CMS Issues Proposed Rule for Calendar Year 2016

On July 8, 2015, the Centers for Medicare and Medicaid Services (CMS) published a display copy of a proposed rule titled “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016”.  The proposed rule makes a number of changes to the Medicare Physician Fee Schedule.  It also makes certain changes to the Medicare Ambulance Fee Schedule.  These proposed changes are summarized below.

Continue reading

Spotlight: David Tetrault

David Tetrault
Farmington, MO, USA
Administrator/CEO, St. Francois County Ambulance District
Director, AAA Board, Region 4

Tell us a little about yourself, please.

I grew up in Jennings, Missouri, a small town in St. Louis County. I’m the baby of six kids—four brothers and a sister. I am very proud of my twin girls who just graduated from high school while simultaneously completing their associates degrees. They are now off to college to Rolla, Missouri, to finish their bachelors degrees. In addition to sharing time with my family and friends, I enjoy softball, camping, swimming, tennis, and walking.

How did you come to work in the industry? How long have you been involved?

David with some of his staff at a recent AAA workshop.
David with some of his team at a recent AAA workshop.

Years ago I was involved in part of the law enforcement arena called “Police Explorers”, primarily because my brother was a police officer. From there, I progressed through many different facets of law enforcement. The one thing that sticks out in my mind is that every time I was involved in an incident including a sick person or trauma, I really felt as if I would filling my calling. I could calm people and make them feel better, even when at that point I had only first responder training.

I have been involved with EMS for more than 30 years now, from my early days as a dispatcher, then up the ranks to Training Officer, then Manager, and now CEO/Administrator here in St. Francois County.

What do you enjoy most about your job?

I enjoy working with the public, people in our community, and my staff. They are my second family.

What is your biggest professional challenge?

Dealing with the younger spirited individuals coming into the world of EMS. Understanding the different challenges in funding, retention of our employee’s, the right mix of people and balancing the good/bad at the same time.

Making sure the Emergency Medical Services is not the forgotten one in the mix of Fire and Police. We all have a very important roles and the same amount of responsibility.

What is your typical day like?

My day typically starts with putting out fires and finishing my to do list from the previous day. Having 24/7 responsibility for a large program has its ups and downs—including sometimes getting called into work in the middle of the night. By sunrise, I have usually been up and on the highway for several hours. During typical office hours, I attend meetings and handle projects, budgeting, scheduling, and other tasks that need to be completed to keep our service operating. I also address any concerns or needs of the board of directors.

How has participation in AAA membership and advocacy helped your organization?

The American Ambulance Association has bridged the gap for me in my role as a service Administrator/CEO. AAA has many valuable resources, and provides me access to a vast network of ambulance services across the United States. My fellow AAA members as well as staff are always available to answer questions.

AAA has been the leader in ambulance services resources for many years, and they continue to strive to be the best in everything they offer. I enjoy the daily updates, and feel that the work AAA does with benchmarking and standands forms the backbone of the industry. The American Ambulance Association is truly a leader for EMS.

 

aaa conference

Spotlight: Matt Zavadsky

Matt Zavadsky
Fort Worth, TX, USA
Public Affairs Director, MedStar Mobile Healthcare

Tell us a little about yourself, please.

Originally from Connecticut and have lived in Lincoln, NE; Augusta, GA; Orlando & Daytona Beach, FL; Lacrosse, WI and now Fort Worth in the Republic of Texas since 2008. Married to my best friend, Tessa, and we each have grown children, and one grandchild (so far!). Aside from doing what I love at work, Tessa and I are avid Harley Davidson Riders (“it’s not a motorcycle, it’s a lifestyle”). We also do a lot of volunteer work with the North Texas Patriot Guard Riders and the Fort Worth Police Code Blue Citizen’s on Patrol program. I’m also a licensed amateur radio operator and certified storm spotter working with the Tarrant County (TX) Radio Amateur’s in Emergency Service (RACES) program.

How did you come to work in the industry? How long have you been involved?

My dad died suddenly in 1979. The hometown Trumbull, Connecticut volunteer ambulance crew that came to help him so impressed me that I signed up to volunteer the week he died. I started as a “driver” at age 17 and was originally trained in a High-Top Cadillac ambulance (the best unit I ever worked in!).

aaa emt membershipWhat do you enjoy most about your job?

Two things. First, making a difference! Whether you are an EMT, Paramedic, EMD, billing specialist, maintenance tech, logistics tech, scheduler, whatever—what we do MATTERS in people’s lives. Second, is the innovation occurring in the healthcare system, and the role the ambulance industry is now playing in the healthcare system every day, literally! The ability for us to define and redefine our profession’s future is an incredible in the environment we are in today!

What is your biggest professional challenge?

Keeping up with the rapid pace of change in the healthcare environment AND helping others see the future. There are a handful of leaders in our profession who can truly see the opportunity that lies ahead of us and are daring enough to take the risk to do something totally different. At the same time, helping our own folks, the people who really matter at the patient contact level, understand how important they are to our future as an industry.

What is your typical day like?

Up at 3:10 a.m., workout with Tessa at the MedStar gym, in the office by 6:00 a.m. to get more done before 8:00 a.m. than I’ll get done the rest of the day. Run from meeting to meeting to community events, in between try to get projects done until I leave for home at 6ish to finish up emails in the evening…

How has participation in AAA membership and advocacy helped your organization?

The education and communication is invaluable. The daily happenings updates, the education at events like the Annual Conference and Tradeshow, combined with the collaborative work with committees for things like government affairs, professional standards and reimbursement reform is invaluable. The ideas shared by visionary entrepreneurs that do this work every day helps make our profession stronger, both locally and nationally.

AAA’s 2015 Ambulance Ride-Along Toolkit

It is that time of year. With the summer heat, fireworks, baseball and barbecues comes your greatest opportunity to meet with and influence your federal legislators, the August Recess. This year, Congress is scheduled to begin recess early in August and return to normal business after the Labor Day Holiday. The recess means that many members of Congress will be in their districts and states. This will be a great opportunity for you to educate your members of Congress about current issues affecting our industry. In particular, it will give you the chance to talk about permanent Medicare ambulance relief.

The easiest and most effective way to discuss key issues with your members of Congress is to invite them and their staffs to participate in a tour of your operation and on an ambulance ride-along. This gives you the opportunity to show all of the valuable services that you provide to the community and how Congress can continue to help. The AAA has made the process of scheduling and arranging a ride-along easy for you with the release of our 2015 Congressional Ride-Along Toolkit.

In April of this year, Congress extended the temporary 2% urban, 3% rural and super rural bonus payment through December, 2017. While this was a great victory for the AAA and ambulance services nationwide, a permanent solution is still needed. With temporary extensions of Medicare ambulance relief, ambulance services are incapable of adequately preparing for their financial future and providing quality care to their patients. The AAA has worked hard to have legislation introduced in the both the U.S. House of Representatives and the Senate that would make the temporary relief become permanent. We are still seeking cosponsors for the bill (H.R. 745, S. 377) and hope that you will assist in our search.

We invite you to use the Ambulance Ride-Along toolkit as you prepare to meet with your members of Congress over the coming months.

CMS Ambulance Open Door Forum Thursday, July 9

Mark your calendar to have your voice heard! The next Centers for Medicare and Medicaid Services Ambulance Open Door Forum (CMS ODF) call is scheduled for this Thursday, July 9 from 2–3 p.m. ET.

Call-in Number: 1-800-837-1935
Conference ID: 12780373

“The Ambulance Open Door Forum (ODF) addresses issues related to the payment, billing, coverage and delivery of services in the ambulance industry. The Ambulance Fee Schedule rules, rural and other ambulance payment enhancements, requirements for ambulance service certification and payment determinations, are just some of the many types of issues addressed within the forum. In addition, discussions differentiating the rules related to provider-based and independent ambulance services are facilitated. Timely announcements and clarifications regarding important rulemaking, agency program initiatives and other related areas are also included in the forums.” — CMS

For the agenda and additional information, please visit the CMS website.

Welcome to the New AAA Website!

The American Ambulance Association is proud to welcome you to our new site. Although the look and feel of our website have changed, please be assured that all of your favorite AAA resources are still available. Additionally, our new platform will allow us to continue to improve our site over time—please check back frequently for new tools, resources, and benefits.

As always, thank you for your support. We look forward to serving you for many years to come.

Quick Website Tips

Logging In

Your existing AAA website login (email address and password) will grant access to the new site.

Clearing Cache

Does something look a little strange? Your browser may have cached images or material from the old site. To ensure you have the best experience on the new www.ambulance.org, please clear your cache. Here are simple instructions for doing this on popular browsers:

Getting Started

The AAA Members Center and the AAA Blog are a great places to start exploring the new site. (Not yet a member? Learn more about membership benefits and categories.)

Have Questions or Feedback?

Please contact ariordan@ambulance.org. We deeply value your thoughts and suggestions.

Cross-Cultural Communication for EMS

Ambulance services interact with people from all walks of life, and from all parts of the world. AAA checked in with expert Marcia Carteret, M.Ed., for some tips for communicating more effectively with people from other cultures. Marcia is an instructor of intercultural communications at University of Colorado School of Medicine in the Department of Pediatrics. She trains residents, faculty, and staff in healthcare communication with a focus on cross-cultural patient care and low health literacy. She has also trained in over 120 private pediatric and family practices across Colorado.

Marcia also developed a robust cross-cultural toolkit for AAA members. [Learn more about AAA membership]

Barriers to Understanding

In all healthcare settings, successful communication with patients and families depends on awareness of three key barriers to their understanding and compliance:

  1. Cultural Barriers: Understanding western medicine and the U.S. healthcare system is a challenge for many of us, but it is especially problematic for recent immigrants and refugees. 72% of U. S. population growth in the next 20 years will come from immigrants, or the children of immigrants.
  2. Limited English Proficiency: The number of people who spoke a language other than English at home grew by 38 percent in the 1980s and by 47 percent in the 1990s. While the population aged 5 and over grew by one-fourth from 1980 to 2000, the number who spoke a language other than English at home more than doubled.
  3. Low Health Literacy: While poor understanding of the health care system and difficulty understanding health care instructions may be associated with language and cultural barriers, low health literacy is also found in patients who are proficient in English and who share the common U.S. culture. This latter group may be especially at risk of having their low health literacy go unrecognized. 90 million “mainstream” Americans cannot understand basic health information.

Addressing These Barriers

How do people understand one another when they do not share a common cultural experience? Nowhere is this a more pressing question than in healthcare settings, especially in emergencies. There is no easy list of things “to do” or “not to do” that can be applied to each culture. What can be useful are communication guidelines that work for people from all cultures. These guidelines are also important for people with low health literacy.

[quote_left]“The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” — Edward T. Hall[/quote_left]

Perhaps the most important is framing questions to elicit appropriate answers. As Edward T. Hall, anthropologist and cross-cultural researcher wrote,“The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” What could be more crucial when, for example, an EMT or paramedic is attempting to establish level of consciousness by directly eliciting information from a patient? Being able to get quality responses from patients from any culture is a communication skill that comes with experience. Learning and practicing a set of strategically designed questions is key to building confidence in this important skill.

Key Communication Tips

  • Explain your professional role
    911 is the number to dial in an emergency, but some people may not understand the roles of different emergency responders. You can’t expect people who are still learning to function in the U.S. mainstream society – recent immigrants or refugees especially – to understand the role of the EMT or paramedic.
    Suggested explanation: “I am not a doctor. I am an emergency medical professional. I have come to help because someone called 911. I will take this person who is hurt/sick to the hospital safely.”
  • Use simple familiar words and short sentences
    “Stabilize” is a complex word, even though it might be the best word to describe what you do for a patient in an emergency. Help is a better word. With Limited English Proficiency (LEP) patients and families, the 5¢ word is always better than the 75¢ word.  Basics such as give, take, more, less will be better choices than administer, increase, decrease.
  • Be clear when you are asking a question versus giving an instruction.
    Running questions and statements together is confusing for second language learners. Avoid sentences like this: “It looks like you are having a reaction (a statement of observation) so I need to know if you have taken any medication that made you feel sick.”Examples of concise phrasing:

    • “What medicine have you taken?
    • “Show me this medicine.”
    • “Show me where it hurts.”
  • Avoid close-ended questions
    These usually begin with do, did, does, is, are, will, or can. These can be answered with a simple yes or no – or a head nod. Avoid the use of close-ended questions with Limited English Proficiency (LEP)  patients because in many cultures people will frequently simply say yes even if they don’t understand you.
  • Use open-ended questions
    These usually begin with the 5 Ws – who, what, when, where, why (and how or how many). It is awkward to answer these questions with a nod, shrug, or simple yes/no. For example, you might ask: When did you take these pills?” instead of “Did you take these pills?”
  • Avoid starting sentences with negations such as isn’t and didn’t.
    Though this is a common speech pattern in English, it may be confusing for people who speak a different native tongue. For example:  Didn’t you call 911? (Read more about this speech pattern.)
  • Clarify understanding – yours and theirs
    Even if you are using simpler words and shorter sentences, you can’t be certain there has been communication until the receiver acknowledges it with feedback. Remember, head nodding does not count as feedback with people from many different cultures. Even with Americans, and definitely with children, head nodding is often a sign of partial comprehension. So you must ask clarifying questions.
  • Repeat back what you have understood. 
    • Examples: “Yes? – you took the medicine?”
    • “Yes? – you are his/her grandmother?”
  • Not understanding vs. misunderstanding
    When people do not understand what you say, there is more likely to be an indication of confusion than when they MISunderstand you. A person struggling with English, for example, may ask you to repeat what you have said. Their face may show confusion. But when people MISunderstand, it can be far less obvious. For example, the English words want and won’t sound very much alike to a non-native speaker. You may say to a person, “I want to help you,” but she may hear “I won’t help you.” She may be perplexed that this is your response, but she may be very inclined to accept the word of a healthcare professional. She may perceive you as being uncaring, but certainly won’t say so. Many MISunderstandings go unnoticed by both parties. Asking clarifying questions is crucial.
  • Speak slowly and clearly—NOT loudly
    Often when people don’t understand our language, we treat them as if they are hearing impaired or “slow” without realizing we are doing so. Articulate your words in shorter phrases rather than just speaking more loudly.

Cultural Norms

Cultural norms vary around the world. Here are some key norms to keep in mind when assisting patients and their families.

    • Eye Contact
      An EMT or Paramedic will often be perceived as an authority figure by the people from more traditional cultures. If a person is avoiding eye contact while listening to you or while answering questions, be aware that in some cultures direct eye contact with an authority figure is very rude. In trying to be respectful, people may appear to be avoiding looking you in the eye. This is not to be taken immediately as any indication of disrespect, dishonesty, or evasiveness
    • Silence
      Silence may be the only response a person can muster if he or she is frightened. Silence might also be a way of showing respect, similar to avoiding eye contact. Being thoughtful about answering a question shows humility and real effort in giving the best answer. Unfortunately, silence on the part of the non-English patient or family member is often interpreted as open hostility by Americans. It can be helpful to say: “I need your help. Please try to answer my questions. Your answers help me help you.” Also, try not to rush answers. Americans allow very little time between questions and responses. Impatient and in a hurry we tend to start talking before the other person is able to answer the question asked.
    • Reverting to Native Language
      Bilingual patients may revert to their language of origin in times of stress, and while this hinders communication with an EMT, it should not be seen as manipulative or uncooperative. Calmly ask the person, “Can you speak in English? Please try English.” If the person does not speak any English, this will at least help them realize you can’t understand.

Summary

As first-responders, EMS is often working in high stakes situations where communication is a challenge even without the added barriers associated with the “triple threat” to healthcare communication—language barriers, cultural understanding, and low health literacy. No matter which culture an EMT or Paramedic is interacting with, the key to good communication is asking good questions and phrasing all dialogue in simple short sentences. It should be clear that a question is being asked or a statement of information is being made by the EMS professional. Asking for clarification is essential. Head nods and affirmative answers should not be accepted immediately as evidence of sufficient understanding or agreement. EMTs will find that enhanced communication skills will not only improve cross-cultural interactions, these skills improve outcomes with all people –  even “mainstream” Americans. Also, be aware that low health literacy is a problem for 90 million Americans. Never assume that same-culture communication in English requires less intentional speech on your part.

The Fairness in Ambulance Reimbursement Act

On July 11, 2014, The Centers for Medicare and Medicaid Services (CMS) published a proposed rule for the 2015 Medicare Fee Schedule (PFS) that adjusted ZIP code classifications for ground ambulance reimbursement based on 2010 data. The proposed rule initially indicated that only 122 ZIP codes would be reclassified from rural to urban in 2015.  However, the final PFS rule, which was published on November 13, 2014, re-designated 3000 ZIP codes from rural to urban. Thanks to work by the AAA’s legislative team, champions on Capitol Hill, members and other organizations, on December 16, 2014, CMS once again revised the ZIP codes that would be adjusted from rural to urban to 1,599.

CMS’s error, which contributed to the drastic changes from the proposed rule in July to the final rule in December, effectively denied interested parties the opportunities to participate in the notice and comment process and did not give ambulance service providers enough time to process and adjust for their losses.

The Fairness in Ambulance Reimbursement Act of 2015

The Fairness in Ambulance Reimbursement Act of 2015 (H.R. 817) would delay implementation of the rural to urban ZIP code reclassification until January 1, 2016, which would provide ambulance services with the necessary time to evaluate and respond to recent changes made by CMS.  This legislation is critical to ensure that ambulance services have needed funding and that Medicare beneficiaries continue to have access to high quality medical care as they are transported to hospitals and other healthcare facilities.

What You Can Do to Help

Unlike the permanent Medicare relief bill, the changes in zip codes to do not affect every ambulance service in the country.  That being said, we invite AAA members, organizations, and individuals to support our efforts to delay implementation of the zip code reclassification.  Cosponsors and support for the bill are still needed.  Please reach out to your members of Congress and ask them to cosponsor and support this important piece of legislation.  If this issue will affect you and your service, raise the issue with your legislators during your ambulance ride-along

Legislation Tracking

Here is federal legislation that the AAA is currently tracking. Questions? - Contact the AAA's advocacy team at hello@ambulance.org. Bill - Sponsors - Stance: Non-Emergency Ambulance Transportation Sustainability and Accountability (NEATSA) Act of 2019 - S. 228 - Sen. Bill Cassidy (R-LA) and Sen. Doug Jones (D-AL). - AAA Supports Summary: Would restructure the offset passed as...

On July 11, 2014, The Centers for Medicare and Medicaid Services (CMS) published a proposed rule for the 2015 Medicare Fee Schedule (PFS) that adjusted ZIP code classifications for ground ambulance reimbursement based on 2010 data.

Ambulance Cost Collection

CMS Ambulance Cost Data Collection Overview What is Cost Collection? Following the passage of the Bipartisan Budget Act of 2018, all ambulance services that bill Medicare will be required to report certain cost related data to CMS.  The reason CMS is collecting cost data is to assess the adequacy of the Ambulance Fee Schedule.  Cost...

On July 11, 2014, The Centers for Medicare and Medicaid Services (CMS) published a proposed rule for the 2015 Medicare Fee Schedule (PFS) that adjusted ZIP code classifications for ground ambulance reimbursement based on 2010 data.

Ambulance Cost Data Collection & Payment Reform

Ambulance Cost Data Collection Sign Up for Cost Data Collection Email Updates! In 2012, the AAA engaged The Moran Company, a DC-based health care analytics firm, to determine the most appropriate way for the Centers for Medicare and Medicaid Services (CMS) to collect cost data from ambulance service suppliers and providers. Due to the high...

On July 11, 2014, The Centers for Medicare and Medicaid Services (CMS) published a proposed rule for the 2015 Medicare Fee Schedule (PFS) that adjusted ZIP code classifications for ground ambulance reimbursement based on 2010 data.

State Track

StateTrack helps you follow legislative and regulatory developments in one state or all of them. The map below will pull legislation with any of the following key words: Affordable Care Act Ambulance Community Paramedicine EMT Medicaid Medicare Mobile Integrated Health Paramedic Members can view the full text of each piece of legislation as well as edits...

On July 11, 2014, The Centers for Medicare and Medicaid Services (CMS) published a proposed rule for the 2015 Medicare Fee Schedule (PFS) that adjusted ZIP code classifications for ground ambulance reimbursement based on 2010 data.

Position Papers

CMS Data Release Position StatementApril 17, 2014 On April 9, the Centers for Medicare and Medicaid Services (CMS) released data describing the number and type of health care services provided by physicians and other health care professionals in 2012. Although extremely different than other health care providers, ambulance services were included in the data release....

On July 11, 2014, The Centers for Medicare and Medicaid Services (CMS) published a proposed rule for the 2015 Medicare Fee Schedule (PFS) that adjusted ZIP code classifications for ground ambulance reimbursement based on 2010 data.