may reflect a lack of resources, comfort, or expertise among emergency providers for the care of pediatric patients (Derrington et al., 2005).

Rural emergency care providers and provider organizations face a number of operational challenges not encountered by those in urban or suburban areas. In rural areas, the relatively low volume of emergency calls in relation to the high overhead of maintaining a prepared staff results in very high costs per transport. To lower those costs, many rural EMS squads rely on volunteers rather than paid EMS providers, which by nature results in a less stable system. In many rural communities, younger residents are leaving while the remaining population becomes more elderly. As a result, the pool of potential volunteers is dwindling as their average age and the demands on their time increase. The closure or restructuring of many rural hospitals has further increased the demand on rural EMS agencies by creating an environment that requires long-distance, time-consuming, and high-risk interfacility transfers. Another challenge facing some rural areas is that the population can swell—double or triple—during the tourist season. Thus the EMS staffing required throughout the year varies.

Under the Balanced Budget Act of 1997, Congress established the Medicare Rural Hospital Flexibility Program. In additional to providing cost-based reimbursement to certain rural hospitals, the “Flex Program” provides states with grants to support their rural health infrastructure and foster the growth of collaborative rural health care delivery systems. In fiscal year 2003, states received approximately $22 million under the program, with the average state award being approximately $500,000. Development of EMS systems has been a growing focus of state planning efforts under the grants (Flex Monitoring Team, 2004). The committee finds this trend promising and encourages states to focus attention on pediatric needs within rural EMS systems.

REIMBURSEMENT FOR PEDIATRIC EMERGENCY CARE

The costs of providing emergency care services reflect not just the operational costs of responding to each emergency call, but also the costs associated with having personnel available around the clock. Appropriate reimbursement for pediatric emergency care services is of obvious importance. It allows emergency care organizations to increase their readiness by hiring and retaining providers with the right mix of skills and training, to offer continuing pediatric education, and to equip providers with appropriate pediatric supplies. It also allows providers to make investments that can improve the quality of care delivered, from the development of new quality initiatives to the installation of information systems.

Funding for pediatric emergency care differs from that for adult emergency care in that the payer mix is different, which has important implica-



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