[Congressional Record Volume 144, Number 64 (Tuesday, May 19, 1998)]
[Senate]
[Pages S5129-S5131]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRAMS:
  S. 2091. A bill to amend title XVIII of the Social Security Act to 
ensure medicare reimbursement for certain ambulance services, and to 
improve the efficiency of the emergency medical system, and for other 
purposes; to the Committee on Finance.


           emergency medical services efficiency act of 1998

  Mr. GRAMS. Mr. President, I rise this morning on behalf of all those 
who serve their fellow citizens through their active participation in 
the Nation's emergency care system to introduce the Emergency Medical 
Services Act.
  Mr. President, as a Senator who is deeply concerned about the ever-
expanding size and scope of the Federal Government, I have long 
believed Washington is too big, too clumsy and too removed to deal 
effectively with many of the issues in which it already meddles.
  However, I also believe there's an overriding public health interest 
in ensuring a viable, seamless, nationwide

[[Page S5130]]

EMS system. By designating this week as National EMS Week, the Nation 
recognizes those individual who make the EMS system work.
  There is no more appropriate time to reaffirm our commitment to EMS 
by addressing some of the problems the system is presented with daily.
  I have been privileged to get to know the men and women who dedicate 
their talents to serving others in an emergency. We have together 
discussed problems within the EMS system and concluded there are areas 
in which the Federal Government can help.
  The original result of our discussions concerning the Federal role in 
EMS was S. 238, the Emergency Medical Services Act [EMSEA]. When I 
introduced S. 238 on January 30, 1997, I acknowledged that it wasn't 
intended to solve all the problems EMS faces; it was merely a first 
step toward a meaningful national dialog on EMs. Indeed, this first 
step was a productive one.
  Last summer, I assembled EMS and health care leaders in Minnesota, 
asked them to take another look at the EMSEA, and report back to me 
with their thoughts. In January, I received a copy of their report.
  I was extremely pleased with their efforts and have used those 
suggestions as the basis for the legislative language comprising the 
new Emergency Medical Services Efficiency Act I am introducing today.
  I have often said that Congress has a tendency to wait until there's 
a crisis before it acts, but Congress cannot wait until there's a 
crisis in the EMS system before we take steps to improve it. There is 
simply too much at stake.
  Whether we realize it or not, we depend on and expect the constant 
readiness of emergency medical services. To ensure that readiness, we 
need to make efficient and effective efforts to secure the stability of 
the system.
  This has been my focus in redrafting this legislation.
  There are many similarities between S. 238 and the new bill I am 
introducing today.
  For instance, we continue to assert that the most important thing we 
can do to maintain the vitality of the EMS system is to compel the 
government to reimburse for the services it says it will pay for under 
Medicare.
  In the meetings I have had with ambulance providers, emergency 
medical technicians emergency physicians, nurses, and other EMS-related 
personnel, their most common request is to base reimbursement on a 
``prudent layperson'' standard, rather than the ultimate diagnosis 
reached in the emergency room.
  While the Balanced Budget Act of 1997 [BBA] contained a provision 
basing reimbursement for emergency services on the prudent layperson 
standard, we have yet to see HCFA's interpretation of the provision and 
whether it will include ambulance services.
  I have written letters to HCFA and Senate Finance Committee Chairman 
William Roth indicating my understanding that ambulance services would 
be considered part of ``emergency services'' as defined in the BBA.
  I have been given no assurances from HCFA that they intend to include 
ambulance services as part of the ``emergency services'' definition in 
the balanced budget agreement.
  To illustrate how prevalent this problem is, I want to share with you 
a case my staff worked on relating to Medicare reimbursement for 
ambulance services. Please keep in mind that this is the fee-for-
service Medicare program.
  It was back in 1994 that Andrew Bernecker of Braham, MN, was mowing 
with a power scythe and tractor when he fell. The rotating blades of 
the scythe severely cut his upper arm. Mr. Bernecker tried to walk 
toward his home but was too faint from the blood loss, so he crawled 
the rest of the way.
  Afraid that his wife, who was 86 years old at the time, would panic--
or worse, have a heart attack--he crawled to the pump and washed as 
much blood and dirt off as he could. His wife saw him and immediately 
called 911 for an ambulance.
  He was rushed to the hospital where Mr. Bernecker ultimately had 
orthopedic surgery and spent some time in the intensive care unit.
  In response to the bills submitted to Medicare, the Government sent 
this reply with respect to the ambulance billing:

       Medicare Regulations Provide that certain conditions must 
     be met in order for ambulance services to be covered.
       Medicare pays for ambulance services only when the use of 
     any other method of transportation would endanger your 
     health.

  The Government denied payment, claiming the ambulance wasn't 
medically necessary.
  Apparently, Medicare believed the man's wife--who was, remember, 86 
years old--should have been able to drive him to the hospital for 
treatment. Mr. and Mrs. Bernecker appealed, but were denied, and they 
began paying what they could afford each month on the ambulance bill.
  After several years of paying $20 a month, they finally paid off the 
ambulance bill. Medicare however, later reopened the case and 
reimbursed the Berneckers.
  I believe the experience this family had with Medicare's denial of 
payment for ambulance services happens far too often, and Congress 
needs to make sure it doesn't happen again.
  Another similarity between the two versions of this bill is the 
creation of a Federal commission on emergency medical services to make 
recommendations and to help provide input on how Federal regulatory 
actions affect all types of EMS providers.
  EMS needs a seat at the table when health care and other regulatory 
policy is made.
  Few things are more frustrating for ambulance services than trying to 
navigate and comply with the tangled mess of laws and regulations from 
the Federal level on down, only to receive either a reimbursement that 
doesn't cover the costs of providing the service or otherwise a flat 
denial of the payment.
  Mr. President, I came across this chart last year, the chart I have 
with me on the floor this morning, that demonstrates how a Medicare 
claim moves from submittal to payment, denial, or write-off by the 
ambulance provider.
  If you look at this chart, I ask you, tell me how a rural ambulance 
provider who depends on volunteers has the manpower or the expertise to 
navigate through this entire mess. And, in the event that it is 
navigated successfully, ambulance services are regularly reimbursed at 
a level that doesn't even cover their costs.
  Now let us talk about how much it costs to run just one ambulance. 
There is the cost of the dispatcher who remains on the line to give 
prearrival assistance, the ambulance itself, which costs from $85,000 
to $100,000 to put on the road, the radios, beepers, and the cellular 
telephones used to communicate between the dispatcher, the ambulance, 
and the hospital, the supplies and equipment in the ambulance, 
including defibrillators, stretchers, EKG monitors, and bandages, and 
the two emergency medical technicians or paramedics who both drive the 
ambulance and provide care to the patient, the vehicle repair, 
maintenance, and insurance costs, and the liability insurance for the 
paramedics. As you can see, the list goes on and on.
  Yes, the costs can be high, but it is clear to me that, with the 
uncertainty ambulance providers face out in the field each day, they 
need to be prepared for every type of injury or condition. Mr. 
President, that is expensive, but we as consumers expect that in the 
case of an emergency.
  I am convinced those who complain about the high costs of emergency 
care would be aghast if the ambulance that arrived to care for them in 
an emergency didn't have the lifesaving equipment needed for their 
treatment.
  Let us be honest with ourselves: We want the quickest and best 
service when we face an emergency--and the bottom line is that costs 
money.
  Mr. President, many of our political debates in Washington center 
around how to better prepare for the 21st century.
  I have always supported research and efforts to expand the limits of 
technology and continue to believe technological innovations and 
advances in biomedical and basic scientific research hold tremendous 
promise.
  Under the new bill I am introducing today, Federal grant programs 
will be clarified to ensure that EMS agencies are eligible for programs 
that relate to highway safety, rural development, and tele-health 
technology.

[[Page S5131]]

  Emergency medical services have come a long way since the first 
ambulance services began in Cleveland and New York City way back during 
the 1860's.
  Indeed, the scientific and technological advances have created a new 
practice of medicine in just 2 short decades, and have dramatically 
improved the prospects of surviving any serious trauma.
  There is reason to believe further advances will have equally 
meaningful results.
  Innovations like tele-health technology may soon allow EMT's, nurses, 
and paramedics to perform more sophisticated procedures under a 
physician's supervision via real-time, ambulance-mounted monitors and 
cameras networked to emergency departments in specific service areas.
  By not considering EMS agencies for Federal grant dollars, we may 
cause significant delays in the application of current technologies. 
That would be a mistake.
  Perhaps the most dramatic departure the reintroduced bill takes from 
S. 238 related to the designation of a lead Federal agency for EMS.
  In August of 1996, the National Highway Traffic and Safety 
Administration and the Health Resources and Services Administration, 
Maternal and Child Health Bureau issued their report, ``Emergency 
Medical Services: Agenda for the Future.''
  The report outlined specific ways EMS can be improved, and one of the 
stated goals was the authorization of a ``lead Federal agency.''
  My original legislation instructed the Secretaries of Health and 
Transportation to confer on and facilitate the transfer of all EMS-
related functions to the Department of Transportation.
  While we recognized that there would be some who would applaud the 
notion and others who would berate it, the suggestion compelled people 
to consider the issue and offer alternative approaches.
  The recommendations of the advisory committee and the comments I have 
received from national groups indicate we have yet to reach a solution 
to the problematic designation of a lead Federal agency.
  As such, under the new legislation, we call for an independent study 
to determine which existing agency or new board would best serve as the 
lead Federal entity for EMS.
  The concerns expressed to me about designating the Department of 
Transportation as the lead Federal agency were virtually identical to 
the concerns about granting lead-agency designation to the Department 
of Health and Human Services. It just didn't seem to fit.
  Therefore, I believe the most appropriate action is to take our time 
and get it right by conducting this study.
  Mr. President, in 1995, there were approximately 100 million visits 
to emergency departments across the country.
  Roughly 20 to 25 percent of those visits started with a call for an 
ambulance. Each one of those calls is important, especially to those 
seeking assistance and the responding EMS personnel.
  The Nation owes a great deal to the EMS personnel who have dedicated 
themselves to their profession because they care about people and they 
want to help those who are suffering.
  Nobody gets rich as a professional paramedic, and there is even less 
compensation as a volunteer. The field of emergency medical services 
presents many challenges--but offers the reward of knowing you helped 
someone in need of assistance.
  Every year, the American Ambulance Association recognizes EMS 
personnel across the country for their contributions to the profession, 
and bestows upon them the Stars of Life Award.
  This year, 124 individuals have been chosen by their peers to be 
honored for demonstrating exceptional kindness and selflessness in 
performing their duties.
  I ask unanimous consent to have printed the 1998 American Ambulance 
Association Stars of Life honorees in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                      1998 Stars of Life Honorees

       Alaska--Monica Helmuth.
       Arizona--Jeff Mayhew, Michael Norling, Tammy Smith, Karen 
     Deo, and Sharon R. Featherston.
       California--Eva Eveland, John Erie Henry, Chris McGeragle, 
     Nephty Landin, Victor Oseguera, Todd Hombs, Kathy Hester, Les 
     Hutchison, David Pratt, Ted Boorkman, and Paul Maxwell.
       Colorado--Kurt Dennison and Jed Swank.
       Connecticut--Leonard Sudniek, Michael Pederson, and Alfonso 
     Anglero.
       Delaware--Mary McGuire.
       Florida--Sean Kelley, Kenneth Warner, David Meck, and John 
     Morrow.
       Georgia--Damon Wisdom and Dwayne Friday.
       Hawaii--Thomas Sodoma.
       Iowa--Elaine Snell and Gary Soderstrom.
       Illinois--Julie Burke.
       Indiana--Thomas Shoemaker, Rebecca Johnson, and Betty 
     Nickens.
       Kansas--Darren Root.
       Kentucky--Aaron Gutermuth.
       Louisiana--Mark Reis, Wilson ``Billy'' Hughes, Patrice 
     Shows, and Dennis McKinley.
       Massachusetts--Warren F. Nicklas, Shawn Payton, Bernard 
     Underwood, Chester ``Chuck'' Cummens, Michael Ward, Dana 
     Gerrard, Priscilla Gerrard, and John Conceison, Jr.
       Maryland--James Pirtle, John Dimitriadis, Chad Packard, and 
     Jeff Meyer.
       Maine--Paul Knowlton and Doug Chapelle.
       Michigan--Nancy Hunger, Craig Veldheer, Jeffrey Buchanan, 
     Timothy Waters, Lydia Paulus, Thomas Scott, and Tonya 
     Prescott.
       Minnesota--Daryl Howe, Dan Anger, and John Hall.
       Missouri--David Michael, Royce McGuire, and Kirk N. 
     Wattman.
       Mississippi--Denise Pilgreen.
       North Carolina--Cynthia Seamon, Amy Beinke, Jerry 
     Cornelison, Ronald Corrado, Thomas Wright, Tim Marshburn, and 
     Heather VanRaalte.
       Nebraska--Jodi Kozol.
       New Jersey--Kimberly Matthews and Michael Maciejczyk.
       New Mexico--Gergory Pollard.
       Nevada--Mike Denton and Eric Guevin.
       New York--Thomas Murphy, Vicki Knarr, Tina Pawlukovich-
     Cross, Lynn Pulaski, Stacey Wallace, Larry Abbey, Edward 
     Schaeffer, Brent Sala, Dana Peritore, Jean Zambrano, Darrel 
     Grigg, Debra Yandow, John Falgitano, Sam Lubin, and Jim 
     Mazzucca.
       Ohio--Kenton Kirkland, Robert Good, and James Drake.
       Oklahoma--Terri Farmer.
       Oregon--Gregory Sanders, Doug Carlson, and Shawn Hunt.
       Pennsylvania--Lisa Mauger, Stephanie Schmoyer, and 
     Christine Webster.
       Tennessee--James Quilliams.
       Texas--Cory Jeffcoat, Eric Silva, Christine Saucedo, Elaine 
     Tyler, and Brad Redden.
       Utah--Marcie Mehl, Charles Cruz, and Patrick Eden.
       Virginia--Gerrit ``Bip'' Terhune.
       Vermont--Eric Davenport and Paul Jardine.
       Washington--George McGibbon and Jim Hogenson.

  Mr. GRAMS. Mr. President, in closing I have talked with many EMT's, 
paramedics, and emergency nurses, and most tell me that they wouldn't 
think of doing anything else for their chosen career.
  So, in honoring them during this National EMS Week, I can think of no 
better way to recognize their service than through the introduction of 
legislation that will help them to help others.
  I ask my colleagues to support them by supporting the Emergency 
Medical Services Act.
                                 ______