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Rural Hospital Flexibility Program Tracking Project

Chapter 4
EMS Activities Under the Rural Hospital Flexibility Program

Julie A. Schoenman, Ph.D., Penny E. Mohr, M.A., and Curt D. Mueller, Ph.D.
Project HOPE Walsh Center for Rural Health Analysis

Introduction

While the creation of critical access hospitals (CAHs) is one cornerstone of the Rural Hospital Flexibility Program (Flex Program), improvements to rural emergency medical service (EMS) systems constitutes another critical component of the program. The Balanced Budget Act of 1997 (BBA), which provided cost-based reimbursement for CAHs and established the associated Federal grant program, provided explicitly for two uses of grant funds: 1) to support conversion of hospitals to CAH status, and 2) to support improvements to rural EMS systems. Furthermore, these EMS projects need not be linked to a CAH conversion. Recognizing the prominence given to rural EMS improvements by Congress, the Federal Office of Rural Health Policy (FORHP) has made EMS one of the five areas states must address each year in their applications for grant funds. In this chapter, we report on states' use of Flex Program grant funds related to rural EMS improvements.

In addition to grant-funded EMS initiatives, there are several reasons why CAH conversion, in and of itself, may affect the local EMS systems. First, CAHs must establish written agreements regarding patient transfers and communications between the CAH and at least one referral hospital. These arrangements could change the provision of emergency medical services in the CAH community and surrounding areas. In more developed systems, CAHs may become part of a more extensive network, which could involve additional hospitals and other types of providers, including EMS providers. Recent legislation making it possible for some CAHs to qualify for reasonable cost reimbursement for ambulance services may provide an added incentive for CAHs and local EMS providers to change to hospital ownership of ambulance services and integrate services.

Second, even short of formal inclusion of EMS providers in the CAH network or CAH ownership of an ambulance service, changes in the day-to-day operations of the CAH may have spillover effects for its own emergency department (ED) or the local EMS system. For example, CAHs must provide access to emergency care around the clock, but on-site requirements and staffing provisions have been relaxed relative to acute-care hospital standards. Likewise, post-conversion changes in the CAH's scope of services, changes in the community's support for the facility, improved ties to the network hospital and/or area trauma system, and the 96-hour limit on average length of stay may affect the volume and type of patients coming to the hospital emergency room as well as the number and type of patients transferred by ambulance between the CAH and other facilities. For these reasons, we also report here on EMS system changes related to CAH conversion.

Data Sources

Information presented in this chapter was drawn from five main sources. First, the telephone survey of certified CAHs (discussed in more detail in the Introduction) included questions asking for the CAH administrator's perception of the local EMS system and how CAH conversion has affected various aspects of the EMS system and the CAH emergency department. Second, Walsh Center staff reviewed the Year 02 Flex Program grant applications from approximately 20 states in order to learn about the types of EMS improvement activities states intended to undertake during this year of the program. Third, information on other states' EMS initiatives was gathered through phone interviews that the University of North Carolina staff conduct periodically with representatives of each state. 

Fourth, all 12 states visited during Year 01 of the Tracking Project were re-contacted by phone in order to learn about any changes that had taken place since the time of the earlier visit. Walsh Center staff conducted interviews focused specifically on EMS issues for five of the Year 01 states (Georgia, Maine, North Carolina, Texas, and Wisconsin), and relied on follow-up interviews conducted by other team members for the remaining seven Year 01 states. Typically, we interviewed representatives of the state offices of rural health (or the Flex Program grantee organization), the state EMS office, the administrators of the two CAHs visited in that state during Year 01, and (as warranted) EMS providers and other contacts in the CAH community.

Finally, the Walsh Center conducted site visits to four new states to learn about their Year 02 EMS activities. These states were selected after consideration of the information presented in the Year 02 grant applications, and represent a mix of initiatives ranging from EMS needs assessments and training programs to EMS regionalization efforts and feasibility studies regarding CAH acquisition of the local EMS service. Three of these states (Michigan, Oregon, and West Virginia) were also targets of the broader site visits conducted concurrently by other members of the Tracking Project consortium. The fourth state (South Dakota) was selected solely for study of its EMS activities and was not visited by any other Tracking Team staff. Additionally, EMS information was collected by other members of the consortium during their own site visits to five more states (Iowa, Nebraska, New Mexico, North Dakota, and Tennessee). As in Year 01, the focus of these interviews was to understand how the state was using Flex Program funds to improve rural EMS systems, and whether CAH conversions had brought about any changes in the hospital's ED or the local EMS system.

Findings

Data from the Survey of Certified CAHs

Functioning of the EMS System. In the CAH survey, CAH administrators were asked to rate the overall functioning of the local EMS system using a 5-point scale, where 1 was "poor" and 5 was "excellent." Figure 1 shows that nearly three-quarters of the administrators felt the local EMS system was working well, giving a rating of 4 or 5. Only 11 percent of administrators gave the local EMS system a negative rating overall.

Major Problems Facing EMS Systems. Despite the generally favorable ratings for overall functioning, administrators were able to list specific problems when asked an open-ended question about the major problems facing the local EMS system. By far the most common problem noted by administrators was the difficulty of recruiting and retaining EMS staff, particularly in areas that relied heavily on volunteer providers (Table 1). More than half of the CEOs indicated that this was a major problem in their market area. A large number of CEOs cited inadequate reimbursement and funding as a major problem (22%), and 12 percent listed difficulty obtaining initial training and continuing education as a major problem. Not surprisingly, these same themes were echoed during virtually all of the site visits, and correspond very closely with findings from our review of the rural EMS literature. 

Table 1.  Major Problems with EMS Systems

Table 2.  Provision of Ambulance Services, Before and After CAH Conversion

The remaining EMS-related questions in the survey asked about changes in the local EMS system and in the hospital's interactions with that system that may have occurred following conversion to CAH status. Topics included CAH provision of ambulance services, responsibility for EMS medical direction, the volume of patients brought to the CAH emergency room by ambulance, the volume of patients transferred between the CAH and other facilities, and use of CAH RNs to accompany critically-ill patients during interfacility transfers.

Hospital Provision of Ambulance Services. With the Flex Program's focus on the creation of rural health networks, some observers have speculated that CAHs may seek to acquire local ambulance providers. Provisions of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) that permit certain CAHs to receive reasonable cost reimbursement for ambulance services provided by units that they own and operate might add further incentive to such integration of hospital and EMS operations. In fact, however, as shown in Table 2, the vast majority of CAHs surveyed (79%) did not provide ambulance services prior to becoming a CAH, and only four hospitals began providing ambulance services following CAH conversion. Two other hospitals stopped providing ambulance services after conversion. To date, then, most CAHs are not operating ambulance services, nor has there been any rapid movement in this direction. Additionally, it is important to note that not all ambulance services owned by CAHs are providing emergency care; some provide only non-emergency transports.

Medical Direction. Likewise, to date there has been almost no change in the responsibility for EMS medical direction following CAH conversions, with only 4 percent of surveyed facilities indicating that any change had occurred (Figure 2). Nor were there clear patterns when changes occurred. Two of these facilities indicated that a physician at their hospital had assumed responsibility for medical direction following CAH conversion, while three others indicated that responsibility had moved to a physician at another hospital.

ER Volume. The volume of patients brought by ambulance to CAH emergency rooms might change for any number of reasons following conversion. For example, expanded hours of ER operation, expanded staff or capabilities, improved relationships with local EMS providers, formal participation in a hospital network or regional trauma system, and increased public confidence in the facility are all factors that could lead to increases in ER ambulance volume. Conversely, real reductions in the hospital's scope of services (e.g., elimination of after hours surgery) or perceptions of the public and/or ambulance providers that the capabilities of the CAH have declined could lead to a fall in ER ambulance volume. 

From Figure 3, we see that only 14 percent of CAHs experienced a change in their ER ambulance volume following CAH conversion. Of this number, ER volume increased for 70 percent of the facilities, and decreased for 30 percent of the CAHs. Many of those reporting an increase cited their expanded ER hours/staff, improved ER quality, and increased support from the community, local physicians, and local EMS providers as the main reasons behind this increase (data not shown). Several administrators, however, reported that the increase was due to factors not related to the CAH conversion, such as an influx of retirees and tourists, closure of a nearby hospital, and greater local availability of health insurance. Those with ER volume decreases, on the other hand, indicated that they are still struggling with lack of community, physician, or EMS system support, or have scaled back their scope of services.

Figure 3.  Changes in ER Ambulance Volume Since CAH Conversion

Interfacility Transfer Volume. There are also a variety of reasons why the volume of patients transferred between the CAH and other health care facilities may change following conversion. Most notably, the limit on length of stay could bring about more transfers from the CAH, although the change to a 96-hour average has weakened this impetus. Reductions in the CAH's scope of services and stronger ties to referral facilities could also increase the number of patients transferred between the CAH and other hospitals, including patients transferred back to the CAH swing beds for convalescent care. With many rural EMS systems currently struggling to find personnel and operate multiple rigs, a significant increase in interfacility transfers could stress already fragile EMS systems if these transfers remove the ambulance from the community for long periods of time. On the other hand, expansions of the CAH's ability to treat more patients-or a wider range of conditions-could reduce transfers from the CAH.

Figure 4 shows that four of every five CAHs surveyed said they had not experienced a change in the volume of interfacility transports following CAH conversion. Of the approximately 20 percent that reported a change, the vast majority (78%) reported an increase in interfacility transport volume. The most common reason cited for these increases was the restriction on CAH length of stay (data not shown). Administrators also attributed the rise in transfers to the CAH's inability to provide needed services (e.g., intensive care, general surgery, orthopedics, diagnostic testing); their closer ties with other hospitals, which encourage them to stabilize more critically-ill patients and then transfer them elsewhere; and a general rise in the number of patients coming to the CAH. CAHs that have experienced a decline in interfacility transfers typically noted an expansion of their internal capabilities (e.g., addition of obstetrics services, a new CT scanner, additional medical staff, improved ER coverage and capabilities) and increased support from their community as key reasons for the decrease in transfers from the CAH.

Figure 4. Changes in Interfacility Transport Volume Since CAH Certification

Use of RNs for Ambulance Transports. In areas without adequate paramedic support, in particular, hospitals occasionally find it necessary to send their own RNs to accompany critically-ill patients during ambulance transfers from the hospital. This practice could, in turn, compromise the hospital's ability to provide care to its remaining patients. Such stress on the hospital staff could be exacerbated by CAH conversion to the extent that conversion leads to an increase in interfacility transfers of critically-ill patients.

Table 3.  Use of CAH Nurses for Interfacility Transfers

Table 3 shows that two-thirds of CAHs do send their own RNs on interfacility transfers of critically-ill patients. Not surprisingly, however, given the earlier finding that CAH conversion has not affected transfer volume for most CAHs, very few administrators indicated that they have had to use staff nurses for interfacility transfers more frequently since CAH conversion. Of the 20 hospitals reporting such an increase, eight administrators felt that this increased demand on their staff had compromised the capacity of the nursing department to meet patient needs.

Overall Impact of Conversion. The final EMS question in the CAH survey asked administrators to assess the overall impact of the CAH conversion on the local EMS system. More than three-quarters of the CAHs thought the conversion had not affected the local EMS system (Figure 5). When they reported an impact, it was nine times more likely to be positive than negative.

Overview of States' Rural EMS Improvement Initiatives

As described in the Year 01 report from the Tracking Project, EMS initiatives were often given a relatively low priority by states during the first year of the Flex Program. Understandably, the focus of most states during the first year was on the state health plan and the CAH conversion process. Additionally, states whose grant awards were significantly below their requested budget had to reduce their planned scope of work, and EMS activities seemed to be among the first items to be scaled back. It also appeared that many states used the first year of the grants to form EMS work groups, initiate EMS needs assessments, or otherwise collect information so as to formulate more detailed initiatives for subsequent years of the program. 

During the second year of the grant program, most states received grant awards more in line with their budget request, a large number of states have the CAH conversion process well in hand, and many states have completed their collection of EMS data in at least a few areas of the state. Accordingly, as the Flex Program grants move into what might be called their "second generation," states are giving much more attention to EMS projects. The Federal Office of Rural Health Policy (FORHP) estimates that, collectively, states plan to spend between $3 and $4 million of the Year 02 grant funds on activities related to rural EMS improvements. 

In keeping with the flexibility afforded to states in the use of Flex Program grant funds, a wide diversity of EMS activities are being undertaken in Year 02. Table 4 at the end of this chapter summarizes these activities for most of the states. While there is great variation in the EMS projects, there were some common patterns. EMS training programs were, by far, the most popular initiative proposed; some states had scholarship programs built into their proposal, as well. EMS needs assessments were also still a popular activity in Year 02. In some cases, the state was continuing assessments begun in Year 01, while in other states the assessments were a new activity. A relatively large number of states were using Flex Program grant funds to establish systems to collect and/or analyze ambulance run data. States were also purchasing computer hardware or software, which could be used to support not only these pre-hospital data collection activities, but also EMS billing systems and training programs. Several states proposed other small capital acquisitions, such as upgrades to communication equipment and Automated External Defibrillators. These capital purchases were typically small, however, due to the federal limit on capital expenditures under the Flex Program grants. Finally, a few states proposed grant writing assistance designed to help EMS provider organizations, for example, compete more effectively for other sources of funds. 

States' Distribution of EMS Grant Funds

It appears that the majority of states are distributing at least a portion of their Federal grant funds to other entities within the state, rather than maintaining state control over the full grant amount. Most commonly in the early stages of the program, states have provided grants to hospitals for financial feasibility studies and other activities related to CAH conversion. As conversions have proceeded, some states are continuing to split a portion of their Federal award among the state's existing CAHs, with the hospitals given wide discretion in the use of funds. While these grants could encompass hospital-initiated EMS activities, there is typically no requirement that hospitals use any of the money for this purpose and little evidence that hospitals are doing so.

This "mini grant" financing mechanism is also a very popular way for states to distribute Flex Program grant monies that they have earmarked specifically for EMS improvements. Despite the focus of these grants on EMS activities, it is still most typical for the award to be made directly to CAHs. This situation may be the result of strong state hospital associations or of a general belief that the Flex Program should be centered around hospitals. While these grants will, by definition, be used for EMS-related projects, the hospital may not be required to involve local EMS providers or other concerned parties in the grant activities. For example, New York planned to make grants to CAHs to establish transport agreements, Tennessee intended to make hospital grants for the purchase of telemetry equipment, and Vermont proposed grants to its hospitals so they could conduct EMS needs assessments in their markets. On the other hand, Arkansas is making small grants of $3,500 to each CAH in the state, but requires the funded project to involve the local EMS unit. Recent applications have included a joint Advanced Cardiac Life Support (ACLS) training program, and the purchase of mini ventilators that will be used by both the hospital and the ambulance service.ⁱ Similarly, Iowa was planning small grants to each CAH to convene meetings with local EMS providers to discuss opportunities for collaboration. 

A relatively small number of states have structured their EMS mini grants so that the money is distributed beyond the CAH. North Dakota, for example, set aside $30,000 of its Year 02 award to make two EMS grants. Grant applicants were required to represent a collaboration between a CAH, another hospital (e.g., the network hospital), and at least two EMS provider organizations (e.g., one in the CAH's area and one in the network hospital's market area). One application was received and funded. Washington state makes grants to EMS providers working in conjunction with either a CAH or tribal organization, and Mississippi proposed grants for each of the state's six trauma system regions where a CAH is located. South Dakota planned to distribute money to "critical access ambulance services," which the state defines as the sole ambulance provider in an area, often in a financially fragile situation, and whose closure would result in significant hardship for the local residents. Wyoming was also planning to award grants to small rural EMS services for training initiatives and equipment purchases.

EMS Training Initiatives

Training initiatives are being carried out by a very large number of states. The popularity of this initiative is not surprising given the high level of need identified above, and the fact that training programs are fairly straightforward and inexpensive to implement, and produce very tangible results. Most states proposing training initiatives appear to be trying to make the courses convenient for rural providers, either by conducting the training at rural sites or by using distance learning techniques. Such efforts are especially important for volunteer personnel, who typically must undertake training on their own time, and in areas facing personnel shortages, where it can be difficult for providers to leave the area for extended periods of time. Additionally, a number of these training programs were to be conducted jointly with CAH staff, which could help to establish or reinforce ties between the hospital and local EMS providers. In Kansas, for instance, Flex Program funds have been used to establish a computerized learning center at a CAH to provide training in pre-hospital care. The training is provided by the network hospital via the Internet, and is utilized by local EMS personnel as well as CAH staff. 

Several states are using Flex Program funds for scholarships to help students obtain needed training. Texas, for example, started such a scholarship program in Year 01 and expanded it in Year 02, for a combined budget of approximately $135,000. Scholarship recipients are given up to $2,000 to cover training costs, and are required to work in their rural community for at least a year after completion of the training. Although Texas originally planned to ask the community to match the state's contribution, this approach was abandoned so that students from communities unable to generate the match would not be penalized. Now, the community is asked to contribute only when the training costs exceed $2,000. As of spring 2001, seventeen scholarships had been awarded, with students about evenly divided between basic, intermediate, and paramedic training courses. While most of the initial participants were from CAH communities, the program has now been expanded to all rural communities. Florida and Iowa are among other states planning to offer scholarships for EMS training.

The training programs funded through the Flex Program grants encompass a very wide range of topic areas. On the clinical side, there are courses for EMS personnel ranging from first response to paramedic level of care. Advanced cardiac and trauma life support courses for ER personnel (usually in CAHs) were also very popular, as were pediatric Advanced Life Support (ALS) and trauma nursing core courses. Several states planned to offer training for physicians serving as EMS medical directors (South Dakota) or for family practice residents working in rural hospital ERs (Illinois). Still other states (e.g., Kansas) are considering "bridge" courses that would facilitate emergency medical technicians (EMTs) receiving nursing degrees; such dual licensing would then permit these personnel to serve in hospital ERs as well as work as EMTs in the pre-hospital setting. Nebraska and Louisiana each planned to offer courses to train EMS instructors, an approach with great appeal since having more instructors available will make it easier to offer additional courses locally in the future. On the non-clinical side, states are offering management and administrative training for people in charge of ambulance squads, as well as courses in billing and collections. Finally, many of the states seeking to establish pre-hospital data collection systems are also providing training to EMS personnel in data entry for these systems.

EMS Needs Assessments

As stated above, many states have used these early years of the Flex Program to collect information about their EMS systems. This information gathering may range from production of aggregate statistics at the state or sub-state, regional level (which are often used for revisions to the state health plan), to more detailed assessments at the community level. In general, the intent of the more in-depth community assessments is to measure EMS system performance systematically along a number of dimensions, identify problem areas, and develop and implement solutions to these problems. States are approaching these assessments in different ways. In some cases, the assessments are conducted as part of a preliminary survey of visit to a potential CAH by state officials, and results may be used to support the CAH application. In other cases, the assessments are independent of the CAH conversion process (and may even be conducted in non-CAH communities), and results are used to develop "stand alone" EMS projects.

States also vary in the degree of central control they maintain over the assessment process, and in the decisions made once the assessments are completed. Wisconsin, for example, is using Flex Program funds to hire a single contractor to conduct all of the state's EMS needs assessments. State officials feel this approach is important for ensuring consistency in the assessments across sites. Initial assessments are typically conducted during the CAH certification site visit, and culminate in recommendations regarding possible steps to take to address identified problems. CAHs receiving Flex Program grant money from the state in subsequent years are expected to use a portion of these funds to implement the EMS recommendations. As of April 2001, the state had 17 hospitals that had either converted to CAH status or were in the process of applying. EMS assessments had been completed for 12 of these communities, and the remaining five were expected to follow shortly. Recommendations made to date have dealt with improvements to training and communication systems, equipment purchases, and alternative ways to provide interfacility transfers.

Idaho is also conducting EMS assessments but is using a somewhat less centralized approach, especially for determining the activities that will flow from the assessments. While the state has developed a uniform assessment tool to be used for all assessments, different teams of evaluators conduct each assessment. Shortly after completion of an assessment, the evaluators return to the community to discuss assessment results and work with interested parties to develop recommendations for projects that would address identified problems. The state makes $11,000 available to the community to implement these recommendations. Local stakeholders are given the flexibility to determine their funding priorities, and the process is open to any local organization that is willing to cooperate with the larger group in these decisions. In theory, at least, this approach should help to foster collaboration. Seven assessments had been completed by mid-April 2001, and three more were expected to occur by the end of August. Four communities have received Flex Program funds, and are beginning to implement their projects. These projects have included emergency medical dispatch training and purchase of equipment.

Oregon is using a similar assessment strategy, designed to promote collaboration between local EMS providers and other relevant community members. The state has developed a comprehensive assessment tool, and hired two "EMS Regional Coordinators" plus "Community EMS Liaisons" from approximately ten communities (including one without a CAH or potential CAH). The state is training the EMS Liaisons in the use of the assessment tool as well as in techniques for facilitating group meetings and building consensus. With help from one of the Regional Coordinators, the EMS Liaisons will conduct the assessment for their area, then convene a community meeting to discuss results and attempt to develop collaborative activities to address identified needs. Ideas generated from these meetings will be reported to state officials, who hope to implement the most promising projects in future years of the RHFP grant. Iowa is also using an EMS Coordinator, who meets with the many independent EMS units operating in a given county to review the status of EMS in the area and to discuss opportunities for increased collaboration and cooperation. Both Oregon and Iowa appear to be viewing these assessments and discussions as the first step toward building more coordinated, regional EMS systems.

Efforts to Create Regional EMS Systems

Many rural counties do not have the population or tax base to support individual county-based EMS systems. Moreover, in some communities, neighboring EMS squads may work at cross-purposes, resulting in duplication of effort and higher total system costs. By sharing resources across geopolitical boundaries, it is possible to increase provider coordination and make better use of scarce resources. Both Michigan and Georgia have used Flex Program funds to support the creation of regional EMS systems. Their approaches differ, but both raise important issues about the potential barriers to the creation of a regional EMS system, and how these might be circumvented.

In Michigan, the oversight for EMS is provided by county (or multi-county) entities called Medical Control Authorities (MCAs). MCAs are organized by and around the hospital(s) in the area, and include a medical director, hospital representatives, and representatives from all levels of EMS providers serving the area. These participants are volunteers, serving on their own time. The principal responsibility of each MCA is the development of protocols to guide the provision of pre-hospital care in its area.

Three MCAs in Michigan's eastern Upper Peninsula are working together to create a regional EMS system. Flex Program funds are being combined with significant funds from other sources to support this effort. Although the accomplishments of this regionalization effort are far from uniquely-attributable to the Flex Program, the project has important lessons that may help others seeking to establish regional systems using Flex Program funds. The network envisioned by area planners has five main components:

1. Standardized EMS patient care protocols;
2. Collection of pre-hospital data to support quality improvement initiatives;
3. EMS training programs at local sites throughout the area;
4. Strategic placement of advanced life support (ALS) services throughout the region; and
5. On-going planning, development, and funding for EMS resources and services.

The regionalization process was initiated several years ago when staff from a large area hospital began working with the three MCAs to standardize EMS protocols across counties. Participants recognized that the joint development of protocols could reduce the burden on the volunteers serving on any one MCA, and could lead to improved care when patients cross county lines. The goal of creating standardized protocols has nearly been attained, and the collaboration resulting from this process appears to be helping further the other regionalization activities. 

Regional planners are now working on the adoption of a computerized system to collect pre-hospital data in a centralized manner. These data will be used to pinpoint quality problems, which could then trigger revisions to protocols, new training initiatives, and/or new prevention programs. Data system development had been delayed due to difficulty in identifying a software package to meet the area's needs, but it appears that progress has recently been made on that front. Additionally, some volunteer providers have been resistant to adoption of such a system due to concerns about the time requirements for data entry and skepticism about the value of collecting the data centrally. Thus, regional proponents of the system are moving slowly in the implementation, and are investigating the feasibility of having area hospitals be responsible for data entry, at least initially. Flex Program funds have been targeted to help pay for the software and hardware to support this data system.

Area planners have also been active in the area of EMS training, recognizing that by consolidating efforts and sharing scarce resources they will be better able to meet the increasing national and state standards for training. The hospital that initiated the standardization of EMS protocols has obtained a large grant (from a state grant program unrelated to the Flex Program) to build several trailers and outfit them with all equipment required to teach up to the paramedic level of certification. These trailers will move throughout the region, as needed, so that training courses can be offered in students' home communities. As an example of further community involvement, the network planners have obtained permission from local school boards to hold EMS classes in schools on nights and weekends, thus fulfilling the state's requirement that training take place in approved facilities. (That requirement had tended to centralize training in community colleges, and made it more difficult for volunteers to obtain training locally.) There also have been discussions between a local community college and an area high school about offering a college-credit EMS class to high school students. This approach is being promoted as a way to attract a new generation of volunteers into the area's EMS system. Several other entities in the region have also received grants from the state (not through the Flex Program) for additional EMS training programs, including teleconference-based training and scholarships.

In the longer term, as more paramedics are trained through these efforts, area planners hope to create additional ALS "hubs" at strategic points throughout the region. Use of a "blended" system that combines the existing mix of volunteer first responder and basic services with carefully-located, paid ALS units is viewed as a rational way to improve EMS services in a region where the supply of volunteers is waning yet call volumes cannot support an all-paid system (see the following section). 

Planners realize that movement to this system could be threatening to some volunteers fearful of relinquishing their role to ALS providers. Nonetheless, the area already has a good example of a successful transition to a paramedic intercept model of the type envisioned by area planners. Approximately five years ago, a local township ambulance service expanded its capabilities to include ALS services, and began providing paramedic intercepts. Paramedics might travel to the scene to assist, or might meet the transporting basic life support (BLS) unit en-route. Initially, some BLS corps resisted calling for the ALS intercepts, and even some area planners were reluctant to support the initiative because they feared that volunteers would quit, leaving the area worse off. However, the paramedics were very careful to stress that they were there to support the BLS providers, not to take the patient from them. Additionally, the medical director at the hospital receiving these patients was a strong advocate, and made it clear to the BLS providers that they were expected to call for ALS intercepts whenever it was appropriate. Over time, the BLS providers have come to value the ALS intercepts, and the volume of ALS intercepts has increased steadily: from 250 in 1998 to more than 1,000 expected for 2001. The idea is now so well accepted that there are occasions when the intercept is called when it is not needed. Likewise, area planners who were initially resistant now feel that the availability of ALS services is helping to sustain the volunteer corps by relieving some of the burden on them and enabling them to be involved in providing better patient care.

There are some features of the Upper Peninsula that are facilitating these regionalization efforts, and may make this type of initiative more difficult to replicate in other areas. In particular, there is a strong history of regional cooperation in the Upper Peninsula, perhaps due to the unique "island-like" geography. A non-profit EMS foundation, funded largely by the state, has operated in the region for several decades and is very active in promoting the development of EMS in the area. Most of the key players have worked together for years. Similarly, the two largest area hospitals have demonstrated a clear interest in strengthening the local health care system, and have worked closely with smaller hospitals and EMS providers. Both hospitals have also been successful at obtaining large grants from other sources to support their efforts. Additionally, all hospitals in the region have fairly natural catchment areas, leading them to cooperate rather than compete. However, a key ingredient for success appears to be the enthusiastic core group of people--representing diverse interests and involved since the early stages of project planning--who are committed to improving the EMS system. This ingredient need not be unique to the Upper Peninsula.

In their first application under the Flex Program, Georgia proposed to use grant dollars to help support the creation of a regional EMS system across six counties in Southwest Georgia, which are now home to two CAHs. These counties are among the poorest in Georgia and are primarily served by volunteer EMS squads. Two of the six counties do not have their own EMS system. According to the Director of the state's Office of EMS, the ideal structure of such a system would include:

• Centralized dispatch;

• A regional 911 system;

• A single regional EMS director who would take advantage of economies of scale in billing, procurement, and equipment maintenance; and

• The stationing of trucks on the basis of call volume and population (to reduce response times). 

The idea of a cross-county partnership was conceived at a regional EMS level. The intent was to start small (focusing on the collaboration among two of the six counties-one with an EMS system and one without a system) and to build greater cooperation as the benefits of such a system were demonstrated to others. Flex Program funds during the first grant year were used to help pay for equipment purchases in one of these counties. The regionalization process was initiated several years ago by holding meetings with local officials. Unlike in Michigan, however, area hospitals and many of the local squads have not been involved in the planning stages. 

After three years, there has been little progress toward the establishment of an EMS partnership between the two counties initially targeted. The expectation was that the county without the EMS system would pay the one with the system to station some of its trucks in their jurisdiction. So far, the county without the EMS system has not produced the $90,000 required under the proposed plan, and is currently considering building its own EMS capacity instead of participating in the cross-county partnership. Progress on the proposed cross-county 911 system has also been stalled. That effort was being spearheaded outside of this six-county area, but local officials could not reach an agreement about the siting of the system.

There are some important observations that may be made in comparing the approaches of the two states toward developing a regional EMS system. As Georgia and other states have found, collaboration across existing geo-political boundaries will almost always be threatening to some stakeholders. As a result, the process of building such partnerships may take time. In Michigan, an agency responsible for promoting EMS development has been active for several decades. Two other systems we visited in North Carolina that had consolidated smaller EMS entities recounted a decade or more of collaborative and educational history that preceded their eventual success. However, Michigan's success to date may also be due to the fact that they started with fairly non-threatening aims and common goals (to standardize EMS protocols), which allowed the process of collaboration to start. More potentially threatening objectives (stationing paramedic intercept providers strategically throughout the region) will be attempted only after relationships among the stakeholders have been confirmed. 

In both Georgia and Michigan, as well as in many other states participating in the Flex Program, difficulty in the recruitment and retention of EMS personnel was identified as a critical problem of the local EMS system. Whereas in Michigan the cross-county regional effort focused on alleviating staff shortages by increasing provider supply, in Georgia, the proposal involved sharing existing staff between counties. Since staff are already scarce, it is understandable that sharing staff between counties could pose a significant barrier. Georgia's current goal for the region is to focus on training programs for first responders. These programs are slated to take place in some of the local CAHs. In this manner, they are moving toward developing a common regional program that will involve multiple stakeholders and help to alleviate staff shortages in the area.

Movement toward Paid EMS Systems

Since its inception, EMS has been unique in the field of health care due to its heavy reliance on volunteer providers, especially in rural areas. More recently, EMS systems have been slowly moving from volunteer-based organizations to systems based in part, or in full, on paid staff. For example, 26 of West Virginia's 192 EMS agencies changed from all volunteer to part-paid within the past five years, and the number of ambulance runs including a paid staff person increased by two-thirds in just one year in Vermont.¹ This trend is being observed to varying degrees in many rural areas of the United States. Accompanying the transition to paid staff is often an upgrade from BLS to ALS services.

One major impetus for this change is the ever-increasing difficulty in finding volunteer staff-particularly for daytime shifts. Faced with this serious staffing shortfall, rural services have had little choice but to begin offering paid positions. Not surprisingly, several EMS providers we visited reported that their staffing difficulties had been largely resolved once they moved to a paid staff. Retention of current volunteers can be enhanced, too, by using paid staff to handle jobs that volunteers may not wish to do (e.g., ordering supplies, entering run data into computerized registries, and other administrative tasks). 

Of course, as systems move away from complete reliance on volunteer staffing, additional revenue sources must be found. Payment from Medicare, other insurers, and patients is one source that may not have been fully tapped in the past, given the reluctance of many rural providers to bill for their services, or their inability to bill effectively. Initiatives to support the implementation of computerized billing systems and programs to train personnel in coding and billing issues should enhance the ability of EMS squads to generate revenue in this way. A number of states are using Flex Program grant funds to support these types of programs. North Carolina, for instance, has used Flex Program money to help implement a billing system in one county, which improved their collection rate by 21 percent and facilitated the county's move to paid paramedic service. Several other states are providing training in billing procedures. 

Rural EMS providers may also receive billing assistance from an area hospital. For example, a paramedic intercept service in Michigan will soon begin paying the large hospital that receives its patients $2 per case to handle all billing and collections related to the pre-hospital care. Since the hospital is already billing for all other care related to the episode, it is a relatively straightforward matter for it to assume billing responsibility for this initial portion of care as well. While this hospital is neither a CAH nor the referral hospital for the area CAHs, it is an essential part of the health care network and works closely with area EMS providers and other area hospitals. One could envision a similar cooperative model between EMS providers and their local CAH or the CAH's referral hospital (depending on where the ambulance delivers emergency patients).

Despite the promise of enhanced revenues from improved third-party reimbursements, however, it is important to realize that revenue from this source alone will never be sufficient to sustain EMS providers as long as payment rates fall below the full cost of providing ambulance services. Historically-based payments that fail to recognize the tremendous cost subsidy provided by volunteer labor, and transport-based payments that do not permit low-volume providers to recover high fixed costs associated with stand-by time will always result in a shortfall in operating revenue. Thus, additional sources of revenue will be needed to support the transition to paid staff.

A large number of EMS providers receive an operating subsidy from their county or township. This contribution may be financed through general revenues or through dedicated EMS taxes. We visited one county in South Dakota, for example, that has just passed taxing authority to support EMS, and they plan to use the revenue to support a core of paid EMS personnel. Many other areas, however, already provide tax-derived subsidies to EMS, and are unwilling or unable to increase these taxes. More than one informant spoke of the need to educate the public about the contributions of EMS providers, the cost of maintaining service, and the importance of supporting a paid system, through taxes or other means.

In addition to tax support, we saw a few creative examples of funding that capitalize on unique, local opportunities in the provision of ambulance services. For example, one service in Michigan's Upper Peninsula has a contract with the state to provide ambulance services for five state prisons located in the area. Likewise, an informant in West Virginia spoke of non-emergency transports as a potential source of revenue, and stressed the importance of seeking innovative ways to expand transport volume (e.g., through contracts with the VA or Indian Health Service). While each situation will be unique, rural EMS providers need to take advantage of available revenue-generating opportunities.

Using EMS personnel to provide non-emergency services during the time they are not on emergency runs is another strategy that may generate added revenue to sustain the EMS system. This approach can also help to keep skills current, alleviate shortages of other personnel, and enhance local access to health care in areas with provider shortages. One EMS service in Michigan, for example, is currently using its paid staff to provide safety and risk management services for the local casinos in exchange for tribal financial support. Area leaders hope that these providers can eventually take on additional public health duties at local clinics and schools. In another example from Michigan, three CAHs are opening a new rural health clinic, which they will staff jointly. The hospitals are considering a staffing model that includes paramedics (to be implemented as additional paramedics are trained as part of the area's current training initiatives-see above). Under this plan, the clinic would become one of the region's strategically-placed "ALS hubs." Advanced Echo vehicles ⁱⁱ would be based at the clinic, and paramedics would supplement the clinic staff when not needed for an emergency run. Many of the CAHs visited during this past year also appear to be interested in more extensive use of EMS personnel in the hospital ER. Movement to expand the use of EMS personnel in these settings may face several obstacles, however-most notably, restrictive state laws regarding scope of practice and objections from other provider groups that may feel threatened by an expanded scope of practice for EMTs. 

Hospital Ownership of Ambulance Transport Services

One way to strengthen the local EMS system may be for the hospital to take over system ownership. In West Virginia, Flex Program grant funds targeted for EMS have mainly supported feasibility studies of hospital integration with the local EMS system. According to state office of rural health personnel, integration can be achieved in varying degrees-from simply sharing resources (such as personnel, billing, or administrative capabilities) to outright ownership by the hospital. The latter model is perceived in West Virginia as having the best potential for improving local EMS operations. Successes demonstrated by one of the state's hospitals that acquired the local EMS system during the Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) program had an important influence on the orientation of the current program in West Virginia, and are worth recounting here.

This hospital acquired the local EMS system in 1997, shortly after converting to an RPCH. After the acquisition, the county-financed volunteer squad was transformed into a hospital-based operation with two stations operating with a paid staff and full-time paramedic capability. As a result of this change:

• Response times were sharply reduced (because of full-time paid staff and the operation of two stations, rather than one);

• The quality of care improved as the staff had more consistent and better training; 

• Call volume increased (attributed to increased trust in the community); and 

• The level of sophistication of equipment and personnel improved to such an extent that the EMS system is now considering becoming a critical care transport (CCT) provider for the region.

During the course of our site visits, informants cited several additional advantages of hospital ownership of the EMS system, which underscore the potential for this strategy under the Flex Program. These advantages include:

• Reduced costs for medical and pharmaceutical supplies;

• Reduced costs for medical liability;

• Availability of hospital funds for capital acquisition;

• Integrated training programs for paramedic and emergency response teams;

• More opportunities for EMS staff to use their skills when based at the hospital;

• Daily communication with the medical director;

• Shared equipment and biomedical support;

• Availability of experts (e.g., marketing, human resources); and

• Availability of a full-time billing staff with an expertise in the nuances of Medicare and Medicaid regulations, which can enable a better collection rate for ambulance transport fees.

However, many of the successes realized by this West Virginia hospital may be more difficult to attain in this current environment. Most critically, movement from a volunteer to a paid staff was facilitated by the fact that Medicare paid on a cost basis for hospital-owned ambulance services at that time, which sharply improved their revenue. Although BIPA will allow some CAHs that own an ambulance service to obtain cost-based reimbursement from Medicare, in order to qualify, there must be no other ambulance providers operating within a 35-mile radius from the hospital. All other EMS systems (whether hospital-owned or not) are to be paid under Medicare's new national fee schedule for ambulance services. (Medicare payment policies for ambulance transports and their interface with the Flex Program are discussed in more depth in the following section.) CAHs that would currently qualify for cost-based reimbursement and that may be considering acquisition of the ambulance service have expressed concern that they might lose cost-based reimbursement if an independent firm subsequently sets up operations in the area. This down-side risk poses a significant barrier to their acquiring the local ambulance service.

The intent of this provision of BIPA was to discourage hospital divestment of EMS in vulnerable areas and to encourage closer integration (e.g., acquisition) by some CAHs. The potential financial benefits of cost-based reimbursement, however, must now be weighed against the potential revenue available from the new Medicare fee schedule. Ironically, the new fee schedule is expected to improve reimbursement rates for another West Virginia independent volunteer squad so much that they no longer feel the same financial imperative to merge with the local CAH. 

Other CAHs and EMS squads in West Virginia are demonstrating that hospital acquisition of the local EMS squad is not a solution for everyone. Some of the issues that are arising as feasibility studies are being completed are:

• Resistance by local squads to losing their autonomy;

• Local squad distrust of the management capability of the CAH or of its long-term viability;

• Concern in the community that a hospital-owned system would make it more difficult to elect to by-pass the CAH in the event of an emergency;

• Concern by the hospital regarding its inability to break-even with EMS; and

• Continuing barriers to the cross-use of paramedic staff in emergency rooms (seen as a great potential benefit of basing the EMS squad at the hospital but one that cannot be realized without changes in state regulations).

The Director of an EMS provider in North Carolina that had successfully merged with a regional hospital system also cautioned that the hospital needs to employ managers with an expertise in EMS in order to make this strategy work. According to him, it is unrealistic to manage an EMS system like the emergency room. For example, some hospitals may pay substantially more for staff than a county-based EMS unit, and might design work shifts so that people work less. Without good management of shift time, exposure to overtime pay can easily double. Also, differences may arise in setting priorities for collections because EMS is typically a low-fee, high-volume service compared with other aspects of the hospital. Finally, collection rates will not necessarily improve with a hospital-based rather than independent responsibility for billing. Hospitals may lack expertise with the specific nuances of ambulance billing. According to this director, good management can lead to a break-even service, even for a small-volume EMS provider.

Medicare Payment for Ambulance Services

Medicare has historically paid for ambulance services on the basis of customary, prevailing, and reasonable charges, and the rate of growth in payments was capped to not exceed general inflation. Although most ambulance providers were paid under this charge-based system, hospitals that owned or contracted for ambulance services were reimbursed on the basis of costs. The Balanced Budget Act of 1997 (BBA) required Medicare to pay for all ambulance transports (regardless of ownership) on the basis of a new national fee schedule. This ambulance fee schedule was slated to take effect on January 1, 2001, but implementation has been delayed to an unknown date. 

A proposed rule describing the framework for the fee schedule was issued in April 2000. The proposed fee schedule was expected to disadvantage small, rural providers, who were thought to have higher costs per transport than larger providers due to natural economies of scale in the industry. It also was expected to hurt hospitals that had been operating their own ambulance service and receiving cost-based reimbursement, as well as ambulance services that were under contract to a hospital that billed Medicare (on a cost basis) on their behalf. As a result, there were concerns about the new fee schedule's impact on EMS providers serving CAHs and that it might work at cross purposes to the intent of the Flex Project, which is to strengthen the rural health care network. 

As noted above, BIPA now allows CAHs that own and operate an ambulance service to receive reasonable costs for these services, as long as there is no other provider of ambulance services within 35 miles of the CAH. For CAHs that qualify, this provision helps to mitigate the proposed fee schedule's disincentive to providing ambulance services, and may even encourage CAHs without ambulance services to begin providing these services. BIPA also required the completion of a study to better understand policy options to fairly compensate low-volume, rural ambulance providers.

During our site visits, informants raised several issues relating to the interface of Medicare ambulance payment policy and the Flex Project. First, despite concerns that Medicare's new ambulance fee schedule will adversely affect small, rural providers, some of the providers with whom we spoke are anticipating that the new fee schedule will improve their Medicare receipts. Anecdotal information suggests that localities served historically or currently by volunteer squads will benefit (because these firms traditionally charged low to nominal fees). One ambulance provider estimates its Medicare receipts will increase by $1.6 million over the 4-year phase-in recommended in the proposed rule (about 30% of current collections). Another provider estimates that the increased revenue under the new payment schedule will allow it to move toward 24-hour staffing of its station. Thus, fears that the new fee schedule will detrimentally affect EMS systems serving CAHs do not appear to be uniformly true, at least under the form currently proposed.

Several hospital-owned ambulance providers with whom we spoke are also pleased about the BIPA provisions that would allow them to continue to receive cost-based reimbursement. Concerns were raised, however, about the requirement that no other provider may be operating within a 35-mile radius in order for the hospital to qualify for cost-based reimbursement. Several felt this mileage criterion should be modified to take travel time or local weather conditions into consideration. Some EMS directors of hospital-owned systems were concerned that they would lose the favorable reimbursement if a competing provider moved into the area. They noted that distinctions should at least be made in the type of service being offered. For example, a hospital-owned system offering paramedic services could maintain cost-based reimbursement if the new provider offered only basic life support (rather than paramedic) services. Or, similarly, a new provider offering only non-emergency transports would not jeopardize the cost-based reimbursement for a hospital-owned service providing emergency transports. As we noted above, the uncertain future about cost-based reimbursement, which depends on distance to next nearest provider, will likely be a disincentive to CAHs contemplating acquisition of their local ambulance service. 

Some informants suggested that reasonable cost-based reimbursement from Medicare would not provide a large enough incentive for hospitals to acquire ambulance services. These predictions are partially supported by data on the revenue structure of rural firms. Although an estimated 56 percent of patients transported by small rural firms are Medicare beneficiaries, rural ambulance providers also incur a high level of bad debt. Based on a survey of Medicare-billing ambulance providers, bad debt (which encompasses charity care as well as reflects a low collection rate due to inefficient billing) comprises about one-third of total costs for rural providers. Thus, the acquisition of an ambulance service may not be wise for CAHs in already-precarious financial situations. The Director of one state office of rural health suggested, however, that as CAHs improve their bottom line in the future, they may begin to consider acquiring a capacity in EMS.

Lessons Learned and Expectations for Future Years 

Our observations strongly suggest that the Flex Program has been very important for opening lines of communication regarding rural EMS systems and fostering new collaborations between state EMS representatives and other state officials. Due to the special emphasis given to rural EMS improvements in the Flex grant program, many states are involving representatives from the state EMS Office in Flex Program decisions. This input ranges from inclusion of an EMS component in the state health plan and consideration of EMS issues during CAH conversions to the development and implementation of specific grant-funded initiatives to improve rural EMS systems. Furthermore, since EMS representatives are working with officials from other state agencies, they have an opportunity to coordinate EMS system changes with larger changes to the rural health system. It is no longer just EMS representatives who are striving to improve rural EMS systems. And in states that have been more progressive in involving the community in CAH conversions and other Flex Program initiatives, it was also common to find that the program has resulted in greater communication between EMS providers, hospitals, and other local stakeholders. 

While better communication alone will not result in sweeping EMS improvements, it seems to be a critical first step. We have observed repeated examples of the importance of providing opportunities for all key players to become involved at the outset so that they can begin to build consensus and work toward common goals. Projects built upon this solid foundation appear to be progressing more quickly and to have a better likelihood of long-term success. On the other hand, some initiatives that were developed without input from critical players are stymied and may never reach fruition. Along these same lines, it is important to realize that fundamental change will take time and will probably require compromise among parties who may be resistant to change. Efforts to demonstrate how a planned change can be mutually beneficial and to build consensus for the proposal are likely to reap large benefits when it comes time to implement the project.

Mini grants are a very popular method used by states to distribute their Flex Program grant money, with most of the awards being made directly to CAHs. As a way of encouraging communication and collaboration, states may wish to consider requiring more explicit participation of EMS representatives when grants are made to CAHs for the purpose of funding EMS improvement projects. Likewise, several states are awarding their EMS funds directly to EMS organizations, or to formal collaborations between CAHs and EMS organizations. This approach appears to hold greater potential for fostering cooperation, ensuring that the projects being implemented are what the local EMS system needs, and enhancing the probability for successful implementation.

During our site visits, a number of observers stressed the critical interdependence of hospitals and EMS systems. If the hospital closes, for example, additional stress will be placed on the local EMS system. In particular, transport times-and time that an ambulance must be away from its home community-are likely to increase significantly when the local hospital closes. EMS units may also be called upon to provide a higher volume of services due to the loss of the hospital's emergency room. Therefore, keeping hospitals functioning, as through the CAH program, is likely to be of significant benefit to local EMS systems. Similarly, if the EMS providers in an area cannot be sustained, the hospital is often left responsible for ambulance services and emergency care. It is in the hospital's best interest to have a viable EMS system. Thus, the Flex Program's emphasis on strengthening rural EMS systems merits continued support and attention-from states as they implement current Flex Program grant activities and from Federal legislators as they consider program reauthorization for future years.

Despite the overall size of the Federal Flex Program, the budget is fairly limited when divided among all participating states. Awards become even smaller when divided among all participating communities within a state. We observed several strategies that appear sensible as a way of maximizing the effectiveness of limited funds. A number of states are using the grant funds as a carrot to encourage collaboration, requiring interested parties to participate in the process of developing projects in order to share in any of the grant funds. But even then, the individual grant amounts may be too small to generate interest. Some states are also attempting to leverage the effectiveness of Flex Program funds by targeting their money to communities where there are already on-going efforts to strengthen the EMS system. These are likely to be areas that have already received financial support from other sources. Although mingling Flex Program grant money with other sources of funds minimizes the ability to attribute any changes solely to the Flex Program grants, it can maximize the effectiveness of limited funds. If projects in these communities are successful, they can be used as models for subsequent reforms in other communities.

While much more difficult to implement, the grant program's focus on EMS structural changes, as opposed to simple capital expenditures, is wise. This approach is expected to help change EMS systems in more fundamental ways, and the benefits of the grant activities should outlast the grant funding. Furthermore, a number of states have other funding sources available for large capital expenditures for EMS (e.g., funds derived from criminal fines or the tobacco settlement), and pending Federal legislation (S. 587) would create a new Federal grant program that could be used for large equipment purchases.

Similarly, the early emphasis of many states on EMS training programs has probably been a wise approach since these programs respond to critical identified needs. If the pending Federal legislation is enacted, however, additional Federal money will become available for EMS training beginning in FY 2002. In this case, states may wish to pursue these funds and refocus their Flex Program-funded EMS initiatives on other areas, such as increased collaboration and integration between CAHs and EMS providers, creation of regional systems, and EMS quality improvement initiatives. 

In sum, we are optimistic about the possibility of achieving significant improvements to rural EMS systems under the Flex Program. The flexibility afforded to states by the Flex Program-and the flexibility that many states are, in turn, offering to individual communities-is well suited toward development of creative initiatives designed to meet specific local needs. Several strategies mentioned above might be adopted to foster additional collaboration among key players and move EMS improvement projects from the drawing board to successful implementation. We are encouraged by the progress made by states during the second year of the current Flex Program grant cycle, and expect to see more substantial initiatives in the remaining two years. Most states are now moving past the CAH conversion stage, completing their EMS needs assessments, and defining and implementing projects to address identified EMS needs. 

Within the next year, Congress will be deciding on reauthorization of the Flex Program grants. There is no assurance that the grant program will continue, nor that it will continue to include a focus on rural EMS initiatives. States' success in implementing solid EMS projects in Year 03, and documenting results of these investments, is likely to be critical to a favorable reauthorization decision.

Table 4. Flex Program EMS Activities for Selected States

Chapter 5: Critical Access Hospitals and Community Development

Back to Table of Contents

Footnotes

ⁱ Information reported by Arkansas representative during a "Flex Program Hour" organized by the Technical Assistance and Service Center, April 11, 2001.

ⁱⁱ Information reported by Arkansas representative during a "Flex Program Hour" organized by the Technical Assistance and Service Center, April 11, 2001.

¹ "Waning Volunteerism is Emergency for Rural EMS," Medicine and Health, Perspectives, Volume 55, No. 19, May 2001.

² Mohr PE, Cheng CM, and Mueller CD. "Establishing a Fair Medicare Reimbursement for Low-Volume Ambulance Providers." Under review.

³ Mohr PE, Cheng CM, Mueller CD, and Good CD. Findings from the National Survey of Ambulance Providers: Final Report. Submitted to the American Ambulance Association, January 2000.

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