Welcome to the third issue of EMS on the Hill, a newsletter representing the work of a broad group of EMS organizations dedicated to achieving positive change and recognition for emergency medical services at the state and federal levels. In July 2007, this group of organizations met to review the recommendations of the 2006 IOM Crossroads report and develop priorities and action items to help make these recommendations reality. This newsletter will provide updates on those action items, plus discuss other critical industry issues.

BUDGET STRAIN
EMS leaders concerned about big cuts in President's FY09 plan

In February, President George W. Bush released his proposed federal budget for fiscal year 2009. It was not greeted warmly by emergency medical services leaders, who were presented with the prospect of slashed funding in a number of key programs, and the total elimination of several others.

In the Department of Homeland Security, three key programs face major funding reductions. Funding for Basic State Formula Grants is cut by $750 million, a whopping 79%. Assistance to Firefi ghters Grant money is reduced by $260 million, or 46%. Emergency Management Performance Grants are cut by a third, or $100 million. In addition, the Metropolitan Medical Response System is eliminated entirely.

"A recent report issued by the Department [of Homeland Security] shows that EMS providers continue to receive only 4% of the total fi rst responder grant funding," Advocates for EMS President Dr. Bruce Walz noted of the budget. "EMS is already receiving such a small piece of the pie, to cut fi rst responder grant programs would be even more harmful to EMS providers' ability to respond to a disaster."

In the Department of Health and Human Services, several popular programs are done away with entirely: the Emergency Medical Services for Children and Traumatic Brain Injury programs, and the Preventive Health and Health Services Block Grant. The Trauma Systems Planning and Development Act, which provides grants to develop states' trauma response plans and was reauthorized in 2007, is not funded.

PREPAREDNESS FUNDING

A report released by the Department of Homeland Security in February found that EMS is still only receiving around 4% of available funds under key preparedness programs. The Congressional Report on Support for Emergency Medical Services Provided Through the Department of Homeland Security's Offi ce of Grants and Training looked at funding under the Homeland Security Grant Program, Urban Areas Security Initiative and Assistance to Firefi ghters program. Under the HSGP (excluding UASI monies), EMS got slightly more than $50 million out of a possible $1.664 billion in fi scal 2005--that's just 3%. Of $854.7 million in eligible UASI funding that year, EMS got $12.1 million--a mere 1.4%. With AFG awards, EMS got $63.6 million out of $650 million-- a relatively generous 9.8%.

Factoring in FY04 awards for all three programs and FY02--03 AFG funding, EMS received a total of $339.9 million out of a total pot of $7,885,700,000 examined. That's a total of 4.3%.

In an election year, that's not likely to improve much, says lobbyist Lisa Meyer of Cornerstone Government Affairs, which works with Advocates to support EMS interests in Washington.

"There's more political posturing than policy-making going on, especially with the election process running as long as it has," Meyer says. "Even the little things are slowed down. [House Appropriations] Chairman [David] Obey has made it very clear that he would like to be able to compromise with the president, but if the president isn't willing to budge on these numbers, they may just wait until a new administration comes in."

Still, Advocates and its member organizations have kept up the pressure as relevant House and Senate committees have held their budget hearings. There was hope on the EMS-C front, where a bill to reauthorize the program, H.R. 2464, was introduced in March. Other priorities include funding for the National EMS Information System (NEMSIS), and passage of H.R. 3822, which would expand the public safety offi cer death bene- fi t to nongovernmental employees and certain uncovered EMS and fi re volunteers.

For more, see www.advocatesforems.org.
--John Erich, Associate Editor

WISH LISTS
What EMS leaders would like to see from the President and Congress in 2008

With money matters on everyone's minds, we surveyed some top EMS leaders as to the fi eld's biggest needs and what they'd like to see in this year's budget. Here are some responses.

"(The biggest problem is) lack of Homeland Security funding dedicated to improvement in EMS systems, which is the health and safety net for prehospital care in this country."
--David Jaslow, MD, Chief, Division of EMS, Albert Einstein Medical Center, Philadelphia

"Dedicated funding for EMS with clarity on use of funds. EMS is a broad term and often misrepresented. It has been used in reference to fi rst responders, ambulance transportation, hospitals, fi re services, law enforcement, business and industry, and a plethora of governmental entities."
--Rick Patrick, Deputy Fire Chief, Estero, Fla.

"Medicare reimbursement (help). We all know the Medicare system is broken; further, we know the EMS community's pleas for assistance have fallen on deaf ears. We have continually demonstrated that the Medicare payment system for ambulance reimbursement is grossly unfair, and that it doesn't even cover the cost of providing the service. In an industry that typically has a payer mix that's majority Medicare, we must get Congress' attention. The situation is nearing crisis."
--Jerry Johnston, President, NAEMT

"The single greatest funding issue facing EMS today is the lack of interoperability in communications infrastructure among all public safety agencies. This is the greatest hurdle to EMS systems actually functioning as systems, and it is only correctable on the national level by fully funding the issue to all agencies and essentially forcing them onto interoperable systems."
--Matthew Streger, NREMT-P, Associate, Kern, Augustine, Conroy & Schoppman, Bridgewater, NJ

"It is so diffi cult to actually craft legislation that is effective and doesn't result in unwanted consequences and more pain than creating solutions without legislation. But if there was one wish: Tort reform at the national level for emergency providers and for EMTALA-related activities at the hospital. This action would rationalize more effective medical care, reduce the legal burden that drives emergency caregivers out of our fi eld at every level, reduce cost, and allow EDs to more effi ciently move patients through to reduce patient loads and delays. Here are some other suggestions:

• Promote an EMS career ladder.
• Reduce infectious disease risks and provide care for EMS providers who contract infections from work.
• Fund home care and house calls for nursing home patients. Fund EMS in nontransport situations.
• Fund vehicle safety programs and research for ambulances.
• Fund a demonstration project of regional, accountable emergency systems."

CLEARING A PATH FOR DISASTER VOLUNTEERS TO HELP

When something big happens--big, like Katrina or 9/11--trained caregivers from around the nation are typically willing to come to a stricken area and help. But from EMTs to MDs and beyond, they are often delayed or even prevented from assisting because they're not authorized to practice in the state where the emergency occurred.

In an effort to get those hands helping faster, the National Conference of Commissioners on Uniform State Laws (known for short as the Uniform Law Commission, or ULC), is working with states to pass the Uniform Emergency Volunteer Health Practitioners Act. The ULC is a group of lawyers appointed by the states to help them develop consistent, compatible rules and procedures; its UEVHPA legislation would let out-of-state medical professionals be quickly utilized by disaster states under clear, common rules that provide a defined and easy-to-use framework for multiple kinds of assistance.

"It's intended to create a system that's reasonably uniform and easily understood," says Raymond Pepe, JD, who chaired the committee that drafted the Act, "and that provides sort of a presumptively open door to get people in, as long as they're working with local facilities or organizations in coordination with local emergency management."

States already recognize each other's professional licenses during disasters under the Emergency Management Assistance Compact, but EMAC generally applies only to employees of public/governmental services, and typically requires personnel be deployed through their home services under formal mutual aid agreements. During Katrina, this limited the involvement of private-sector medical volunteers, in particular many working through nongovernmental groups (e.g., Red Cross, Salvation Army). States tried to solve the problem with executive orders and directives, but this led to a confusing lack of coordination.

Consequently, "There was felt to be a need for a separate body of law that specifically authorized activities by the nongovernmental volunteers," says Pepe, a partner in the Harrisburg, PA, firm of Kirkpatrick & Lockhart Preston Gates Ellis, "and provided reasonable certainty that credentials were reviewed, that people were deployed in full coordination with local officials, and that dealt with issues relating to scope of practice."

Those were among the areas members of the drafting committee had to reconcile. The process, which took roughly two years, entailed recruiting key stakeholder input and research assistance. Views were sought from a range of experts and advisers, including top medical organizations like the AMA, ACEP, American Red Cross and more. The final product was approved by the full Conference and the American Bar Association's House of Delegates.

In states that have enacted UEVHPA, providers can register before or during an emergency to serve as volunteers. States can use a variety of mechanisms for the registration process, including federal structures like the Medical Reserve Corps or systems established by disaster-relief groups, professional organizations and healthcare systems. Healthcare facilities and disaster relief groups in those states, working with local response agencies, can then freely use those providers who remain licensed and in good standing.

"In a major disaster," Pepe notes, "communications may be down, and you might not be able to get everybody to one place to register. That could create a substantial bottleneck. So we felt it was important to provide for multiple pathways for registration and evaluation of credentials, using the major national groups and organizations that have done this historically, like the American Red Cross, and who have demonstrated that they can do it well." Volunteers' licenses will be recognized in disaster states as long as an emergency is declared. Licensing boards in those states retain jurisdiction over out-of-state volunteers and must report any misbehavior or discipline to a worker's home jurisdiction. Host states' scopes of practices apply, and volunteers would not be allowed to exceed their home-state scopes unless the host state authorizes it.

As the Act was being developed, stakeholders voiced concerns about matters of civil liability and Worker's Compensation for those volunteering out of state. The ULC addressed these issues with a pair of amendments last August. In providing civil liability protections, states have two options:

They can shield volunteers and associated parties entirely for acts and omissions short of things like willful misconduct or gross negligence, or they can do this plus additionally limit the compensation a volunteer can receive at $500 a year without a cap on vicarious liability. States enacting UEVHPA can choose the option that fits best with their existing Good Samaritan protections and implementation of federal law.

In the event of work-related illness or injury, volunteers not covered by Worker's Comp through their host or home state can choose to be classified as an employee of the host state if they need to make a claim. Enacting states are expected to coordinate implementation of this coverage among themselves. Seven states have adopted the Act, with Indiana, New Mexico and Utah this year joining Colorado, Kentucky, New Mexico and Tennessee. Several others have introduced it, and others plan to. That's a pretty good start, considering it wasn't finalized until late in 2007.

But as it moves forward, Pepe says, the UCL and Act's advocates still have some educating to do.

"We've tried to reach out to state officials, but I fear there's not a high level of understanding about how this statute interrelates with other state emergency management law," he says. "There may be a concern that it will encourage the deployment of a lot of spontaneous volunteers who might not be well coordinated with local forces. We've tried to make sure those issues are addressed, but we'll have to work with state and local emergency management agencies to make sure they understand we provide for full and effective coordination."

For the full text of the Act, see www.uevhpa.org. --JE

LOBBYING FOR EMS
An interview with O.J. Doyle
By Marie Nordberg, Associate Editor

A funny thing happened to O.J. Doyle on his way to becoming an archaelogist. He ended up at the State Capitol in St. Paul, MN, lobbying for emergency medical services.

Coming from a long line of family politicians, Doyle got into government work years ago and has been told he's the only full-time EMS state lobbyist in the country. He's at least the only one with past experience as an EMS provider. Other states have lobbyists, he says, but EMS is usually only one of many industries they're contracted to represent.

So what exactly does Doyle do that distracted him from archaelogy? "I draft legislation and send it to a special bureau within state government that does the formal drafting," he explains. "I meet with legislators to try to secure their interest in our EMS issues and ask them to author or co-author bills once they're drafted. Much of my job is the detail-type work like making sure our bills get introduced and referred to the proper committee and ensuring that hearings are scheduled. There are about 6,000--7,000 bills introduced during a legislative session and roughly only 7% are signed into law. I work closely with committee staff members and with the legislature in general. One fortunate thing is that EMS issues are nonpartisan, so we're treated well by everybody.

"I can't emphasize enough the importance of building strong relationships with staff members," Doyle adds. "There are a few professional lobbyists who treat staff like second-class citizens and have little respect for them. They forget that without access, you can't have infl uence, and the staff controls the access. As a former staffer, I tend to be very sensitive to those folks."

Working with various state agencies, like public safety, is another important part of his job, says Doyle. People tend to forget that EMS is part of emergency response "when all hell breaks loose," and he works closely with anyone who may be involved in those activities.

"As a lobbyist, you exist in a world of opportunities, and I take every opportunity I can to benefi t my clients, as long as it's not to the detriment of someone else," says Doyle. "Because I was part of the EMS delivery system professionally (15 years as a paramedic), I try to be careful about issues I get involved in. If I were asked to support an issue that doesn't fi t well with EMS, I would walk away from it.

"The last thing I do is work to defeat or amend legislation that would hurt the ability of our providers to do their job," says Doyle. "The new healthcare reform in Minnesota is so complicated and diffi cult to understand, but from an ambulance perspective, it looks like it will take a chunk of the money we now get under no-fault automobile insurance, so we're looking at losing a signifi cant source of revenue. The way it's written, we'd be put on a fee schedule not unlike what we see with Medicare, and you know what that's done to the ambulance industry. We're working hard to modify that piece of legislation so we'll have an ambulance industry left."

How does one become an EMS lobbyist? The best place to start, says Doyle, is gaining an understanding of how government works and learning more about the laws that affect your area of interest. "The number of people in high-ranking positions in EMS who don't know much about the laws that regulate them is scary," he says. "It's important for them to understand how they're regulated, what regulates them, and what the consequences are for not complying with the law." Go to the capitol and watch the process, Doyle advises.

"There's an advantage to states having someone like me to lobby for them," says Doyle. "If you have a strong EMS delivery system, it enhances the quality of life. If your system is under siege and you don't have someone watching out for what public policies are being made, bad legislation passes that can negatively affect your ability to provide care, and it's all downhill from there."

ACHIEVING LEGISLATIVE SUCCESS
A summit approach to collaboration
By James L. Jenkins, Jr., RN, BSN, EMT-P, & Steven R. Skinner, BS, APR

Rivalry among EMS, fi re and the other emergency services can deprive us of government funds, improved oversight, specialized training programs, enhanced benefi ts and new laws that advance our services and protect us from harm.

When it comes to petitioning elected offi cials for support with an issue, the only way to succeed is to put aside differing viewpoints to come together in a solid, unifi ed front to prove to law- and policy-makers that what you bring to their attention carries the weight of consensus and represents the voice of the collective. But how do you go about acquiring that unity when you see things so differently? The answer is through honest, ongoing dialogue between groups that culminates in a legislative summit, bringing all the parties together to build consensus and establish an agreed-upon collection of legislative initiatives or positions that will be that year's legislative agenda. This agenda will become the foundation of a coordinated lobbying effort.

WHAT IS A SUMMIT?

As a conference of top offi cials, a summit differs from a committee or association meeting in that it represents the fi nal step toward action on behalf of every constituent. There is no board of directors to receive recommendations--a summit is a decisive conference of organization leaders.

The best time to host a legislative summit depends on whether the purpose is to address national, state or local concerns. For national and state issues, a summit should be held 4--6 months before the legislature convenes. Such lead time is critical for two reasons: First, enough time must be allowed for the legislative agenda to be drafted and reviewed by participating groups. Second, governors and legislators prepare, adjust and begin promoting their agendas well in advance of a bill or resolution being introduced.

DESIGN & STRUCTURE

The design and structure of a legislative summit will vary according to the issues to be addressed and the level of government to which lobbying efforts will be directed. Two key ingredients are a summit organizer and a neutral third-party moderator/ facilitator. For the moderator, consider using a civic leader, former legislative aide or government agency representative. A lobbyist familiar with emergency services concerns, but not working for any participants or involved with the issues, could also be of assistance. The moderator's role is to provide an unbiased process for group decision- making.

Participants should be identifi ed based upon the level of government at which the issues are to be heard. Local and regional matters are best dealt with by summits consisting of local agencies only, while statewide concerns will require the attention of regional and state associations. Prior to the summit, ask invited organizations to solicit their membership for legislative ideas, prioritize this information based upon need and appoint a single representative who will speak to the interests of the entire group.

DURING THE SUMMIT

During the summit, the moderator should keep track of all ideas expressed via an overhead projector, easel with paper or other similar device. Deciding which items make their way to the legislative agenda will require each participant to cast a vote of support, opposition or neutrality for each issue.

Positions should be recorded by the moderator and forwarded in writing to everyone in a timely manner following the meeting. Once voting has concluded, a consensus list of items should be sorted into priority order by majority rule. Doing this improves subsequent lobbying efforts by identifying areas of immediate need.

The summit's fi nished product becomes the offi cial position paper delivered to lawmakers. This document should include a title for each supported topic, followed by a one- or two-line summary and 3--5 key talking points for every listed item.

This is an excerpt from an article that appeared in the April 2007 issue of EMS Magazine. To read the original article, visit www.emsresponder. com/legislativesummits.

James L. Jenkins, Jr., RN, BSN, EMT-P, is past chair of the Virginia 97th Legislative District Committee. Contact him at jim.jenkins.jr@gmail.com. Steven R. Skinner, BS, APR, is public information manager for the Richmond (VA) City Council.

ADVOCATES FOR EMS HOSTS POLICY SUMMIT
First annual EMS policy summit held in Baltimore, MD
By Heather Caspi, EMSResponder.com

The 1st Annual EMS Policy Summit hosted by Advocates for EMS took place in Baltimore, MD, on March 27. The event brought together EMS providers and representatives from various federal agencies involved in EMS, and proved to be a lively and productive information exchange.

The event featured a keynote speech by Jeff Runge, MD, FACEP, assistant secretary and chief medical offi - cer at the Department of Homeland Security's Offi ce of Health Affairs, followed by a session on EMS advocacy by Lisa Meyer of Cornerstone Government Affairs, and then a roundtable discussion featuring the federal partners from agencies within the U.S. Department of Health and Human Services, Department of Homeland Security and National Highway and Traffi c Safety Administration (NHTSA).

The overall theme of discussion was that EMS providers and leaders need to get involved in making EMS policy, and they need to act together to maximize their strength and combined expertise.

Runge strove to illustrate the relevance of political involvement to the group by posing it as another form of patient care.

"Policy affects patients in ways we can't one by one," he said.

Runge also spoke about the need for an EMS caucus, for which efforts are underway, and the importance of the Federal Interagency Committee on Emergency Medical Services, which serves to coordinate the efforts of all the EMS federal partners.

Runge admitted that FICEMS got off to a slow start when it was created in 2006, but added that "FICEMS is the right thing to do and it must work... it will not succeed unless EMS holds it accountable."

The audience did hold the panelists accountable at the meeting. Several attendees were concerned about changes to the Ryan White CARE Act, which previously mandated that EMS personnel have the opportunity to learn whether they were exposed to diseases while providing patient care. During the reauthorization of the act in 2006, the emergency-response provisions were struck by Congressional staff members because they were not the legislation's main purpose.

"How did that slip through the cracks?" one provider asked. Another attendee asked what the federal agencies are doing in response to the recommendations of the Institute of Medicine's 2006 report on the future of emergency care. Several panelists said their agencies are working toward goals in the report, but not as direct responses to the report. Drew Dawson, director of NHTSA's Offi ce of EMS, said there is a FICEMS report on what each group is doing relative to the report and that it would be made available at www.EMS.gov.

Another attendee asked, "There seems to be little reaction from Congress to reports like IOM. Can NEMSAC change that?" NEMSAC, the new National Emergency Medical Services Advisory Council, was recently created to advise NHTSA.

"Yes, I do think so," Runge said. He said it will still take time and repetition to get ideas through to Congress. "When you're sick to death of saying something, they're just starting to hear it. Keep talking about it," he said.

Meyer shared similar sentiments in her lesson on EMS advocacy. "Policy makers assume information will come to them--they don't seek it out," she said.

Meyer advised EMS personnel to act both individually and in organization. She advised personnel to go to briefi ngs and hearings and to know their representatives in both the Senate and the House. Invite them to events and mail them relevant news clippings, she suggested, and make personal connections to them or their staffers. Look at their websites to learn their causes and interests, and look for common acquaintances, hometowns, etc. Anticipate their needs, Meyer advised, and be a resource.

Many in the audience raised concerns about the feasibility of asking EMS providers to go so far as to attend hearings in D.C. Involvement costs time and money, making it unrealistic to expect most providers even to mail a letter. Meyer's response was to send e-mail, the fastest and easiest action of all. "The system is designed for your input," she said. "It's your right, so exercise it."

Advocates for EMS plans to host a second EMS Policy Summit in 2009. For more, visit www.advocates forems.org.

For the second year, EMS EXPO will host a federal roundtable at the 2008 EMS EXPO in Las Vegas, NV, October 15--17. For more information, visit www.emsexpo2008.com.

WHERE TO SPEND PUBLIC HEALTH RESEARCH DOLLARS?

The supersize emergencies we face today--from natural disasters to terrorist attacks--have major public health implications. Mitigating their effects and protecting our citizens takes smart, effective efforts that make good use of limited dollars. But how do we determine what's effective? What areas should we examine and work to develop with our finite research funds?

With a report published in January, the Institute of Medicine offered some answers. Its Research Priorities in Emergency Preparedness and Response for Public Health Systems: A Letter Report, available through the National Academies Press ( www.nap.edu), identified four short-term priority areas for research on emergency preparedness and response in public health systems. These areas were:

• Enhancing the usefulness of training;
• Improving timely emergency communications;
• Creating and maintaining sustainable response systems; and
• Generating effectiveness criteria and metrics.

The report was prepared by an ad hoc IOM committee convened to help the nation's Centers for Public Health Preparedness--CDC-funded academic centers that work with public health institutions to prepare providers for emergencies--define research priorities in the field. The 2006 Pandemic and All Hazards Preparedness Act encourages CPHPs to perform public health systems research, and the CDC's Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) asked the IOM to fast-track a report offering guidance. The priorities will be reflected in a research agenda being developed by COTPER to help guide research funding opportunities.

"Our job was to have these institutions that will be getting funding look at some really important things, but not get too far into the weeds of telling them exactly how to do that," says committee member Ed Gabriel, a veteran of FDNY and past deputy commissioner for planning and preparedness in New York City's Office of Emergency Management. The committee began work last winter, focusing its efforts on areas articulated by the CDC in its 2006 publication Advancing the Nation's Health: A Guide for Public Health Research Needs. They sought input from a range of stakeholders, experts and interested parties. "That gave us a real, live flavor of what might be integrated into the process," says Gabriel.

One key concept that emerged was the systems nature of emergency preparedness and response. It includes elements of public health, public safety and healthcare, and involves academia, government and more. A wide range of providers have roles, both horizontally and vertically. How do these interests work together, train, communicate, etc.? How do they interconnect?

"I think every presenter believed we should look at this as a collaborative effort from the beginning of the event to the end," says Gabriel. "With each part of the system, we wanted to make sure, as we move forward with preparedness funding, that we make sure planning has an all-hazards focus, and that it's inclusive and includes EMS right up front, as well as other areas of the healthcare system. It's not just hospitals, not just public health, not just homeland security. We want EMS to be considered in that mix." --JE

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