Wrap-Up Discussion with Federal Partners
Workshop chair Arthur Kellermann introduced the final session, describing it as the final opportunity for the workshop’s three federal partners—the Departments of Transportation, Homeland Security, and Health and Human Services (HHS)—to offer summary comments about what they heard over the course of the two-day workshop.
Drew Dawson, director of the Office of Emergency Medical Services at the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation, led off the response. He highlighted several key points. First, he said, by and large the workshop participants view regionalization (however, that will later be defined), as a good idea. But he emphasized that the “devil is in the details” with respect to how regionalization gets accomplished, by whom, when, how it’s structured, and how it’s financed.
Second, he emphasized that we need population-based data in order to determine the effectiveness of regionalized systems and to evaluate how well they are operating. Data should drive what we are doing, he said, whether that is hospital-based data, population-based data, or data from the National Emergency Medical Services Information System (NEMSIS).
Third, he underscored the importance of systems research. He said we have talked a lot about various types of systems. However, we have also acknowledged that we do have the ability to evaluate different systems or to assess whether one is more effective than another. Then, if we find one more effective than the other, how can we determine which components of the system contributed to the increased efficiency or the improved patient outcomes? He noted there had been quite a bit of discussion about aligning
reimbursement with system performance and system design. He also noted that comparison against system benchmarks is important, whether those are generated at the federal, state, local, or regional level.
Dawson concluded, “It seems to me that perhaps one of the most important things is relationship building … continuing to build relationships among emergency services providers [and] among the components of the system, so that you have day-to-day honest dialogue and the people just get along with each other. That may be one of the most critical things we do.”
Jon Krohmer, principal deputy assistant secretary and deputy chief medical officer in the Office of Health Affairs at the Department of Homeland Security, said he would support all of Dawson’s comments. He pointed out that “something that came up in the preparedness discussion [Chapter 8] is the fact that the system is stressed on a daily basis right now… . We have to figure out ways to address that.”
Another key point of the discussion, Krohmer said, was the issue of leadership and how that comes about. At the federal level there has been a lot of controversy about who the federal lead agency is and how the federal partners should work together. Krohmer said that, through a combination of the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the Emergency Care Coordination Center (ECCC), the federal agencies have over the last couple of years been able to increasingly work together on these issues.
But, he said, he is not sure about the leadership or authority responsibilities held at the state and sub-state levels. Obviously, it varies state to state, but he said to his knowledge, within most states there is nothing that authorizes or empowers an entity to become the regional leader. He challenged the group to focus on who will provide leadership at the state and sub-state levels and what authorities and responsibilities these groups must have.
Andrew Roszak, senior health policy fellow at the Emergency Care Coordination Center (ECCC), within the Office of the Assistant Secretary for Preparedness and Response (ASPR), in the Department of Health and Human Services, endorsed Dawson and Krohmer’s comments, especially those regarding federal leadership. He said that with the advent of FICEMS and the Council on Emergency Medical Care and the establishment of the ECCC, “we are at a unique place in time where emergency care is finally getting a voice within the federal government—and very importantly, a centralized voice.”
Roszak said that the ECCC is very interested in regionalization. He said, “We are tasked with looking at the delivery of daily in-hospital emergency care. Regionalization, obviously, plays right into that.” He said the ECCC’s goal is also to coordinate emergency care issues throughout the federal government. Currently, these issues are scattered among many different agencies
and it seems that “everyone kind of has a hand in it.” He said if there is a way to align some of the incentives, and some of the research, and some of the grant work that is going on so that it makes more sense, “I think we’d be doing a great service.”
“That being said, it seems clear that regionalization is ultimately a state issue—just with the way the licensure works and the way EMS systems have traditionally been set up.” Roszak noted, “We do have to work on that relationship building with the state and local partners.”
Roszak recalled that reading the materials written by Dr. Boyd in the 1970s “is a reminder that these issues have been around for a long time, even something as simple as defining the term ‘regionalization.’ The more we get together and work on these issues and begin to develop a common lexicon, the better off we will all be.”
Kellermann stated that “Regionalization is a paradigm that applies to the critically injured or highly technically complex patient who needs a level of technical expertise that is not available at an isolated local facility, but is available in a tertiary care setting. But a point of emphasis this morning was that regionalization needs to be a web, not a funnel. Ultimately that may provide us with additional efficiencies and opportunities—but first we will need to get beyond the competitive turf battles and the regulatory, financial, and cultural barriers we have identified.” He concluded that the workshop had established an important concept that “the idea of bidirectionality is very, very important—regionalization must be a win-win proposition.”
Waeckerle agreed that in order for regionalization to be supported, “it has to be win-win.” He said regionalization should not be viewed as “centralization with a one-way funnel. [It is] collegial communication and coordination, so that everybody wins—the patient, the local medical community, the local health care professionals, EMS, [and] the secondary and tertiary-care center. It has to work for the public institutions and the private institutions. They have to come together. … We can’t sell it unless everybody wins.”
Waeckerle concluded by noting that “A few things will result if we approach regionalization from that mindset. First, there will be improved care at the community level. Second, we will likely get more primary care docs out into places they haven’t been before (which has been a goal in this country for a long time). And third, we might incentivize more people to enter the health care field, whereas now young people, including my own children, are shying away from the field, saying, “I don’t know if I want to do this, Dad. I don’t know if I want the hassles, and I don’t want to work for somebody who is telling me what to do all the time.” Waeckerle said
that “our greatest advocates are our citizens and our population.” As the health reform debates move on, “we need to get them on our side. They need to win.”
ENVISIONING A CONGRESSIONAL ACTION PLAN
Andrew Bern, of the American College of Emergency Physicians, posed a hypothetical question to the panel: Congress is working on a health reform bill and a Congressional leader calls asking how much money would be needed to enact the reforms we have been discussing. Also, what would need to be in the legislation? How would you answer?
Kellermann responded that the short answer would be that we need a renewal of the EMS Systems Act of 1973. It would be the EMS Act of 2009 and it would provide a clear, comprehensive vision. “It would be a big win for everybody,” he added.
Dawson said he didn’t think we had done enough work on this to be able to estimate exactly what a program would cost. It would depend on how the legislation was structured and what was included in it. Krohmer thought the price tag to do it right could be substantial. Roszak agreed that the cost could be high, but noted that demonstration projects would make a lot of sense, with an eye toward examining what works in urban versus suburban versus rural areas.
Dawson added that it’s important to emphasize that improving the nation’s emergency care system is not just about dollars. “It’s about leadership,” he said. “It’s about coordination. It’s about ensuring that emergency medical services and trauma systems and emergency care are included in the national health security strategy. It’s important that those items be included in all of the grant funding. It’s [also] important that the evidence-based practice guideline process drive the improvements in the emergency care system.” He said, “I think sometimes we look at legislation and dollars, and although they are very important, that isn’t always the solution to improving emergency care in the nation.”
Boyd noted that his original plan in 1975 was a $500 million plan. He said that total today would be a reasonable request. As to the specifics, he responded, “it’s not complicated. Read what we did last time. See how we put it together. That’s what needs to be done again. There needs to be a grants program. There needs to be a technical assistance program. There needs to be a research program. There needs to be an interagency committee. There needs to be a lead agency in the federal government that speaks to the clinical systems that we are talking about here, the old ones and the new ones.”
He emphasized the importance of the federal lead agency concept. He said people should “look at the success of the lead agency in the nine years
that it was [within the U.S. government]. We went from the dark ages to modern systems just about every place, and many of them were successful.” If you give HHS $500 million as the lead agency, they will provide the technical assistance, build up the systems, and the health departments. HHS will also be in a leadership position to redirect and make some sense out of some other programs.
What needs to be purchased and what needs to be allocated is very straightforward, Boyd said. “There is a lot of money that needs to go to communication systems, maybe 40 percent. Some has to go into training of all kinds of people in all kinds of ways. There is also an administrative component. … It’s not a very difficult model.” In addition, he argued that the research program has to be focused on systems, “not redos from other agencies.”
Boyd said that if we go the route of demonstration projects, say the amount is $10 million, we need to remember to demonstrate, not build, programs. “We don’t need to put money out there to subsidize somebody’s developmental lead agency, but to demonstrate issues.” But he argued, we don’t just have rural and urban. “We have urban communities that group themselves into megalopolis kinds of arrangements. We have other communities, about 60 percent of this country, that are actually the rural-metropolitan model—the Lexington, Kentucky, and the other places that have trees” (see Chapter 1). “Then we have frontier settings—places in the middle of our country that don’t have any trees and they don’t have any trauma centers or regional centers. They are sparsely populated and sparsely resourced.” Boyd said all three models are important in framing how the issues in the demonstrations should be tested.
THE ROLE OF A FEDERAL LEAD AGENCY
Dia Gainor, chief of the Idaho Emergency Medical Services Bureau, argued that “for any of us to say this problem has been around for a long time is really no excuse. I don’t think it should [lessen] any of our enthusiasm to seek positive change or solutions.”
With respect to the federal lead agency issue, Gainor said that many past arguments about this topic have been centered on which agency should be the lead federal agency for EMS. But, she observed, there has not been a substantive conversation or any consensus about what such a lead federal agency would do. She asked the panelists if they agreed that more should be done at a federal level and, if so, what specific tasks, deliverables, programs, and grants would they see coming out of it?
Dawson agreed that the functions of a potential lead agency have never been clearly delineated, including in the 2006 Institute of Medicine (IOM) report. It is not up to him to define what those functions should be—that is
something we should do collectively, he said. The focus should be on defining what the responsibility of the federal government as a whole should be with respect to emergency medical services. Once that is defined, “there may be a whole variety of ways to get there.”
Dawson elaborated, “We have heard during the course of this workshop that the federal government should have an active role. We have also heard that perhaps the federal government should not have as active a role, for example with respect to providing benchmarks. I think we haven’t arrived at what we want the role to be. If we can collectively define—not just as a federal government, but in conjunction with all of the participating organizations and agencies throughout the nation—what those functions should be, then we can also collectively determine how to meet those functions. Otherwise,” Dawson concluded, “We are proposing a solution before the exact problem has been defined.”
Krohmer said that he agreed with Gainor and Dawson that we have not yet defined what the appropriate roles and responsibilities of a federal lead agency would be. However, having said that, based on his own experience, he believes that a single lead federal agency—if it was given the authority—could be very helpful when it comes to issues such as disaster preparedness and mutual aid. He continued, “A lead agency could also be helpful in identifying five levels of EMS providers and defining their scopes of practice, so that a paramedic in Idaho is the same as a paramedic in Michigan, is the same as a paramedic in Florida. That would allow cross-jurisdictional credentialing and patient-care issues to be addressed much more easily. That would be just one example of what a lead agency could do.”
Krohmer said he would be hesitant to say that within a national system we would need 303 regions and these regions need to do A, B, and C. “I think there is enough uniqueness in each state that my preference would be to leave it up to a state entity to help facilitate that.” He added, “I think there does need to be a state entity to do that. Not all states have that authority currently vested in some entity.”
Roszak echoed Krohmer’s comments. “The federal government currently does a lot with respect to research and data. It’s just scattered throughout all the different agencies.” He said the federal government should make it a goal to incentivize data collection and analysis and should help in dissemination. “This would be a tremendous service,” he said. However, he added, it’s a matter of getting the states on board to figure out ways to do that.
Also, the federal government has a sizable role with respect to disseminating best practices. Roszak said, “If we ever did move to a national system, where a paramedic is a paramedic is a paramedic, it would be a great resource to have the federal government help determine appropriate treatment protocols and then disseminate best practices.”
The federal government is currently doing many things in a lot of different areas, Roszak added. “Bringing all that together is certainly the goal of the Emergency Care Coordination Center, and I hope that we can achieve that goal.” He said that the government has made considerable progress, but that at some point it may make sense to have a discussion of what else they could do to help.
Dawson responded that “the concept of what the responsibility of the federal government should be is a legitimate item for discussion at FICEMS, at the Council for Emergency Care, and, from a non-federal perspective, through the National EMS Advisory Council.”
BUILDING A UNIFIED SYSTEM
Jon Mark Hirshon of the University of Maryland observed that “we have discussed many systems—trauma systems, EMS systems, STEMI systems. There are multiple different systems.” During an earlier part of the workshop, Ken Kizer pointed out that there is no health care system in the United States, no systematic approach to the issues we face. This morning, Ricardo Martinez put forth the vision of an interconnected web. Hirshon argued that this needs to be “multidirectional, not just bidirectional.” However, right now there is no coordinated response from an overall systems perspective.
Hirshon asked, “How do we take this wonderful discussion of the last two days and … integrate that into a functional system? More specifically,” he asked, “what is the role of the federal government within that integration process (recognizing that form follows finance)? How is it that we are going to go from all these different systems into one integrated systems, with multidirectional communication—a kind of web of emergency care?”
Dawson replied, “I’m not sure it’s a realistic expectation to say that the entire nation will be one interconnected web. That may be a bit [too] ambitious. We probably need to concentrate on working with states and state EMS agencies, to help provide them some tools, to help provide some consistency on a nationwide basis. I think it’s a lot easier to try to focus on 50 elements than to focus on every individual agency in the nation. [W]orking with states, so that states assume a leadership role in developing regional or interconnected webs, or whatever we talk about—I think we can provide tools and assistance to help them do that.” He added, “I’m not an advocate of the federal government necessarily doing that. I’m much more of an advocate of building up the capability within the states and local areas.”
Krohmer said we need to continue to refine the model. But while it may not be the total responsibility of the federal government, there is a role at the federal level to get all of the health care disciplines on board so that they accept the concept, buy off on it, and promote it. Then, he said, it becomes
an issue of drawing in the third-party payers and making it a part of the reimbursement system.
Roszak agreed. “The federal government can help significantly on the front end by establishing the relationships necessary to make this a reality and helping to identify some of the potential pitfalls that may run the project afoul, and then on the back end, providing support, data collection, analysis, and performance assessment, and ways to improve.” He added, “They could then package all that up and generate best practices that could be disseminated to other parts of the country. … That would be a commonsense approach for the federal government to take.”
Alex Valadka, a neurosurgeon from Texas, raised the issue of liability reform, which he said he been mentioned a few times during the workshop, but had not been discussed extensively. He noted that the 2006 IOM report cited liability as a factor that dissuades many people from participating in the emergency care system. The perception is that this is a significant risk for providers.
He acknowledged that the issue of medical liability reform, or tort reform, is “a huge, gargantuan thing.” But he suggested focusing first on protection for the people who provide Emergency Medical Treatment and Active Labor Act (EMTALA)-mandated care. “EMTALA requires us to do things and doesn’t give us any protections,” he said. He asked whether it might be reasonable to include some reasonable statutory protections for people who are providing legitimate emergency services as part of any demonstration projects that move forward.
Kellermann replied that there are three major paradigms for tort reform. One is the microcap limits on pain and suffering, which have been a battleground for the better part of a decade. Another, which was enacted in Georgia several years ago under the auspices of an EMTALA give-back, was an increase in the legal standard to gross negligence, as opposed to some lesser standard. The third is a concept of a safe harbor. If you practice within well-established guidelines, you would have a safe harbor for your decisions (e.g., for not getting that computed tomography (CT) scan or not ordering that PET [positron emission tomography] scan).
Valadka responded that if there are guidelines that professional groups can come up with as a specialty and as a group, he would think that could be a starting point. He noted that microcap has been in existence for over three and a half decades in California and there are still problems. So while that is not going to answer all the problems, it would eliminate a potential barrier, making it easier for more people to participate in the emergency care system.