allows certified providers to charge for emergency work only. During the course of the study, a number of instances were found where certified providers were charging Medicare for non-emergency transportation. In most cases this was only for a few calls. In one notable case, however, a state government-based provider charged for over 100 non-emergency Medicare calls in one year. DPH rate regulation staff indicated no waiver had been issued to allow the provider to do this type of work and it appears that DPH was unaware of the status of the provider or its volume of business in this area. The committee believes if the law is interpreted to restrict non-emergency work, it should be done uniformly. Since DPH is mandated to regulate ambulance business practices -- it needs to be aware of those provider practices, and stop violations -- or seek to lessen those regulatory restrictions.

· Missing adjudication documents

Program review requested seven years worth of DON documentation to perform an analysis of decisions. The department lost or destroyed many of its documents including those related to adjudication decisions before and during its move to Washington Street. It is unknown how many cases this effects. Case records are important to understanding what has occurred and to document the decisions of a regulatory agency.

· Reporting requirements not implemented

Regulations require that each emergency medical provider supply information to DPH on transports (§ 19a-177-7(e)). This includes the overall number of transports; the number of prior arranged (non-emergency) transports and number of emergency transports. Even though the department has the authority, it has not implemented this requirement. As discussed in Chapter III, no basic data are available to regulators of the system on the total number of EMS calls, where they occur, or the type of incidents. Nor are any data collected to measure how the system is performing.

Further, other required information DPH needs to be informed on how the system is operating are not recorded with the department and DPH does seek their submission. For example, the regulations require mutual aid agreements be enclosed with a provider’s application and renewal for license. DPH is also not apprised of contracts or agreements providers may have with each other for coverage for certain times of the day, etc., which impact the responsibilities of the designated PSA responder.

Agency management is responsible for maintaining an adequate management control structure to ensure compliance with laws and regulations. Most of the above deficiencies relate to very basic administrative functions, but are essential to understanding, regulating, and managing the EMS system.

The department is taking steps to examine its regulatory scope through a Regulations Review Task Force, made up of EMS parties and DPH staff. The task force meets biweekly and is making recommendations to streamline the EMS regulations to make them reflective of the system and enforceable. In addition, the department appears to have made recent progress in some regulatory areas such as more uniform and prompt handling and disposition of complaints and better development and oversight of the state and regional EMS plans. However, if the department’s regulatory role is to be taken seriously by the community, DPH needs more comprehensive and uniform enforcement of the areas that are important and seek to remove the regulatory components that are no longer relevant.

The scope of the study clearly removed agency structure and organization from the review. However, the committee believes the new leadership at DPH have a unique opportunity to elevate the department’s role in this area. The new Commissioner, Joxel Garcia, M.D., and Deputy Commissioner, Norma Gyle, both appointed during the past year, can establish and manage -- through guidance and directive to DPH employees, and communication to the regulated community -- a clear and strong agenda for regulation of EMS.

Recommendation

The program review committee recommends DPH leadership communicate to department employees and the regulated EMS community the department’s intention to discharge its regulatory and administrative responsibilities in the EMS area diligently and uniformly.