concerns about the lack of uniformity in reimbursement from region to region. The Balanced Budget Act of 1997 required the Health Care Financing Administration (HCFA) to commence a negotiated rule‐making process with industry groups and develop a national fee schedule for ambulance services. That process began in 1999 when HCFA established a rules committee that included HCFA, the American Ambulance Association, the International Association of Fire Chiefs, the International Association of Firefighters, the National Volunteer Fire Council, the AHA, the National Association of Counties, NASEMSO, the Association of Air Medical Services, and a single physician representing both ACEP and NAEMSP.
The regulations and national fee schedule that resulted from the negotiated rule‐making process became effective on April 1, 2002 [69]. The fee schedule established seven national categories of reimbursement for ground ambulances: BLS (emergency and non‐emergency), ALS (emergency and non‐emergency), a second level of ALS for complex cases, paramedic ALS intercept, and specialty care transport. In addition, there were two categories for air medical transport: fixed‐wing and rotor‐wing. The final rule also included adjustments for regional wage differences as well as for services provided in rural areas where the cost per transport is generally higher due to the lower overall numbers of transports. Reimbursement, however, was still generally based on the need for transportation of the patient.
A medical committee was established during the negotiated rule‐making process to develop a coding system for ambulance billing that would better convey to HCFA the medical necessity for transport and the need for ALS. This document was not an official component of the rule‐making process. However, the coding system was eventually adopted in 2005 by the Centers for Medicare and Medicaid Services as an “educational tool.” It was never made a requirement for reimbursement as was originally proposed [70].
National EMS Information System
The collection and use of EMS data had been an issue of discussion since the mid‐1980s. In 2001, NASEMSO, in conjunction with its federal partners at NHTSA and the Trauma/EMS Systems program at HRSA, began developing a national EMS database, which ultimately lead to the National EMS Information System (NEMSIS). By 2003, a detailed data dictionary was completed. Information about each of the data elements, the variables, the definitions associated with the data elements, and how to deploy the elements in a database were described [71].
With funding from NHTSA, EMSC, and Centers for Disease Control and Prevention (CDC), the NEMSIS Technical Assistance Center was established under contract with NHTSA at the University of Utah School of Medicine in 2005. The mission of the Technical Assistance Center was to collaborate with the University of North Carolina at Chapel Hill, where previous EMS data activities were occurring, to provide support to the NEMSIS project.
NEMSIS, with continued support from NHTSA, has continued to promote and develop the growth of EMS data collection and use. The EMS data elements have evolved based on input from the EMS community and subsequent versions of the data set have been released. In addition to defining the data elements and data dictionary, the NEMSIS program is responsible for working closely with EMS patient care record vendors, and it tests vendor products for compliance with the data standard. NEMSIS is using national level EMS data to support multiple research initiatives and is working closely with the CDC, CMS, and other federal agencies on EMS data issues. Working with EMS stakeholders, state EMS offices and data managers and vendors, NEMSIS is providing valuable information at the local, state, and national levels to support clinical, administrative and research activities.
September 11, 2001
The attacks on the World Trade Center and the Pentagon on September 11, 2001 (9/11) changed the way Americans think about the world and the way they live. Efforts to enhance the capability to prevent and respond to terrorist attacks have become routine. Shortly after 9/11, the Department of Homeland Security (DHS) was established, as part of the largest and most expensive reorganization of the federal government in history. Congress began funding preparedness efforts with billions of dollars going to federal agencies, state and local governments, and private entities such as hospitals. Despite the massive funding for public safety and medical preparedness, reports have indicated that only a small percentage (less than 4%) of this funding ended up supporting EMS needs. Advocacy efforts by multiple stakeholders to increase federal funding for EMS, for both day‐to‐day services and preparedness, were largely unsuccessful.
Advocates for EMS
Recognizing the need for greater national advocacy for EMS, NASEMSO and NAEMSP formed a non‐profit organization, Advocates for EMS (AEMS), on October 22, 2002, for promoting, educating, and increasing awareness among decision makers in Washington on issues affecting EMS. Although there had been previous efforts to establish national EMS advocacy coalitions, none was able to sustain efforts for more than a few years. With support from the major EMS stakeholder organizations, AEMS continued to promote a more unified national EMS agenda for the next decade. However, special interest needs of several organizations ultimately led to the demise of AEMS, with various groups focusing on their specific interests.
Federal Interagency Committee on EMS
The Federal Interagency Committee on EMS (FICEMS, https://www.ems.gov/ficems.html) has coordinated efforts between federal agencies on related EMS issues for decades. Although this forum provided an opportunity for collaboration between federal agencies on EMS issues, FICEMS lacked statutory authority and its representatives were not senior officials, which often led to policy and implementation challenges. In 2005, Congress formally legislated a new FICEMS with senior representatives from DOT, DHS, DHHS, the Department of Defense, the Federal Communications Commission, and a single state EMS director. The role of FICEMS is to identify state and local EMS needs, to recommend new or expanded programs for improving EMS at all levels, and to streamline the process through which federal agencies support EMS. FICEMS has established a number of working groups to identify and address EMS issues facing the EMS community at all levels, and continues to coordinate federal initiatives.
National EMS Advisory Council
In 2007, the National EMS Advisory Council (NEMSAC, https://www.ems.gov/nemsac.html) was established by statute to provide advice and consult with FICEMS and the Secretary of Transportation regarding EMS issues affecting DOT. The council is composed of 25 individuals representing the major EMS disciplines, chosen for their expertise in those disciplines. They do not represent specific EMS organizations or employers. Working within established committees, the council identifies, researches, and produces advisory documents on topical issues with recommendations to FICEMS and DOT.
Trends in Air Medical Services
Air medical services in the United States struggled financially for a number of decades; the industry as a whole experienced only modest growth until 2000. However, by 2005, an estimated 700 air ambulances were in operation, more than double the number from a decade before. Unfortunately, that same growth was associated with a more than 200% increase in helicopter crashes. From 2000 to 2005, 60 people died in 84 crashes, and an estimated 10% of air ambulances in the United States had experienced crashes [72]. At the same time, the number of flights paid for by Medicare was up 58% from 2001, and during the same period Medicare payments for air ambulance transports doubled to $103 million [73]. This has led to a belief that the improved reimbursement for air medical services that came with the implementation of the national fee schedule in 2002 was a factor that contributed to this increase in the use of helicopters.
Efforts by states to regulate air ambulance services have been hampered by legal challenges from the industry related to the Airline Deregulation Act of 1978. The act preempts states from regulating Federal Aviation Authority (FAA)‐licensed air transport services in ways that affect their rates, routes, or services. Although the FAA recognizes the role of states in regulating the medical aspects of air ambulance services, questions frequently arise as to what