Return to Ambulance Fee Schedule
FEASIBILITY OF REACHING CONSENSUS ON AN AMBULANCE FEE SCHEDULE
In our telephone interviews with potential participants, we explained the regulatory negotiation process and the role of the FMCS as facilitator/mediator. In addition to a telephone interview, the American Ambulance Association submitted written comments, a copy is attached. A few of the parties were familiar with the negotiated rulemaking process or had participated in other "reg-negs". Almost all of the parties expressed a strong desire to participate in the negotiations and believed that a consensus on an ambulance fee schedule was possible. While all participants believed consensus was possible many challenges were also identified. Many parties identified the short time frame for the "reg-neg" committee (hereafter "the committee") to complete its work as a challenge, despite the proposed schedule of up to eight meetings by June 1, 1999. One party suggested that HCFA consider approaching Congress to allow it to exceed the January 1, 2000, deadline for a promulgation of a final rule to allow the negotiated rulemaking process adequate time. They believed this was not unreasonable in view of a possible delay in implementing the fee schedule because of Y2K concerns. The facilitators share this concern also, and recommend that the time frame and a possible extension be a topic of discussion at one of the early meetings. The fixed pool of money available for ambulance fees was also identified as a challenge for the committee. To the extent a reallocation of fees under a new fee schedule creates winners and losers consensus may be more difficult. Many believe that the problem of a limited pool of money would be further acerbated by the entry of municipal governments and volunteer organizations into the Part B ambulance fee pool. Many, but not all, viewed this as making a limited pie even smaller. On a positive note, many parties expressed the view that if the slices of the pie were divided fairly, consensus is possible. Obviously, the difficulty will be reaching a consensus on what is "fair".
RECOMMENDED PARTICIPANTS
As previously mentioned, all the parties (with one or two exceptions, discussed below) we interviewed were enthusiastic about participating in the negotiated rulemaking. A few expressed the desire to enlist the support of their Congressional representatives in securing a seat at the negotiation table, they were referred to deal directly with the agency. Below is our recommendation for committee membership. One of the concerns of the facilitators is that the committee be balanced in membership to represent all of the interests affected by the rule while not creating a committee that is too big.
In making our recommendations regarding membership we are guided by whether the organization has an interest that is affected by the proposed rule and whether the named party can adequately represent the interest of that group. In this regard, we interviewed four individuals who expressed an interest in participating and who were quite knowledgeable, but did not represent an interest group, per se. Our recommendation is to not include those individuals (discussed in greater detail below). This was a difficult call for the convenors given the fact that these individuals by virtue of their positions would be capable of representing some aspects of the rural interests. There are a number of options for HCFA to consider. To the extent they are affiliated with one of the other recommended participants, they may participate through those organizations. HCFA could invite these individuals to form a coalition to represent the interests of rural providers. The National Association of Counties was suggested as another potential participant, they should be contacted to see if they are interested in or capable of representing the interests of rural counties.
Based on our interviews of the parties below we have identified the following interest groups. They fall in to the following categories: ambulance service providers; health care providers; first-end responders; emergency room personnel; emergency medical system authorities; labor unions; and an "other" category. Within these broad categories of potential parties, several interests have been identified. They are the needs of rural versus urban providers of ambulance services; the unique needs of air service providers; state and local needs.
AMBULANCE SERVICE PROVIDERS
AIR EVAC SERVICES, INC.
Air Evac Services is a for profit provider of air patient transport services (helicopter and fixed wing) and conducts approximately 8,000 transports per year. It previously was hospital based and made the transition to its present form in December 1997. Air Evac Services believes that as funding for hospital ambulance service moves from Part A to Part B, more hospitals will shift to independent providers of air ambulance service as a cost saving measure. The interest represented by Air Evac Services is that of the for profit non-hospital based air transportation industry. We recommend the inclusion of this group.
AMERICAN AMBULANCE ASSOCIATION
AAA is an association representing over 750 ambulance companies throughout the country; its members include a broad spectrum of ambulance service providers. The majority of AAA members are privately owned ambulance companies. We recommend the inclusion of this group.
ASSOCIATION OF AIR MEDICAL SERVICES
AAMS is an association which represents air ambulance service and critical ground providers. They would represent the unique needs of air transportation which may be required due to the different types of mission profiles which exist across the country. AAMS has stated that if coverage is an issue for the "reg-neg", it would like an opportunity to submit a written statement of "coverage" issues. We recommend the inclusion of this group.
HEALTH CARE PROVIDERS
AMERICAN HEALTH CARE ASSOCIATION
AHCA represents skilled nursing facilities, which provide services under both Part A and B. In January, 2000, skilled nursing facilities will begin to bill Medicare for ambulance services as if they were providers of ambulance services under Part B. In essence, they will become the provider and biller of such services, where they previously did not have to worry about ambulance fees or costs. We recommend the inclusion of this group.
AMERICAN HOSPITAL ASSOCIATION
Currently a significant number of hospitals provide hospital based ambulance service. Like the AHCA, hospitals will begin billing for ambulance services under Part B where they previously did not do so. This will represent a major change in billing for hospitals. With respect to the issue of coverage, AHA has indicated that it has previously submitted to HCFA a letter dated on about August 17, 1997, listing the coverage issues it belives still need to be resolved. We recommend the inclusion of this group.
GERALD FIKES
Mr. Fikes is the Director of Emergency Services for Mercy Medical Center in Redding, California. He is interested in participating in the rulemaking in his personal capacity and not as a representative of Mercy Medical Center. In his personal capacity, Mr. Fikes is active with a number of small rural ambulance services in Northern California. The interest he seeks to represent is that of small rural providers, many who, he states, could be severely adversely affected and possibly put out of business by fee schedules that do not cover their costs. Due to the fact that Mr. Fikes does not represent an interest group per se we do not recommend his participation.
FIRST END RESPONDERS
EMS CONSULTANTS
This is a Medicare consultant in the southeastern US. His clients mostly include small governmental entities (counties) that depend on Medicare reimbursements. According to the owner of EMS Consultants, there is no formal national organization that represents the interests of small rural government ambulance service providers and they are not adequately represented by other existing organizations. We believe the needs of rural governments could be represented by the National Volunteer Fire Council, and National Association of State EMS Directors. Of particular concern is the fact that this consultant does not represent a formal organization of rural county providers. Therefore, we do not recommend this group's inclusion.
INTERNATIONAL ASSOCIATION OF FIRE CHIEFS
IAFC represents local fire chiefs and would represent the interest of ambulance services which are provided by fire services. Some parties questioned whether the fire chiefs and the firefighters union actually represented different interests with regard to ambulance fee schedules. We recommend exploring with these two groups the possibility of forming a coalition for purposes of participation in the negotiated rule making.
NATIONAL VOLUNTEER FIRE COUNCIL
According to NVFC nearly 70% of the nation's fire service is provided by volunteer organizations. Even though this service is a volunteer service, funding is a critical issue. Most volunteer services are currently not billing Medicare. Their interests are the conditions under which volunteer services would bill Medicare for ambulance service and what impact would the entrance of volunteer services will have on the overall Medicare system. We recommend the inclusion of this group.
EMERGENCY PERSONNEL
AMERICAN COLLEGE OF EMERGENCY PHYSICIANS
This group represents the interests of physicians who are concerned with the well being of patients. They have expressed the interest that fees not create barriers to emergency medical treatment and the payments not be based on final diagnosis which would constitute the practice of medicine. We recommend the inclusion of this group.
NATIONAL ASSOCIATION OF EMERGENCY MEDICAL SERVICE PHYSICIANS
This organization is a professional society of out-of-hospital emergency service physicians; many of its members are also medical directors. They oversee emergency services in their state; for example, they approve protocols. Their interest is ensuring the medical well being of the patient, and the integrity of the emergency medical system. We recommend the inclusion of this group.
EMERGENCY MEDICAL SYSTEM AUTHORITIES
NATIONAL ASSOCIATION OF STATE EMS DIRECTORS
This organization represents state EMS Directors. Their interests would be in ensuring that reimbursements are consistent with state standards and ensure compatibility with state laws and licensing rules. We recommend the inclusion of this group.
NORTH CAROLINA ASSOCIATION OF EMS ADMINISTRATORS
This is a association of county EMS administrators, representing 68 out of 100 counties in North Carolina (by state law counties are responsible for providing ambulance service). They would represent the interests of rural counties who would bill under Part B. We believe the interests of rural governments could possibly be represented by the National Association of State Emergency Medical Services Directors. The interests of the states is an important one, however, the committee should focus on the interests of all 50 states; this group's expertise is mostly with the state of North Carolina. Therefore, we do not recommend this group's inclusion.
LABOR UNIONS
INTERNATIONAL ASSOCIATION OF FIREFIGHTERS
This is the union that represents firefighters. Their interest is in representing the personnel who directly provides first end response. They have expressed an interest in the "prudent person" standard, when responding to emergency calls. See discussion regarding the International Association of Fire Chiefs. We recommend exploring with these two groups the possibility of forming a coalition for purposes of participation in the negotiated rulemaking.
OTHER
FLORIDA REGIONAL EMERGENCY MEDICAL SERVICES
This is a consulting firm whose clients are mostly 911 providers in Florida, Texas, and Georgia. They manage a number of rural hospital based ambulance systems and do their accounting and billing. They believe that they can represent the interests of rural ambulance providers better than the AHA who as a lobbyist for hospitals in general has not yet developed expertise in the issues associated with billing for ambulance services under Part B. Again, this consulting firm does not represent a formal organization. Therefore, we do not recommend the inclusion of this company
NATIONAL HERITAGE INSURANCE COMPANY
This is an insurance carrier for HCFA. This organization is primarily concerned with issues of coverage. To the extent the insurance carriers would administer the fee schedule, their institutional expertise may be an asset to the committee. It is our understanding that this group has indicated to HCFA that it may not desire to participate in the reg neg. We recommend that this group be invited to participate on an as needed basis to provide technical advise, if the committee agrees to do so.
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION, US DEPT. OF TRANSPORTATION
In our interviews, NHTSA was not sure they would participate.
OTHER POTENTIAL PARTICIPANTS
In the course of our interviews, a number of other organizations were identified as potential participants. They are listed below. We have not interviewed any of these groups. Obviously, we cannot include all of them on the committee. The area of greatest concern is that of rural providers. While many of the recommended providers include rural providers in their membership, there is no one voice that appear to speak solely for rural providers. We have previously discussed the possibility of including the Association of County Governments.
One group of potential participants that stood out in its absence is that of consumers of ambulance services. For this reason, we suggest that serious consideration be given to including a representative of the actual consumers. Additionally, serious consideration should be given to including other emergency personnel such as National Association of EMTs and the Emergency Nurses Association since emergency physicians have been included. Also, the participation of the two other unions (AFSCME and SEIU) should be explored. Consideration should also be extended to the Association of Health Plans, representing the managed care industry.
AMBULANCE SERVICE PROVIDERS
Dialysis Services - also have ambulance services
HEALTH CARE PROVIDERS
Association of Health Plans (representing the managed care industry )
EMERGENCY PERSONNEL
Emergency Nurses Association
National Association of EMTs
National Registry of EMTs
American Academy of Pediatrics, Emergency Medical Division
American College of Surgeons, Committee on Trauma and Pre-Hospital Service
EMERGENCY MEDICAL SYSTEM AUTHORITIES
National Association of Public Utility Models
LABOR UNIONS
Service Employees International Union
American Federation of State, County and Municipal Employees
"OTHER"
MEDAPHIS - billing agent
CONSUMERS
American Heart Association
American Association of Retired Persons
National Rural Health Association
American Trauma Society
GOVERNMENT
Association of County Governments/ National Association of County Governments
National League of Cities
ISSUES FOR NEGOTIATION
At the first meeting we will need to spend considerable time formulating and reaching consensus on the issues to be addressed by the negotiated rulemaking. Most of the parties we interviewed had a good grasp of the Part B billing process and the issues that needed to be addressed there. However, there appeared to be a great deal of confusion over the inclusion of "coverage" issues. The participants were aware that HCFA had issued a NPRM on coverage of ambulance services in 1997. The difficulty seemed to come with separating out what should be part of the August, 1997 NPRM and not part of the current negotiated rulemaking. In fact, some parties did not believe the coverage issue could so easily be separated out and would need to be addressed in this rulemaking before a fee schedule could be developed. It is also possible that the parties are using the term "coverage" to address what may be confusion over definitions. For example, a number of parties cited the need for clearer definitions of "bed ridden, critical care transport, and medical necessity". AAA in its written submission to the convenors stated that it did not believe that the committee should be concerned with coverage of services not now covered by Medicare but advocated including definitions. To the extent HCFA believes that "coverage" is not appropriately part of these negotiation and that it has the authority to determine what will be subject to negotiated rulemaking, it should be prepared to spend time at the first meeting educating committee members of its position.
Other issues identified include the following:
1. How to determine the appropriate level of care and who should determine it.
2. What coding system should be used.
3. Under what circumstances should "add on" payments or adjustments be allowed to address different type of services or geographic differences.
4. Under what circumstances should Medicare pay for advanced versus basic life support, and what about local rules that mandate that all ambulances be advance life support.
5. Should fees be available for non-transport when responding and awaiting transport.
6. Should there be a differential for volunteers versus paid staff. Should there be a differential when rendezvous' take place between BLS and ALS.
INFORMATION NEEDS
Information will probably play a critical role in this negotiated rulemaking. In this regard, the AAA is soliciting its members and other potential committee members to develop information it believes will be helpful to the negotiation process. Some of the other information needs identified by the parties are as follows:
1. What is the status of current billing: are there breakdowns of runs available for each state?
2. What is the data on trips (rural and urban), e.g., numbers, types, costs of air and ground services?
3. What are the allowable charges in each region?
4. What are the demographics across the country upon which services are provided?
5. What are the current prevailing charges in the private sector?
6. What is the amount of money that will be paid in 1999, (in order to determine the pool of money that would be available in 2000)?
7. What data will be used to support estimates of what is "budget neutral"?
8. How many new providers are coming into the system? Is there a reliable estimate?
9. What will be the added costs of hospitals billing for ambulance services under Part B?
SCHEDULES
All participants have indicated that they are available to attend the first meeting on October 20-22, 1998. The first meeting should cover the following:
o Orientation by the facilitator/mediators
o Adoption of group protocols, including a definition of consensus
o Agreement on meeting schedule
o Discussion and agreement on statement of issues to be addressed in the rulemaking
o Agenda for the next meeting
o Time permitting, further discussion
PROTOCOLS
The participants will be provided with examples of group protocols and a recommended group protocol which will outline in more detail items they may adopt as part of their operating procedures. Consensus decision making will be one of the protocols under which the committee must operate. In a consensus dialogue, all parties must be willing to live with any agreement. The committee should at this juncture also discuss what may happen if consensus is not reached.
Return to Ambulance Fee Schedule
Last Updated March 18, 1999
 |
 |