In this episode of EMS One-Stop With Rob Lawrence, Rob is joined by Justin Grohs, general manager at Great Falls Emergency Services, Montana. Grohs also serves the American Ambulance Association as chair of the Rural Task Force.
Together, they discuss the realities, challenges, and funding of rural EMS, where staffing and financial stressors have been further exacerbated by the pandemic.
Great Falls Emergency Services (GFES) has been providing primary ALS ambulance response to the City of Great Falls and communities in rural Cascade County since 1997. In addition to 911 response, GFES provides BLS, ALS, and Critical Care inter-facility transports, event standbys, and Mobile Integrated Healthcare services. GFES employees 54 Paramedics and Emergency Medical Technicians. The GFES fleet is comprised of six Type III ALS ambulances, a type I ALS unit, and two response vehicles.
The Great Falls Emergency Services COVID-19 Response
The COVID-19 situation necessitated some significant initiatives at GFES including:
modified pre-hospital protocols, including treatment in place, minimization of aerosolization procedures, and minimizing the quantity of first-responder patient contact
office and workflow changes such as admin staff working from home and 24/7 duty crew screenings
more sophisticated Personal Protective Equipment capabilities and protocols including decon procedures and capabilities
The GFES staff, once in possession of accurate and timely information, and once equipped properly, were fantastic. Our EMS Providers arrive early to work for screening procedures, responded aggressively to all calls for medical need, maintained an excellent ‘can-do’ attitude, and didn’t flinch in their mission to provide front-line response and medical care to their communities.
The Great Falls Emergency Services Leadership Perspective
My admiration for the men and women at GFES and their families knows no bounds; they approach difficult situations with professionalism, technical competence, enthusiasm, and especially compassion.
—GFES President David Kuhn
Frontline Voices from Great Falls Emergency Services
“We are the first-line responders when someone is having a bad day due to sudden illness or injury. It means a lot to be able to be of service to our friends and neighbors when they are in need.” Kathy Wajer, Paramedic Supervisor and Critical Care Paramedic
“EMS handles the situations that no-one else can: the semi-responsive heavily intoxicated patient found on the street, the child with a broken arm at their Little League game, the elderly person at home having a stroke or cardiac issue–I like being able to contribute to a successful resolution of these events and to help the patient get through their difficult time” – Amber Malave, Paramedic Training Coordinator
How Great Falls Emergency Services Celebrates EMS Week
The centerpiece to our EMS Week celebration is a daily barbeque that Management puts on for that day’s crews (we put on our aprons and fire up a smoker to cook tri-tip, pork loin, and sirloins).
We also do daily bingo competitions with prizes and have general door prize drawings throughout the week. The community usually steps up and we receive a lot of deliveries of snacks and nice gifts.
We are also making vehicle decals that will be given out to staff. We typically offer a free community CPR class and offer child car seat installations.
The American Ambulance Association is proud to announce the winners of the 2017 AAA Legislative Awards, in recognition of their strong advocacy for emergency medical services. Each legislator was chosen for their ongoing service to the ambulance services of the United States.
A top priority of President Trump and congressional Republicans is to repeal and replace the Affordable Care Act (ACA). Since Republicans retook control of Congress in 2012 after passage of the ACA in 2010, they have sought to repeal the ACA. However, they had not developed a consensus on a replacement package, as they knew then-President Obama would veto the repeal bill. Now with President Trump in the White House and Republicans controlling the House and Senate, Republicans in the House have agreed upon a package and moved it through three Committees of jurisdiction: the Ways and Means Committee, the Energy and Commerce Committee, and the Budget Committee. Republicans in the Senate are less aligned and are said to be working on their own package, which is likely to differ in important ways from the House version.
For ambulance services, there are several key components to watch. These are:
Coverage for ambulance services. Expressed in terms of providing more flexibility, there is concern that some insurers are pushing and some Republicans agree that the concept of a minimum set of covered services (essential health benefits (EHB)) should be narrowed or even eliminated. Currently, only emergency services are included as an EHB, but through the designation of benchmark plans, non-emergency services have also been covered. If the benchmark plans requirements are modified, coverage for non-emergency services could become an issue.
Medicaid expansion. The Administration has sent a clear signal that it plans to roll back the expansion of Medicaid, which provide coverage to many Americans who had signed up under the ACA. For ambulance services in expansion States, the elimination of this program could result in more uncompensated care problems.
Coverage more generally. Republicans have clearly indicated a desire to eliminate the individual mandate. This could have two effects that may impact ambulance services. First, if people are not required to have coverage there are many who will not have it. It is not certain whether without coverage these individuals will be able to pay for the services they receive, which could lead to more uncompensated care. Second, individuals who do not purchase health insurance often are younger and healthier. Without such individuals in the risk pool, it is possible that premiums and other cost-sharing requirements will increase making it more likely for sicker individuals who cannot afford care becoming uninsured.
Employer costs and obligations. The House Republican legislation includes several provisions that relax the obligations and/or provide tax relief to employers providing health insurance. Such provisions could be beneficial to ambulance services in terms of providing health care coverage for their employees.
In addition, there are a few other provisions that the current bills being considered do not modify, but potential could be part of the discussions at some point or in subsequent Medicare legislation. Of these, there are three that would directly impact ambulance services.
Productivity Adjustment. As part of the ACA, the annual inflation updates for the Medicare ambulance fee schedule rates are now subject to a productivity adjustment, which reduces the amount of the update. CMS subtracts a projection of the non-farm business multi-factor productivity adjustment (MFP) from the Consumer Price Index – Urban to determine the update amount.
Inflation Index Below Zero. Prior to the ACA, the Medicare inflation update for ambulance rates could not be a negative percentage. Under ACA policies, the update may be a negative percentage. For example, in 2011, the CPI-U was 1.1 percent and the productivity adjustment was 1.2 percent, which resulted in a cut to the rates of 0.1 percent. In 2016, the CPI-U was 0.1 percent and the productivity adjustment was 0.5 percent, which resulted in a cut of 0.4 percent.
GPCI Increases. The ACA made a temporary change to the practice expense component of the physician geographical price cost index (GPCI), which is the entire GPCI for reimbursement under the Medicare ambulance fee schedule. The change established a minimum 1.0 GPCI for ambulance payments from January 1, 2010, to December 31, 2010. As a result of these changes, rates under the Medicare ambulance fee schedule for localities with a GPCI of less than 1.0 saw an additional temporary increase in reimbursement rates. Localities with a GPCI of 1.0 or higher were not be affected by the provision. The provision was retroactive to January 1, 2010 and the increases escalated for 2011 before expiring on December 31, 2011.
The ACA also established a permanent GPCI floor of 1.0 for “frontier” States which took effect in 2011. The designation of a “frontier” applies to those states in which 50 percent of the counties are frontier which have less than 6 people per square mile. The designation is updated with the original frontier states consisting of Montana, North Dakota, South Dakota, Utah and Wyoming. Utah is no longer deemed frontier and Nevada has been added to the list. While a complete repeal of the ACA would not impact the temporary GPCI increases as the provisions were temporary, it would eliminate frontier status.