[Congressional Record Volume 145, Number 74 (Thursday, May 20, 1999)]
[Senate]
[Pages S5734-S5736]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




               EMERGENCY MEDICAL SERVICES EFFICIENCY ACT

  Mr. GRAMS. Mr. President, I rise today on behalf of all those who 
serve their fellow citizens through their active participation in the 
nation's emergency care system to make my remarks on the introduction 
of S. 9-1-1, the ``Emergency Medical Services Act of 1999.''
  Mr. President, as a Senator who is deeply concerned about the every-
expanding size and scope of the federal government, I've 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 and seamless EMS system across the country. By designating this 
week as national EMS Week, our nation recognizes those individuals who 
make the EMS system work.
  There's no more appropriate time to reaffirm our commitment to EMS by 
addressing some of the problems the system is presented with daily.
  I've 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's simply 
too much at stake.
  Whether we realize it or not, we all depend on and expect the 
constant readiness of emergency medical services. To ensure that 
readiness, we need to make efforts to secure the stability of the 
system. This has been my focus in drafting the EMSEA.
  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've 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 room services on the prudent 
layperson standard, I find it troubling HCFA refuses to include 
ambulance transportation in its regulations as a service covered by the 
patient protections enacted as part of Medicare Plus Choice. I also 
believe it is unacceptable that beneficiaries participating in fee-for-
service are not granted the protections afforded to those in Medicare 
Plus Choice.
  There has been a great debate in the Senate for the last year 
regarding protections for consumers against HMOs. Many of my colleagues 
would be startled to learn of the treatment many seniors have 
experienced at the hands of their own government through the Medicare 
fee-for-service program. The federal government would do better to lead 
by example rather than usurping powers from state insurance 
commissioners by imposing federal mandates on health insurance plans 
already governed by the states.
  To illustrate how prevalent the problem of the federal government 
denying needed care to Medicare beneficiaries is, I want to share with 
you a case my staff worked on relating to Medicare reimbursement for 
ambulance services. I mentioned this case last year, but it is worth 
repeating. Please keep in mind that this is the fee-for-service 
Medicare program.
  In 1994, Andrew Bernecker of Braham, Minnesota 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 spent 
some time in the intensive care unit and had orthopedic surgery. A 
tragic story.
  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 began 
paying what they could afford each month for the ambulance bill.
  After several years of paying $20 a month, the Berneckers finally 
paid off the ambulance bill. Medicare later reopened the case and 
reimbursed the Berneckers, but unfortunately, Mr. Bernecker is no 
longer with us.
  I have a few more examples I'd like to share with my colleagues to 
assure them this is not an isolated incident. In fact, I encourage all 
of my colleagues to meet and speak with their EMS providers to see 
first-hand how the lack of consistent reimbursement policy impacts 
their ability to provide services. This one provision of the Emergency 
Medical Services Efficiency Act will bring fairness and clarity for 
both the beneficiary and the EMS provider trying to help those in need.

  In Austin, Minnesota, a 66-year-old male was found in a shopping 
center parking lot slumped over the steering column of his car. The car 
was in drive, up against a light pole with the wheels spinning and the 
tread burning off the tires. An Austin policeman at the scene requested 
an ambulance and the driver was transported to the emergency room. 
Ambulance transportation reimbursement was denied based on the 
assumption that the driver could have used other means to get to the 
emergency room. Apparently, since he was already in the car, he was 
supposed to drive himself to the hospital despite being unresponsive.
  Another case in Minnesota involved a 74-year-old male who was 
complaining

[[Page S5735]]

to his family about an upset stomach when he collapsed. The frightened 
family began CPR and summoned an ambulance via 9-1-1. The city's fire 
department was the first on scene and applied an automatic external 
defibrillator, which advised against shock. Paramedics arrived and 
continued CPR en route to the emergency room. The patient ultimately 
died of cardiac arrest. Again, Medicare fee-for-service denied payment 
for the ambulance because it was deemed unnecessary.
  Finally, Mr. President, a 74-year-old female complained of flu-like 
symptoms. Her family checked on her and found she was acting confused 
and strange. They summoned emergency medical services. Paramedics 
arrived to find the woman awake but confused as to time and events. 
They discovered she had a history of cardiac disease and diabetes. The 
paramedics tested her blood-sugar level and found it below 40. For 
those of you unfamiliar with diabetes, a blood sugar level below 70 is 
dangerous and could lead to seizure. But once again, Medicare denied 
payment.
  Mr. President, I have a stack of actual run tickets from EMS 
providers in Minnesota, with names and other identifiers deleted, all 
demonstrating what a problem this is for Medicare beneficiaries and EMS 
providers. Again, I urge all of my colleagues to meet with their EMS 
providers and ask how these denials affect them.
  Title II of the Emergency Medical Services Efficiency Act creates a 
Federal Commission on Emergency Medical Services which will make 
recommendations and 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 
a flat denial of payment.
  Mr. President, I came across this chart two years ago which 
demonstrates how a Medicare claim moves from submittal to payment, 
denial, or write-off by the ambulance provider. Look at this chart and 
tell me how a rural ambulance provider who depends on volunteers has 
the manpower or expertise to navigate this mess. And, in the event it 
is navigated successfully, ambulance services are regularly reimbursed 
at a level that doesn't even cover their costs.
  Mr. President, I have heard complaints from many individuals about 
the cost of ambulance care. In fact, some within this very body 
criticize ambulance providers for the high prices they charge for their 
services. While I do not doubt there are cases of abuse, I know for a 
fact an overwhelming majority of EMTs, Paramedics, Emergency Nurses and 
EMS providers are trying to provide the best possible care for their 
patients at a reasonable price.
  Let's talk about how much it costs to run just one ambulance. There's 
the cost of the dispatcher who remains on the line to give pre-arrival 
assistance. The ambulance itself, which costs from $85,000 to $100,000. 
The radios, beepers, and cellular telephones used to communicate 
between the dispatcher, ambulance, and hospital. The supplies and 
equipment in the ambulance, including everything from defibrillators to 
bandages. 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. The liability insurance for 
the paramedics. And the list goes on.
  Yes, the costs can be high, but it's clear to me that, with the 
uncertainty ambulance providers face out in the field each day, they 
need to be prepared for very type of injury or condition. Mr. 
President, that's expensive.
  I'm convinced those who complain about the high costs of emergency 
care would be the first to complain if the ambulance that arrived to 
care for them in an emergency didn't have the life-saving equipment 
needed for treatment.
  Let's be honest with ourselves: we want the quickest and best service 
when we face an emergency--and that costs money.
  Mr. President, many of our political debates in Washington center 
around how to better prepare for the 21st century. I've 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 EMSEA, federal grant programs will be clarified to 
ensure EMS agencies are eligible for programs that relate to highway 
safety, rural development, and tele-health technology.
  Emergency Medical Services have come a long way since the first 
ambulance services began in Cleveland and New York City during the 
1860s.
  Indeed, the scientific and technological advances have created a new 
practice of medicine in two short decades, and have dramatically 
improved the prospects of surviving serious trauma. There's reason to 
believe further advances will have equally meaningful results.
  Innovations like tele-health technology may soon allow EMTs, 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.
  In August of 1996, the National Highway Traffic and Safety 
Administration and the Health Resources and Services Administration, 
Maternal and Child Health Bureau issued a 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.''
  After consultation with those in the EMS field throughout the 
country, I believe the most appropriate action is to take our time and 
get it right by conducting a study to determine which current or new 
office would best coordinate federal EMS efforts.
  Those are the major provisions of the legislation I introduce today.
  Mr. President, in 1995, there were approximately 100 million visits 
to emergency departments across this nation. Roughly 20 percent of 
those visits started with a call for an ambulance. Each one of those 
calls is important, especially to those seeking assistance and to the 
responding EMS personnel. While EMS represents a small portion of 
health care spending overall, it is critically important. It serves as 
the access point for the sickest among us and it would be tragic for 
Congress to deny its role in improving the system.

  Over the past several years, I've been privileged to get to know the 
men and women who dedicate their talents to serving others in an 
emergency.
  The nation owes a great deal to the EMS personnel who have dedicated 
themselves to their profession because they care about people and want 
to help those who are suffering. Nobody gets rich as a professional 
paramedic, and there's no monetary compensation at all 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, 94 individuals have been chosen by their peers to be 
honored for demonstrating exceptional kindness and selflessness in 
performing their duties.
  Mr. President, Minnesota suffered a tremendous loss this year. On 
January 14, while extricating a victim of an automobile accident, two 
EMTs were hit by a car. Brenda HagE, an EMT and Registered Nurse, was 
transported in traumatic arrest to a nearby hospital where she was 
pronounced dead. Ms. HagE is survived by her husband Darby and two 
children.
  I ask that the Senate observe a moment of silence for Ms. HagE and 
all EMS personnel who have died in the line of duty.
  Mr. President, I've talked with many professional EMTs, paramedics, 
and emergency nurses, and most tell me they wouldn't think of doing 
anything else for their chosen career. Similarly, volunteer EMS 
personnel tell me of the indescribable satisfaction they feel when they 
help those in their community get the care they need.

[[Page S5736]]

  So, in honoring them during this National EMS Week, I can think of no 
better way to recognize their service than through legislation that 
will help them help others.
  I ask my colleagues to support them by supporting S. 9-1-1, the 
``Emergency Medical Services Act.''
  Mr. President, I ask unanimous consent that the names of the 1999 
American Ambulance Association Stars of Life honorees be printed in the 
Record.
  There being no objection, the list was ordered to be printed in the 
Record, as follows:

                           1999 Stars of Life

       AZ--Theresa J. Pareja, Rural/Metro Fire Department;
       AR--Rae Meyer, Rural/Metro Ambulance and John C. Warren, 
     Columbia County Ambulance Service;
       CA--Marti Aho-Fazio, American Medical Response--Sonoma 
     Division, Dean B. Anderson, American Medical Response--Sonoma 
     Division, Chris S. Babler, Rural/Metro Ambulance, Carlos 
     Flores, American Medical Response, May Anne Godfrey-Jones, 
     Hall Ambulance Service, Inc., Randy Kappe, American Medical 
     Response, Frank Minitello, American Medical Response, and 
     Penny Vest, Hall Ambulance Service, Inc.;
       CO--Doug Jones, American Medical Response;
       CT--Todd Beaton, American Medical Response, Michael Case, 
     Hunter's Ambulance Service, and John M. Gopoian, Hunter's 
     Ambulance Service;
       FL--Clara DeSue, Rural/Metro Ambulance, Leroy Funderburk, 
     American Medical Response--West Florida, Andrea Hays, Rural/
     Metro Ambulance, and Keith A. Lund, American Medical 
     Response;
       GA--Deborah Lighton, American Medical Response--Georgia and 
     Kelly J. Potts, Mid Georgia Ambulance Service;
       IL--Carolyn Gray, Consolidated Medical Transport, Inc., 
     James Gray, Consolidated Medical Transport, Inc. and Cristen 
     Miller MEDIC EMS;
       IA--Paul Andorf, MEDIC EMS, Dennis L. Cosby, Lee County EMS 
     Ambulance, Inc., and Danny Eversmeyer, Henry County Health 
     Center EMS;
       KS--Tom Collins, Metropolitan Ambulance Services Trust and 
     Bill D. Witmer, American Medical Response;
       LA--Pattie Desoto, Med Express Ambulance Service, Inc., 
     Michael Noel, Priority Mobile Health, John Richard, Med 
     Express Ambulance Service, Inc., Scott Saunier, Acadian 
     Ambulance & Air Med Services, and Pete Thomas, Priority 
     Mobile Health;
       MD--Lily Puletti, Rural/Metro Ambulance and Michael Zeiler, 
     Rural/Metro Ambulance;
       MA--Daniel Doucette, Lyons Ambulance Service, Leonard 
     Gallego, American Medical Response, Mark Lennon, Action 
     Ambulance Service, Inc. and Edward McLaughlin, Lyons 
     Ambulance Service;
       MI--Steve Champagne, Huron Valley Ambulance, Edgar 
     ``Butch'' R. Dusette Jr., Medstar Ambulance, Mary Elsen, 
     Medstar Ambulance, Steven J. Frisbie, LifeCare Ambulance 
     Service, Richard Landis, American Medical Response, Tony L. 
     Sorensen, LIFE EMS, and Norma Weaver, Huron Valley Ambulance;
       MN--Barbara Erickson, Life Link III and Jesse Simkins, Gold 
     Cross Ambulance;
       MS--Carlos J. Redmon, American Medical Response (South 
     Mississippi);
       MO--Michelle D. Endicott, Newton County Ambulance District 
     and Lynette Lindholm, Metropolitan Ambulance Services Trust;
       NH--David Deacon, Rockingham Regional Ambulance, Inc., 
     Jason Preston, Rockingham Regional Ambulance Inc., Joseph 
     Simone, Action Ambulance Service, Inc., Joanna Umenhoffer, 
     Rockingham Regional Ambulance, Inc., and Roland Vaillancourt, 
     Rockingham Regional Ambulance, Inc.;
       NJ--Laurie Rovan, Med Alert Ambulance and Roberta Winters, 
     Rural/Metro Corp.;
       NM--LeeAnn J. Phillips, American Medical Response;
       NY--Susan Bull, Rural/Metro Medical Services, Nicholas 
     Cecci, Rural/Metro Medical Services Southern Tier, Daniel 
     Connors, Rural/Metro Medical Services, Scott Crewell, Rural/
     Metro Medical Services--Intermountain, Frank D'Ambra, Rural/
     Metro Corp., Doug Einsfeld, American Medical Response--Long 
     Island, Kevin Jones, Rural/Metro Medical Services--
     Intermountain, Patty Palmeri, Rural/Metro Corp., Carl Sharak, 
     Rural/Metro, Samuel Stetter, Rural/Metro Medical Services 
     Southern Tier, and Jean Zambrano, Rural/Metro Medical 
     Services;
       NC--Chris Murdock, Mecklenburg EMS Agency, Corinne Rust, 
     Mecklenburg EMS Agency, and John Sepski, Mecklenburg EMS 
     Agency;
       OH--Duane J. Wolf, Stofcheck Ambulance Service, Inc. and 
     Eric Wrask, Rural/Metro;
       OR--Larry B. Hornaday, Metro West Ambulance, Tony D. 
     Mooney, Pacific West Ambulance, and Mark C. Webster, American 
     Medical Response--Oregon;
       PA--Jerry Munley, Rural/Metro Medical Services;
       SD--Travis H. Spier, Rural/Metro Medical Services--South 
     Dakota;
       TN--Brian C. Qualls, Rural/Metro and Rodney B. Ward, Rural/
     Metro--Memphis;
       TX--Robert Moya, American Medical Response, Luis Salazar, 
     Life Ambulance Service, and Mike Sebastian, Life Ambulance 
     Service;
       UT--Monica Masterson, Gold Cross Services and Robert 
     Torgerson, Gold Cross Services;
       VT--John G. Potter, Regional Ambulance Service, Inc.;
       VA--Beverly Leigh, American Medical Response--Richmond;
       WA--Jack N. Erickson, Olympic Ambulance, Gary D. McVay, 
     American Medical Response--Washington, Aaron J. Schmidt, 
     Olympic Ambulance Service, and Rand P. Whitney, Rural/Metro 
     Ambulance.

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