In April of this year, the Health Care Financing Administration (HCFA), the federal agency that oversees Medicare, appointed a 14-member National Rulemaking Committee (NRC) to decide how Medicare will fund ambulance service in the next millennium. Subsequently, the NJ EMS Council appointed a special subcommittee to study how the about-to-be proposed reimbursement fee structure will impact New Jersey's EMS community. That subcommittee recently met at the Allentown First Aid Squad, drawing representatives from the state's BLS volunteers, its commercial BLS and ALS providers, and its emergency physicians.

Dr. John Brennan, alternate member to the NRC, and Rod Muench, OEMS director, provided information on the work done by the committee thus far. Brennan told participants that the committee's report will be final on February 14, 2000 and warned them that it is still a "working document". He could, however, strongly speculate on its contents.

In a presentation of the NRC findings, Muench first underlined the fact that the committee's function was to define the levels of EMS service, give each a relative value, and examine regional differences which would affect those values. This committee was not charged with identifying any dollar rate for reimbursements.

*Components of a "matrix" EMS fee structure have been defined: BLS, Simple ALS, Complex ALS, and Critical Care, Rotor and Fixed Wing Transport. Each component has been assigned a "relative value unit"(RVU) Simple ALS would provide advanced assessment and less than three interventions; Complex ALS, three or more interventions.

*A "relative value unit" or RVU, was proposed for the reimbursement of each component. Simple BLS would rate "1"; Simple ALS "1.2"; Complex ALS "1.6"; Critical Care Transport "1.8"; Fixed Wing "10.0"; and Rotor "15.0"

*What adjustments can be made to the fee schedule? The committee is still considering so-called "modifiers" to the reimbursement such as geographical differences; scheduled or unscheduled transport, 9-1-1 calls; rural/urban/wilderness areas; mileage or flight hours. Should the adjustments be part of the base rate? At this time, there are more questions than answers.

*The NRC collected data through "Project Hope" whereby hospital-based MICUs and commercial BLS were surveyed concerning Medicare billing. "Project Hope" came up with RVUs within 0.1% of the RVUs developed by the NRC.

*If NRC members cannot come to a consensus (100% agreement), the final report will include their pros and cons, but HCFA will make the final determination. Members had to sign a contract that their organizations would not submit negative comments on items afterwards if consensus was not reached.

*The greatest conflict in these negotiations seems to be between fire-based interests and the private-based interests.

*The first year trust fund, or "size of the pie" will be approximately $2.4 billion for all Medicare reimbursement for EMS nationwide; the amount spent in 1998.

*Using a fee structure may be the only way to control EMS costs.

*The proposed fee schedule will be "modeled" in small communities in the country to see how it works in different geographical areas. [This would be desirable for NJ.]

*It is unlikely that implementation will begin prior to January 2001. It will not be a changeover date from one day to the next. It will take a long time to educate Medicare providers with the new fee schedule. Implementation and transition will be discussed at the NRC meeting on January 24th meeting. Presentation of the whole package will be February 14th.

*There will most likely be a slight increase in BLS Medicare reimbursement; however, there will be a decrease for ALS. MICUs will have to bill under Medicare Part B, "outpatient services" instead of Medicare Part A, "hospital services". Therefore, hospital-based ALS may no longer be able to "reconcile" their losses with Medicare at the end of each year.

*The NRC meeting minutes are posted on the internet: http://www.HCFA.gov/medicare/ambmain.htm

Mary Ann Ferrara, President of the NJSFAC, stated that proposed NRC changes would place volunteers "smack in the middle of turf wars between commercial BLS and ALS." She continued: "If it's going to be only the transporting agency that gets the money, we're going to get squeezed. The paid providers will want a bigger piece of the pie because the reimbursement is going up; ALS will have to transport to get sufficient money." Ferrarra believes volunteer squads would increasingly be unwilling to serve with concurrent coverage. She also commented that volunteer squads want no part of licensure in order to facilitate reimbursements to MICUs.

"The preservation of the system is essential for all of us," said Ferrara. "There's no argument there," said Brennan.

Martin Hogan, president of the NJ Association of Paramedic Programs, agreed. He believes there is not enough funding to keep the present hospital-based ALS system intact. "With the models out there at present, the ALS units are not going to survive," he said. "You guys are going to be BLS without ALS back-up."

"The money that is saved by having the volunteers in place and not charging for those BLS runs coupled with the money that is paid to the proprietaries and ALS services is overall less expenditure than the model they're looking at." Hogan said. "The model that the NRC is looking at in NJ is going to cost them more."

"The hospital based programs are going to have to figure out how they're going to be able to sustain what they have in place." said Lou Sasso, RWJUH EMS. "It will be an individual hospital decision." "I don't believe two paramedics can provide the same level of care to a critical patient that a team of EMTs and paramedics can provide," said Mary Daley, Community Hospital MICU, "Ultimately patient care will be affected."

Mickey McCabe, subcommittee chairman and commercial BLS representative said, "I believe that whatever we do, it should be to retain the status quo in New Jersey. "If the implementation is 1-2-3 years and the legislative process is available to us, that would be a wonderful thing."

"The goal from my perspective is we need to strive to preserve the best part of the MICU system we have, e.g., 100% coverage in NJ; strong based medical command and QA; paramedic education and certification," commented Rod Muench, OEMS. "Those are my recommendations."

The subcommittee unanimously supported the present EMS system in New Jersey. Some members of the committee -- the ALS and BLS communities (volunteer and proprietary) and the emergency physicians -- have already sent letters to federal congress persons and select state legislators apprising them of the situation and suggesting possible solutions: HCFA may continue to agree to NJ's waiver; NJ may supplement the ALS providers; or an entire redesign of the prehospital system.

A coalition of members was appointed to begin developing strategies on measures to seek federal and state legislative support on this issue in the coming months. Squads will be given legislative packets with information on how to lobby this issue in January, 2000.

Julie Aberger