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From YouTube: Emergency Medical Services Task Force (8-16-22)
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A
A
D
E
F
A
Present,
I'm
informed
we
do
have
a
quorum
and
are
dually
authorized
to
do.
Business
first
item
on
the
agenda
is
approval
of
the
july
minutes.
Chair
will
entertain
a
motion
for
approval
motion
and,
second,
all
in
favor
of
adopting,
accepting
and
approving
the
july
minutes.
Please
say
aye
any
opposed
the
eyes.
Have
it
record
will
reflect
that
those
july
minutes
are
approved.
A
We
have
an
agenda
with
three
items
on
it
today
before
we
start
I'd
like
to
thank
staff,
first
of
all
for
the
packet
that
they
put
together
for
us,
I
direct
members
attention
to
the
information
in
the
packet.
Obviously
we
have
a
copy
of
the
minutes
that
we
just
approved.
We
have
a
one-page
ncsl
legislative
brief,
along
with
slides
from
all
three
of
our
presenter
groups.
In
addition,
we
have
a
response
as
provided,
I
believe
by
the
cabinet.
Is
that
correct?
A
Yes,
the
cabinet
has
provided
response
to
our
questions
around
the
c-o-n
program,
if
you're
in
the
audience-
and
don't
have
a
copy
of
that,
this
information
is
available
on
our
website
or
can
be
made
available
on
the
legislative
website
staff
is
staff
is,
as
often
will
do.
They'll
say
I
should
have
run
these
questions
about
them
first,
but
they'll
say
yes,
because
they
support
so
ably
everything
we
do
up
here,
but
very
good
synopsis
of
the
c-o-n
process,
and
I
would
encourage
all
members
to
all
interested
parties.
Take
a
look
at
that.
A
A
A
H
Hello,
thank
you
chair.
Will
I
be
sharing
my
slides
or
will
you
all.
A
H
Thank
you
so
much.
Thank
you,
mr
chairman,
and
thank
you
coach
harrison
members
of
the
task
force
for
having
me,
I
am
kelsey
george,
I'm
a
policy
associate
with
the
national
conference
of
state
legislatures
health
program.
I'm
joined
here
today
by
my
colleague,
kelly
hughes,
who's,
the
associate
director
of
access
costs
and
coverage
for
the
health
program.
H
A
second
ncsl
is
the
bipartisan
organization
serving
state
legislators
and
legislative
staff
and
america's
50
states
and
territories.
We
create
opportunities
for
lawmakers
and
staff
to
share
knowledge
and
ideas,
so
they
can
enact
laws
and
policies
that
improve
the
lives
of
their
constituents
at
ncsl.
I
cover
policy
issues
related
to
health,
workforce
and
rural
health,
and
that
includes
emergency
medical
services
focused
here
today.
I
greatly
appreciate
the
opportunity
to
talk
with
you
all
about
state
policies
addressing
ems.
H
A
We
can
certainly
see
your
slides
and
you're
welcome
to
move
forward,
even
though
it's
not
in
presentation
mode
and
if
you
change
in
the
midst
of
stream
you'll
be
perfectly
fine.
We're
we're
very
appreciative
of
you
being
engaged
and
involved
with
us
today,
and
this
was
on
relatively
short
notice.
So
thanks
for
pulling
this
together
for
us.
H
Fabulous,
thank
you,
mr
chairman,
so
for
today's
presentation,
I'll
provide
a
brief
overview
of
state
ems
and
then
provide
a
deeper
dive
into
workforce
strategies
to
address
the
shortage
and
or
maldistribution
of
ems
clinicians
certificate
of
need,
laws
and
other
state
efforts
to
increase
access
to
emergency
medical
services
and
reimbursement
by
private
and
public
payers
for
emergency
services.
H
In
addition,
clinicians
may
also
hold
multiple
positions
across
several
agencies,
so
the
workforce
varies
greatly
across
states
and
across
communities,
because
these
variations,
if
you've
seen
one
ems
system,
you've
likely
only
seen
one
ems
system
before
we
dive
into
ems
state
policy.
I
want
to
take
a
moment
to
examine
how
kentucky's
structure
varies
from
the
national
landscape.
H
H
Aemts,
in
addition
to
the
responsibility
of
emts,
may
provide
limited,
advanced
emergency
medical
care
and
paramedics
as
the
most
highly
trained
individuals
provide
advanced
emergency
medical
care
and
transportation
for
critical
and
emerging
patients.
Each
of
these
clinicians
operates
under
a
license
to
practice
within
a
state
which
dictates
the
tasks
that
they're
able
to
perform
under
their
license.
H
The
national
registry
of
emergency,
medical
technicians
or
nremt
is
the
primary
certification
body
for
ems
clinicians
in
the
united
states.
They
serve
nremt
serves
as
the
basis
of
licensure
in
45
states
and
the
district
of
columbia,
including
kentucky
to
in
order
to
recruit
additional
ems
clinicians
into
the
workforce.
Some
states
are
looking
at
lowering
the
age
required
for
licensure
from
18,
which
used
to
be
nre
and
requirement
to
16
or
17
years
old,
so
expanding
the
pool
of
who
can
apply
for
licensure.
H
Nine
states
have
lowered
the
age
requirement
for
emts
and
at
least
three
states.
New
jersey,
virginia
and
wisconsin
allow
individuals
to
attend,
emr
or
emt
training
courses
or
apply
for
a
training
permit
before
their
18th
birthday.
H
H
H
H
Clinicians
paramedics
are
the
most
highly
skilled
medical
providers
on
emergency
response
teams,
but
once
they
reach
this
level
of
training
they're,
often
in
high
demand,
larger
departments
predominantly
in
urban
or
suburban
areas,
may
be
able
to
boost
pay
and
offer
signing
bonuses,
while
smaller
departments,
often
located
in
rural
communities,
may
struggle
to
compete
to
recruit
and
retain
those
individuals
nationally.
We're
also
seeing
a
trend
of
ems
clinicians,
particularly
paramedics,
leaving
the
profession
for
a
career
outside
of
ems.
H
H
Also
in
high
demand,
so
while
the
scope
of
practice
between
paramedics
and
registered
nurses
is
not
comparable
one-to-one,
many
universities
offer
paramedics,
rn
training
programs
that
provide
or
that
build
on
the
field-based
education
and
training
that
paramedics
already
possess
to
prepare
them
for
the
responsibilities
as
a
registered
nurse
to
address
these
challenges,
around
recruitment
and
retention
and
scope
of
practice.
Some
states
have
expanded
the
scope
of
practice
of
other
ems
clinicians
so
upon
completing
additional
education
and
training,
allowing
additional
ems
clinicians
from
other
tasks
to
fill
gaps
in
the
workforce.
H
Nearly
three-quarters
of
volunteer
ems
clinicians
nationally
work
in
rural
communities
compared
to
30
of
paid
professionals
under
compensation,
compensation
or
pay,
is
often
cited
as
one
of
the
top
reasons
that
ems
clinicians
leave
their
positions.
H
So
in
order
to
recruit
and
retain
ems
clinicians,
several
states
have
turned
to
state
tax
credits
to
supplement
compensation.
H
Iowa,
nebraska
and
oregon,
for
example,
provide
income
tax
credits
ranging
from
100
to
two
hundred
fifty
dollars
to
compensate
volunteer
ems
clinicians
for
cert
for
their
services
provided
throughout
the
year
under
benefits.
Ems
has
one
of
the
highest
rates
of
injuries
and
illnesses
of
all
occupations,
but
many
part-time
and
volunteer
clinicians
may
not
be
eligible
for
employee
sponsored
health,
health,
insurance
or
other
benefits.
H
H
In
addition
to
addressing
physical
health,
ems
clinicians
face
high
levels
of
acute
and
chronic
stress,
as
well
as
high
rates
of
depression
and
substance
abuse.
This
increases
their
risk
of
suicide
and
other
mental
health
conditions.
Research
shows
that
burnout
levels
increase
with
the
number
of
years
that
an
ems
clinician
stays
in
their
position
as
well,
as
is
higher
among
clinicians,
who
work
shifts
that
last
longer
than
12
or
24
hours
to
address.
This
utah,
for
example,
established
a
grant
program
that
provides
mental
health
resources
to
emts
aemts
paramedics
and
first
responders.
H
Moving
on
to
the
next
session
of
certificate
of
need,
I
know
you
all
had
a
bit
of
a
conversation
about
this
during
your
last
meeting.
So
I
won't
dwell
here,
but
certificate
of
need
or
con
programs
are
state
regulatory
mechanisms
for
approving
major
capital
expenditures
and
projects
for
certain
healthcare
facilities,
as
the
map
on
the
right
shows,
35
states
and
the
district
of
columbia
maintains
some
form
of
a
con
program.
H
H
There
are
two
states
with
com
programs
that
specifically
exempt
ground
ambulance
services
that
includes
tennessee
and
new
jersey,
and
then
a
few
states
maintain
con
review
processes
for
air
ambulance
services.
Most
are
preempted
by
federal
law
under
the
airline
delegation
act,
which
regulates
air
carriers
and
a
competitive
marketplace
for
air
carriers
nationwide.
H
And
then,
finally,
under
reimbursement
at
the
federal
level,
emergency
medical
services
are
considered
a
transportation
benefit
under
medicare
and
medicaid.
H
Georgia's
medicaid
state
plan
amendment
provides
ground
ambulance
providers
with
that
are
affiliated
with
an
enrolled
hospital
with
supplemental
payments
annually.
H
H
Treatment
without
transport
provides
the
ability
for
ems
clinicians
to
provide
care
to
patients
without
transporting
them
to
a
health
care
facility.
14
states
provide
reimbursement
for
treatment
without
transport
and
under
the
umbrella
of
treatment.
Without
transport
lies,
community
paramedicine,
which
is
a
form
of
mobile,
integrated
care
that
connects
patients
with
non-emergent
or
non-urgent
needs
to
primary
care
and
other
services
through
ems.
H
Other
states
require
public
payers
to
reimburse
including
indiana
indiana
medicaid
began,
reimbursing
for
community
paramedicine
in
2018,
and
the
state
established
grant
programs
in
2019
and
2020
to
assist
communities,
developing
mobile,
integrated
health
care
programs,
and,
last
but
not
least
at
least
seven
states
allow
ems
clinicians
to
transport
patients
to
alternate
destinations
other
than
a
hospital
or
emergency
room.
These
may
include
primary
care
clinics,
urgent
care,
centers,
social
or
psychological
services.
H
Our
new
policy
brief
on
the
ems
workforce
and
recruitment
and
retention,
as
well
as
a
couple
of
web
pages
on
community
paramedicine
and
certificate
of
the
applause.
And
that
concludes
my
presentation.
Thank
you
again
for
inviting
me
to
present.ems
and
what
we're
seeing
within
the
states.
I'm
happy
to
answer
any
questions
or
feel
free
to
reach
out
to
me
directly.
A
Ms
george,
thank
you
for
the
presentation.
Certainly
I
feel
like
there
will
be
some
questions.
I'm
going
to
start
off
with
one
or
two
very
briefly
early
on
in
the
presentation
on
the
second
or
third
slide,
where
you
you
have
your
workforce
bullet
along
with
your
ems
overview
bullet
c-o-n
bullet
reimbursement.
H
There's
conversation
about
whether
within
workforce,
whether
shortage
is
an
accurate
term
and
that
may
be
a
state
while
your
state
may
be
experiencing
a
statewide
shortage
of
ems
clinicians.
There
may
also
be
a
maldistribution
between,
for
example,
urban
and
rural
communities,
so
urban
communities
may
have
enough
clinicians
or
more
than
enough
clinicians,
even
in
some
cases
that
we're
seeing
across
the
country,
while
world
communities
may
be
experiencing
shortages
and
again
that
goes
back
to
some
of
the
structural
and
budgetary
differences
between
those
agencies.
A
Great
another
question
I
had
was
on
your
your
legislative
database.
You
mentioned
26
states,
enacting
44
bills
in
2022,
and
then
you
list
the
series
of
of
buckets
that
the
bills
fall
into.
Among
those
buckets,
was
there
a
specific
bucket
that
was
the
biggest
that
got
the
most
legislative
attention?
Was
it
workforce?
Was
it
one
of
the
other
concerns.
H
Thank
you,
I
would
say
under
those
buckets
we're
seeing
the
most
action
around
funding
and
workforce
at
this
point
largely
because,
like
I
said,
states
are
grappling
with
how
to
ensure
that
ems
services
are
efficient
and
accessible
and
funding
and
making
sure
that
they
have
enough
workers
within
that.
A
So
the
rest
of
your
presentation,
you
did
a
wonderful
job,
providing
some
some
food
for
thought
as
we
talk
about
recommendations
at
the
end
of
our
work
together,
lowering
licensure
age
requirements,
that's
one
that
I
think
we
may
well
investigate
some.
You
mentioned
that
some
states
were
doing
so,
and
others
weren't.
What
is
the
position
of
the
national
registry
now,
as
it
relates
to
age.
A
Very
good,
we
in
our
health
policy,
medical
policy
here
in
frankfurt.
We
never
discuss
scope
of
practice.
I
mean
we
never
ever
tongue-in-cheek,
I'm
being
a
little
on
the
edge
here,
discuss
scope
and
scope
of
practice,
so
we're
not
going
to
discuss
that
one
today
either.
A
H
Absolutely
so,
at
the
federal
level
at
least,
and
some
states
have
changed
how
this
looks
within
their
state
medicaid
programs,
but
from
the
federal
perspective
under
medicare
and
medicaid,
ems
is
treated
as
a
transportation
benefit,
not
as
a
healthcare
benefit,
so
reimbursement
is
only
provided
when
patients
are
transported
to
another
facility,
as
opposed
to
the
care
that
an
ems,
professional
or
clinician
may
provide
on-site.
H
So
if
an
ems
clinician,
for
example,
goes
to
address
a
situation-
and
it's
like,
I
said
it's
a
chronic
condition
that
a
patient
needs,
help
monitoring
or
they're
looking
to
access
primary
care,
and
they
don't
have
it
in
their
community.
They
may
call
9-1-1
with
the
health
what
they
think
is
a
health
emergency,
but
it
may
not
rise
to
that
same
level,
so
they
may
not
require
transport,
in
which
case
most
often
ambulance
services
are
not
reimbursed
for
that
level
of
care.
A
H
I
can
look
into
that.
More
specifically,
I
believe
it
is
either
done
through
a
waiver
or
estate
plan
amendment,
but
I
can
look
into
that
and
get
back
to
you
with
more
information.
F
Thank
you,
coach
gibbons.
Thank
you
very
much
for
for
coming
and
give
us
a
pretty
good
detail.
Presentation
stuff.
I
want
to
get
just
a
clarification.
I
think
it's
on
slide
seven
and
I'm
trying
to
get
my
head
wrapped
around
what
you
said
in
terms
of
workforce.
You
said
the
data
collection
is
difficult
to
gather
throughout
the
country
based
on
workforce.
Is
that
what
I
heard.
H
Yes,
so,
while
while
data
is
selected
through
the
national
emergency
medical
services,
information
system
on
specific
incidents
of
care,
actual
data
on
the
workforce,
it's
very
difficult
to
collect,
there
are
some
organizations
like
the
national
association
of
state,
medical
or
state
ems
offices.
H
That
does
some
occasional
surveys
on
the
topic,
but
in
general
states
collect
data
differently,
and
so
it's
different
it's
difficult
to
compare
across
states
in
that
regard,
and
for
that
reason
it's
also
because
they're
measuring
across
volunteers
and
part-time
employees
that
may
be
working
at
multiple
agencies,
it's
difficult
to
track
the
outcomes
of
some
of
these
workforce
interventions.
F
Well,
let
me
follow
up
another
quick
question
and
trust.
This
is
not
to
be
a
smart
question,
okay
or
or
anything,
but
I'm
trying
to
get
my
head
wrapped
around
the
workforce
and
I
know
intuitive
intuitively
and
speaking
of
folks.
F
There
is
a
workforce
issue,
but
I
I
don't
feel
comfortable
in
terms
of
qualifying
that
data
in
terms
of
of
really
where
they
fall
into
those
different
practices
and
disciplines
and
so
forth.
I'm
here
and
some
people
have
mentioned
that,
but
mention
it
to
me,
but
I'm
trying
to
get
I'm
trying
to
connect
to
two,
because
if
I'm
going
we're
going
to
go
forward-
and
I
think
workforce
by
and
large
across
the
spectrum
from
teachers
to
to
firefighters,
to
police,
there's
a
there's
a
significant
issue,
but
what
the?
F
H
Yeah,
I
believe
that
there
are
some
states
who
have
allocated
money
to
study
the
workforce,
specifically
we've
seen
that
in
other
professions,
like
nursing
or
some
other
support
positions
like
peer
support
specialists,
and
things
like
that,
which
I
know
has
happened
in
other
professions.
I
believe
there
are
a
few
states
that
have
done
that
within
emergency
medical
services.
F
Okay,
all
right,
thank
you.
I
want
to
shift
gears
just
a
little
bit
the
co-chair
mentioned
about
reimbursements,
and
that
seems
to
be
a
sort
of
hot
topic
across
the
mental
health
as
well
as
healthcare
professions
in
in
and
I'm
looking
going
back
just
a
moment.
Your
number
four
structure
and
appointment.
You
looked
at
national
house,
broken
up
between
private
and
fire
fire
departments
and
hospitals
and
look
at
kentucky.
F
F
Some
colleagues
is
about
value
contracting
and
if
there
is
some
type
of
value
contracting,
you
have
to
have
data
supporting
that
and
make
sure
that,
whatever
whatever
that's
being
provided,
that
we're
having
good
outcomes-
and
I
think
we
see
that
in
the
real
part
of
this
of
this
state
as
well
as
you
mentioned
other
parts
of
the
country-
we
need
to
be
conscious
of
providing
that
service.
But
also
I
want
to
make
sure
or
think
about
how
we
can
improve
that.
So
it's
a
little
bit
of
a
value
contracting.
Does
that
make
sense.
D
You
know
real
briefly
on
well
on
the
slides
that
you
have
up
there.
You
mentioned
22
states
have
now
adopted
the
ems
interstate
licensure
compact
legislation.
This
has
been
a
bill
that
I've
been
working
on
for
the
past
couple
sessions
and
I'm
just
curious
out
of
the
22
states.
That's
already
enacted
this.
Have
they
seen
any
positive
growth
in
their
workforce
or
negative?
How
has
it
affected
their
workforce
as
far
as
recruiting
and
getting
more
paramedics
and
emts.
H
So
I
have
reached
out
to
the
ems
compact
directly
on
that
question
and
they
don't
have
any
specific
studies
or
state
examples
that
have
looked
at
like
you
know:
ultimate
numbers
of
ems
clinicians
practicing
for
example,
but
they
they
did
share
that
anecdotally
states
have
shared
that
during
the
kobit
19
pandemic
and
during
certain
wildfires
wildfire
response
surges
in
the
west
that
they
have
seen
that
interstate
licensure
compacts
and
allowing
ems
clinicians
to
practice
across
states
help
them
address
those
particular
situations
and
that
isn't
the
that
isn't
the
ultimate
purpose
of
the
ems
compact.
H
The
ms
compact
is
meant
to
facilitate
the
day-to-day
practice
of
ems
clinicians
across
states.
But
that
is
one
one
outcome
that
we've
seen
so
far,
but
I
don't
have
any
specific
data
and
they
were
they
didn't
have
any
either
on
how
states
have
experienced
workforce
fluctuations
after
joining.
A
Ms
george,
thank
you
wonderful
presentation.
As
always,
ncsl
comes
through
with
some
talent.
Thank
you
for
bringing
that
together
for
us
and
and
for
the
wealth
of
knowledge
you've
provided.
So
we
started
with
the
national
view,
as
provided
by
ncsl,
I'm
going
to
jump
out
of
order
on
our
agenda
today
and
we're
going
to
move
down
the
next
step
to
what
I'm
going
to
consider
a
regional
view
as
we
bring
paul
phillips
with
global
medical
response
forward.
He's
the
regional
director
paul
if
you'll
come
on
up
the
table,
bring
your
guest
with
you.
I
All
right
well,
mr
chair
and
members
of
the
task
force.
We
really
appreciate
the
opportunity
to
come
and
present
today.
One
of
the
things
that
I
wanted
to
do
before
we
actually
present.
I
We've
had
some
crews
in
eastern
kentucky
operate
in
the
eastern
part
of
the
state
that
have
been
incredibly
affected
over
the
past
few
weeks
with
the
flooding,
and
I
just
wanted
to
take
a
moment
to
recognize
them.
They
have
been
they've
been
through
the
wringer,
and
I
wanted
to
share
a
story,
and
I've
told
this
story
several
times:
try
not
to
get
emotional
when
I
speak
of
it,
but
it'll
be
tough.
I
I
I
I
Over
the
past
few
weeks
I
had
a
base
in
nott
county
who
went
a
week
without
water
and
there's
still
residents
there
without
water,
and
I
just
wanted
to
recognize
them
because
they
have
been
doing
a
tremendous
job.
So
I
appreciate
you
entertaining
that
so
we'll
get
in
into
our
presentation.
Paul
I
mean.
I
Absolutely
I
am
paul
phillips.
I
am
the
regional
director
for
the
ground
operations
in
louisville,
lexington
amr
and
then
eastern
kentucky
lifeguard
emergency
medical
services
with
me
is
terrence.
Ramitar,
terence,
is
the
regional
director
for
government
affairs
for
the
13
states
of
the
southeast
region
within
global
medical
response.
G
Well,
and
thanks
for
having
us
just
a
little
bit
about
gmr
global
medical
response,
we're
we're
a
national
provider
with
with
a
heart
and
and
local
ems.
We
we
operate
over
8
000
vehicles
across
the
country,
352
rotary
wing
aircraft
or
trauma
helicopters
and
a
whole
host
of
other
emergency
type
services
across
the
country.
G
We
employ
35
600
that
number
used
to
be
in
the
40s,
so
that
has
come
down
quite
a
bit,
but
we
service
for
over
4
000
communities
with
air
bases,
communication,
centers
fire
stations,
whole
gamut
across
the
country.
You
can
see
a
little
bit
of
our
service
map
there
and
I'll
turn
over
to
paul
who
runs
kentucky.
I
Sure
so,
just
to
give
you
a
glimpse
of
our
footprint
within
the
state
we
operate
in
lexington,
louisville,
owensboro,
northern
kentucky.
Those
are
amr
branded
solutions
and
then,
in
the
eastern
part
of
the
state,
we
operate
in
floyd
county
harlan
county,
not
county
leslie,
county
and
pike
county.
Those
operate
under
the
lifeguard
emergency
medical
services
banner.
So
that
just
wanted
to
give
you
guys
an
idea
of
our
our
footprint.
I
What
we're
going
to
be
presenting
on
today
kind
of
wish.
We
had
gone
first
because
I
think
a
lot
of
our
things
are
going
to
echo
what
was
just
presented
but
we're
going
to
trudge
along
nonetheless
we're
going
to
be
presenting
on
reimbursement
issues
which
is
kind
of
how
ems
is
funded
in
the
state
and
then
we're
going
to
also
speak
to
access,
and
that
can
include
the
logistics
of
actually
doing
the
transports.
I
Basically,
how
we
get
patients
transported
from
their
home,
how
we
get
them
to
definitive
care,
basically
getting
the
the
patient
to
the
right
place
at
the
right
time
and
then
we'll
speak
to
some
of
the
specific
challenges
within
the
workforce
within
kentucky,
and
also
some
of
the
things
terence
will
speak
to
as
far
as
what
is
going
on
nationally.
G
G
That's
dc
based,
I
happen
to
be
a
board
of
director
there
and
the
national
association
of
emts
we've
been
advocating
on
capitol
hill
for
a
number
of
relief
items,
including
grant
programs
of
access
to
federal
grants,
funding
for
recruitment
and
training
and
looking
at
how
we
can
implement
programs
in
rural
areas,
minority
areas,
low-income
areas,
how
we
can
develop
that
workforce,
but
I'm
going
to
speak
to
reimbursement,
because
I
think
when
we
talk
about
those
three
things,
we
talk
about
anything
where
there's
there's
no
margin,
there's
no
mission.
G
So
it's
really
important
that
we
we
address
reimbursement
a
little
bit,
how
we
are
funded,
how
ambulance
services
are
funded,
whether
you're
private
public
or
whatever?
Most
of
us,
if
you're
not
volunteer
bill
for
the
services
to
get
reimbursed.
So
our
major
payer
sources
are
here
in
front
of
you,
and
I
just
want
to
speak
briefly
about
some
of
the
behaviors
that
we're
seeing
and
some
of
the
challenges
that
we
have
with
our
current
payer
sources.
G
Medicare,
as
you
know,
reimburses
us
or
most
of
the
healthcare
industry
below
the
cost
of
providing
services.
So
we've
been
advocating
for
decades
to
continue
to
increase
the
medicare
reimbursement
rate
for
ground
ambulance
services
to
to
try
to
even
get
close
to
what
the
cost
of
providing
services
are.
Medicaid,
we'll
talk
a
little
bit
about
that
is
that
is
controlled
within
the
state
commercial
insurance.
G
We're
seeing
we're
we're
seeing
a
lot
of
changes
within
that
landscape
as
it
as
it
applies
to
in-network
and
out-of-network,
and
I
don't
want
to
open
up
a
can,
but
I
just
want
to
talk
a
little
bit
about
that,
so
commercial
insurance
providers,
if
we're
not
in
network,
we
charge
a
usual
and
customary
rate,
and
most
of
those
charges
across
the
state
in
these
communities
are
reflective
of
the
service
level.
You
want
to
provide
or
or
the
the
level
of
clinical
expertise.
G
That's
in
that
area,
there's
a
there's
a
charge
behind
that.
Obviously,
if
you're
in
a
rural
area,
it's
probably
more
expensive
to
get
to
keep
ambulances
afloat,
so
commercial
insurance
is
if
you're,
not.
If
you
have
not
signed
an
agreement
to
be
in
network
and
accept
what
they
want
to
pay,
you
will
pay
you
what
they
deem
necessary
so
we're
currently
in
a
struggle
with
commercial
insurances,
to
try
to
get
them
to
reimburse
us
for
the
cost
of
providing
that
service.
So
patients
don't
get
a
balanced
bill,
private
pay,
post
pandemic.
G
We
see
we
saw
a
huge
increase
in
the
private
pay,
uninsured
or
underinsured.
So
those
folks
that
had
that
were
carrying
health
plans
were
able
to
reimburse
for
the
services
or
the
unemployment
rate
was
affected
there.
So
we
saw
we
did
see
a
decrease
in
reimbursement
there,
and
we
saw
definitely
saw
an
increase
in
the
underinsured
and
tied
to
commercial
insurance.
Now
we're
seeing
these
health
plans
with
these
astronomically
high
deductibles.
G
So
if
you
are
in
in
a
vehicle
accident
or
need
to
be
transported
to
the
hospital-
and
we
bill
your
insurance
and
it's
january
at
the
beginning
of
your
plan
year-
then
you're
responsible
for
that.
So
we
do
see
challenges
there
in
ems
in
terms
of
the
first
quarter
of
the
year
getting
reimbursed
for
our
services,
because
most
of
that
is
out
of
out
of
pocket
for
the
patient.
G
G
Our
payment
model
was
mentioned
before
we're
paid
for
transport
and
not
necessarily
treatment.
So
most
of
the
fee
schedules
in
medicare,
medicaid
or
even
commercial
side
are
based
on
transporting
a
patient.
There's
limited
to
no
reimbursement
with
with
some
exceptions
and
pilot
programs,
and
some
states
are
now
starting
to
implement
some
pieces
of
this,
but
there's
really
no
reimbursement
for
readiness.
G
So
a
medicare,
patient
or
medicaid
patient
that
that
fee
schedule
pays
us
a
fixed
amount,
whether
we
got
there
in
five
minutes
or
whether
we
got
there
in
20..
There's
no
there's
no
difference
there.
We
just
have
to
remain
ready
and
meet
the
expectation
of
that
community,
so
there's
no
reimbursement
for
the
response.
All
this
up
until
we
get
unseen
is
not
covered.
When
we
get
on
scene
is
when
we
treat
the
patient
if
the
patient
is
not
transported,
but
we
do
treat
them
in
a
lot
of
instances.
G
The
majority
of
the
instances
we
are
not
reimbursed
for
that.
So
the
case
of
a
diabetic
who,
in
the
middle
of
the
night
or
sugar,
drops
because
maybe
they
over
over
bolused
on
insulin
or
didn't
eat
enough
and
their
sugar
level
drops
and
their
loved
one
calls
911,
because
they
don't
know
what
to
do.
Maybe
this
is
a
diabetic
for
20
years
knows
how
to
manage
themselves
for
the
most
part,
but
that
night
may
have
had
a
bad
night.
So
what
we
do
is
we
show
up.
G
We
treat
the
patient,
maybe
we'll
administer
some
glucose,
maybe
we'll
get
them
going,
we'll
wait,
we'll
check
his
sugar
and
a
lot
of
times.
Those
are
patients
that
probably
don't
need
to
be
transported.
So
we'll
we'll
call
the
physician
or
or
talk
to
someone
the
hospital
and
not
transport
those
patients
that
entire
time
that
we've
responded,
treated
the
patient
got
back
in
service
is
uncompensated,
so
there's
mostly
no
reimbursement
for
that.
When
patients
refuse
care,
we
show
up
on
scene,
we
evaluate
them.
We
assess
the
situation,
assess
the
patient
to
see.
G
If
there's
a
medical
emergency,
that's
all
time
being
consumed.
We
do
not
generally
get
reimbursed
for
that
time.
So
I
think
it's
we
want
to
make
sure
we
communicated
that
when
we
look
at
kentucky
medicaid
and
specifically,
we
haven't
we've,
it's
remained
flat
for
at
least
10
years.
G
That's
as
far
back
as
we
can
go,
but
we're
not
finding
any
traceable
evidence
of
the
last
medicaid
fee
schedule
increase
for
ambulance
services,
the
cost
of
providing
services.
You
know,
I
can't
harp
on
enough
fuel,
the
cost
of
vehicles
and
a
lot
of
areas
we're
seeing
we're
not
able
to
get
vehicles
because
of
the
chip
shortage.
There's
some
departments
that
are
waiting
one
to
two,
even
three
years
to
get
an
ambulance
on
on
the
ground
because
of
that
required
medications.
G
I
think
it's
important
to
note
that,
over
the
decades
that
ems
has
been
progressing,
we've
kept
up
with
the
the
scope
of
practice.
We've
kept
up
with
advancements
in
the
industry.
Advancements
in
medicines
we're
carrying
a
whole
lot
more
medications
on
board
than
we
did
in
1974..
G
So
as
we
continue
to
to
progress
and
advance
the
level
of
care
that
we
are
giving,
we
still
struggle
to
get
insurance
companies
or
or
payers
to
pay
for
that
significant
investments
in
physical
infrastructure
and
buildings
and
wages,
and
we'll
talk
about
that
a
little
bit
more
in
detail,
but
medicare
and
medicaid
just
want
to
make
sure
those
are
fixed.
Fee
schedules.
Medicare
will
increase
their
fee
schedule
just
slightly
every
every
year,
but
certainly
not
not
to
where
it
compensates
us
for
the
cost
of
doing
that
service.
G
There's
two
types
of
ambulance
calls
on
in
the
911
sector
in
terms
of
emergencies,
advanced
life,
support
and
basic
life
support,
they're,
two
different
reimbursement
structure,
whether
the
person
needs
basic
life,
support
care
or
advanced
level,
paramedic
care.
These
are
the
reimbursement
rates.
You
can
see
that
we
as
a
state
commonwealth
and
kentucky
struggle
amongst
our
contiguous
states,
at
least
to
keep
up
with
reimbursement.
G
But
when
we
look
at
non-emergency
ambulance,
reimbursement
rates
in
this
slide,
you'll
see
that
kentucky
still
trails
behind
the
surrounding
states
in
terms
of
what
we
can
get
reimbursed
for
those
als
and
bls
rates
are
60
and
75
70,
respectively,
which
is
significantly
below
the
cost
of
providing
ammo
services.
I
I
A
lot
of
the
challenges
that
we're
seeing
from
especially
in
the
rural
area,
is
with
having
only
two
level
one
trauma
centers
in
the
state
and
there's
really
only
one
additional
level.
Two,
the
two
are
in
lexington
and
louisville,
and
then
pikeville
has
the
the
additional
level
two
well.
The
problem
is
with
that.
I
It
leaves
a
large
gap
within
the
state
for
that
type
of
care,
and
you
see
we'll
see
that
I've
got
some
maps
on
here
will
show
that
there
are
some
large
gaps
between
the
stroke
centers
too
and,
as
many
of
you
know,
those
are
time
sensitive
issues,
especially
with
the
stroke
like
if
you
don't
get
to
a
definitive
care
institute
within
a
certain
amount
of
time.
I
A
full
recovery
is
not
guaranteed
which
it's
not
ever
guaranteed,
but
it's
the
likelihood
goes
down
exponentially.
So
I'll
speak
to
some
of
my
ambulance
services
in
eastern
kentucky.
So
if
we,
if
we
transport
and
here
we'll,
show
the
map.
H
I
Just
wanted
to
kind
of
show
that
there
are
certain
counties
here
in
the
state
that
don't
have
a
hospital
in
them
and
what
was
kind
of
jumped
out
at
me
was
the
finger
that
goes
out
just
east
of
of
montgomery
county
there
that
there's
a
gap
within
several
counties
there.
If
you
can
go
on
to
the
next
one.
I
So
this
is
the
the
trauma
system
map
so
you'll
see
the
two
in
yellow
those
are
the
those
are
the
level
one
that's
fayette
and
jefferson
county
and
over
on
the
east
is
pike
county
and
that's
pikeville
and
they're
the
level
they're.
The
only
level
two
for
the
state
there's
several
that
are
in
process
for
the
level
three
and
level
four,
but
there's
a
significant,
especially
in
south
central
kentucky,
a
pretty
big
gap
there.
I
I
I
The
the
problem
is
that
when
we
speak
of
reimbursement
and
and
miss
george
touched
on
it
as
well,
there's
this
distribution
maldistribution
of
reimbursement
where
there's
large
pockets
of
medicaid
and
underinsured
citizens,
then
there's
not
enough
volume
to
support
having
maybe
more
than
a
couple
of
ambulances.
So
if
you've
got
one,
that's
on
a
transfer
to
lexington,
then
you
get
a
emergency
call
within
the
county.
I
What
we
did
here,
yeah
just
step
back,
so
this
is
a
basically
a
transfer
pattern
distribution,
so
we
showed
from
all
of-
and
this
is
from
our
data
only
from
within
amr
and
gmr.
I
We
took
all
the
transports
that
for
2021
that
were
greater
than
50
miles
and
just
kind
of
showed
the
distribution
and
where
they're
going
to
you'll
see
a
great
deal
of
them
are
going
to
lexington
and
louisville.
Of
course,
if
you're
in
northern
kentucky
there
may
be
a
possibility
that
cincinnati's,
closer
or
there's
you
know
you're
you're
going
north,
which
is
understandable,
there's
even
within
owensboro.
I
Over
on
the
west
side,
there
is
there's
a
fair
amount
going
to
evansville
indiana,
so
just
kind
of
wanted
to
show
the
distribution
and
then
also
kind
of
kind
of
illustrate
some
of
the
ills
we're
having
with
the
long
distance
transfers.
I
So
I
want
to.
I
want
to
kind
of
talk
about
medical,
mental
health
versus
non-medical
mental
health,
and
I
don't
at
all
want
anyone
to
think
that
we're
downplaying
the
illness
of
mental
health
because
they're
that's
a
true
need,
but
medical
mental
health
actually
also
has
a
a
medical
diagnosis
that
requires
ambulance
care.
I
I
So
when
I
we
talk
about
the
non-reimbursement
model
for
for
the
non-medical
transports,.
I
There
there
isn't
really
an
a
reimbursement
model
outside
of
you
know,
maybe
a
contract
with
a
health
care
facility
or
billing,
the
patient
for
these
non-medical
transports.
So
a
lot
of
times
they're
longer
distance
transports
as
well.
It's
not
it's,
not!
Maybe
the
adjacent
county.
You
may
be
going
two
three
four
counties
over
to
transport
to
a
place
that
can
actually
give
this
patient
the
appropriate
care
because
those
are
specialized
instances
for
these
patients.
I
We
also,
we
also
have
the
problem
within
kentucky
that
ems
personnel
are
not
allowed
to
detain
the
patient.
So
there's
a
difference
between
restrain
and
detain
so
restrain.
You
know
we
can.
We
can
take
a
cravat
or
some
type
of
device
and
try
to
help
the
patient
stay
on
the
stretcher.
We
can
use
the
straps
that
go
on
the
stretcher,
but
one
if
the
patient
wants
out
and
they
get
out.
I
It's
actually
stated
in
the
kentucky
state
protocol.
We
do
not
pursue
them
because
we
don't
have
any
rights
of
detention,
it's
actually
it
would
be
considered
kidnapping
for
per
se
for
us
to
hold
them
against
their
will
so
and
I'll
big
on
anecdotes.
So
I
actually
had
a
louisville
crew
get
assaulted
by
a
mental
health
patient.
They
got
out
in
a
rural
area,
they
were
transporting
the
patient
to
a
mental
health
facility,
the
patient
overtook
the
crew
and
one
of
my
crew
members
ended
up
with
a
broken
wrist.
I
I
G
I'll
talk,
try
not
to
be
repetitive,
because
I
think
I
think,
through
meetings.
Everyone
understands
we
have
workforce
challenges,
so
I
want
to
talk
just
a
little
bit
more
about
that
nationally
recognized.
Now.
I
think.
Finally,
we
got
some
sort
of
data
nationally
from
hrsa.
It's
reporting
that
by
2030
there'll
be
a
need
for
an
additional
42,
000
emts
and
paramedics
across
the
country,
so,
like
we
talked
about
data,
is
very
hard
to
to
get
here
in
this
industry
for
for
a
number
of
reasons,
but
we
don't.
G
We
do
know
that
we've
got
an
aging
population.
We've
got
baby
boomers
that
are
retiring.
We've
got
health
care
demand,
that's
continuing
continuing
to
increase,
so
our
problem
is
is
quickly
outpacing.
The
solution
we're
seeing
it
all
over
we're
seeing
it
in
news,
journals,
industry,
journals
and
national
networks
are
now
reporting
shortages
in
emergency
medical
services.
G
We
talked
a
little
bit
about
turnover,
but
and
the
former
person
who
presented
did
say
to
cite
this
but
20
to
30
percent
turnover
is
what
we're
experiencing
in
our
industry,
which
means
every
four
years
we're
turning
over
the
workforce.
Now
pre-pandemic
we've
sort
of
modeled
to
that
right.
So
we
know
that
emts.
This
is
a
stepping
stone,
stepping
stool
type
of
work.
For
them
they
get
into
other
forms
of
healthcare.
G
They
become
paramedics,
become
nurses,
they
go
into
that
sector
or
they
get
into
firefighting
or
go
into
some
sort
of
other
related
career.
So
throughout
the
pandemic,
what
we
saw
happen
was
sort
of
a
freeze
in
that
in
the
education
process
and
the
training
process
and
something
that
never
recovered
coming
out
of
2020..
So
we
did
see
across
the
country
we
saw
lower
enrollment
in
emt
and
paramedic
programs,
we're
also
experiencing
some
lack
of
interest.
G
I
think
we
have
a
high
school
population,
now,
that's
getting
more
into
technology
and
some
other
industries
versus
healthcare
and
some
other
some
other
industries
that
suit
somebody
coming
out
of
high
school.
So
we're
working
really
hard
to
to
display
the
industry
to
high
school
students
and
those
folks
that
are
coming
up
through
the
education
system
to
show
them
that
this
is
an
option,
but
what's
what's
what's
important,
it's
a
finite
resource.
G
So
if
we
started
to
when
we
start
today
to
train
someone
from
the
street
to
become
an
emt
and
eventually
a
paramedic,
that's
approximately
two
years
so
right
now.
What
we're
we're
also
seeing
is
paramedics
being
recruited
to
work
in
non-traditional
environments,
so
we're
seeing
paramedics
being
recruited
by
hospitals
and
emerging
emergency
departments
to
provide
clinical
care
within
that
type
of
setting
which
we
didn't
see.
G
We
didn't
see
much
of
up
until
about
a
couple
years
ago,
we're
seeing
them
being
employed
in
long-term
care
facilities,
we're
seeing
them
being
employed
more
in
industrial
workplaces
like
car
manufacturing
plants
that
sort
of
thing.
So,
in
addition
to
the
shortage
and
the
pipeline
shortage,
we
also
have
the
current
workforce.
That's
looking
to
get
out
of
this
environment
into
into
another
environment,
to
work
in
we're.
G
Also
another
important
point:
we're
losing
paramedics
in
in
the
commonwealth
of
kentucky
to
more
concentrated
areas
within
the
state
which
I
think
the
term
mal
distribution
was
used,
but
also
we're
seeing
them
move
out
of
state,
so
they're
chasing
higher
higher
pay,
which
is
another
symptom
of
reimbursement
right.
So
they're
they're
moving
over
into
tennessee
they're
working
in
over
in
the
cincinnati
area,
those
sorts
of
things
we're
seeing
that
happen.
G
Overall,
look
in
the
workforce,
we've
got.
You
know,
lack
of
data
that
that's
an
obvious
year.
Our
applicant
pool
has
has
diminished,
so
we
are
now
doing
programs
to
find
folks
willing
to
become
emts
when,
in
fact,
in
a
couple
places
across
the
state
we're
actually
paying
folks
to
go
to
school,
a
full-time
salary
plus
their
tuition
to
become
emts,
so
we're
having
some
success
there.
Just
the
you
know
the
challenge
is
to
find
where
and
how
retention
is
issue.
G
We
talked
a
little
bit
about
that
and
and
then
inability
to
increase
wages.
So
we
talked
about
the
fixed
reimbursement
so
we're
you
know
we're
capped
in
reimbursement
to
a
certain
extent,
which
means
we're
also
captain
what
we
can
do
for
increasing
salaries
to
the
max.
So
we're
also
seeing
now
a
lack
of
career
advancement,
which
you
talked
about
and
like
keeps
mal
distribution,
I'll
put
them.
In
my
dictionary.
J
G
Unequal
distribution
of
stats
staff
across
the
commonwealth,
so
rural
areas
are
losing
their
paramedics
to
more
concentrated
areas
and
it's
becoming
very
difficult
for
the
rural
areas
to
attract
them
back
to
work
in
their
own
communities.
G
We
did
federally.
We
did
have
some
success
in
the
hhs
appropriations
package
just
a
couple
weeks
ago
we
did
see
a
recognition
of
ems
as
part
of
the
national
workforce
shortage
and
we're
hopeful
that,
on
a
federal
level,
they'll
work
through
some
solutions
there
or
help
us
with
grant
programs.
G
So,
overall,
you
know
with
with
that
reimbursement
issues,
access
challenges
and
workforce
challenges.
We're
looking
at
solving
three
questions
right.
How
do
we
solve
this
innovatively
going
forward?
How
do
we
expand
the
reimbursement
model
so
that
we
can
be
more
sustainable
in
our
communities
and
provide
more
diverse
services
that
can
be
reimbursed?
We
talked
about
treatment,
no
transport
and
some
other
treat
unseen
telehealth
that
sort
of
thing
we're
looking
at
alternatives
to
the
traditional
ems
model.
G
You
heard
some
of
that,
where,
in
some
areas
across
the
country
we're
able
to
transport
to
urgent
care
centers
or
what
we
call
alternative
destinations
so
that
we
can
take
patients
to
the
right
care
to
the
right
care
at
the
right
place
at
the
right
time
and
then
constantly
working
to
improve
recruitment
and
retention
of
ems
personnel
within
within
kentucky
itself.
So
we
think,
while
we're
stuck
with
this
issue,
we've
got
to
innovate
ourselves
out
of
it
and
that's
what
we've
been
working
towards
with
different
programs
across
the
state.
G
So
appreciate
the
the
time
to
listen
to
the
three
big
challenges
we're
experiencing
on
the
ground
here
and
we're
happy
to
take
questions.
E
H
E
Northeast
kentucky
and
thank
god
we
have
alternatives
across
the
rivers,
west,
virginia
and
ohio,
but
we
still,
you
know,
have
needs,
and
we
appreciate
our
the
services
that
we
have.
I
just
thought
you
might
want
to
tell
the
committee
a
little
about
a
non-medical
transport.
Give
us
an
example
of
what
that
is.
I
When
you,
when
you
talk
about
the
mental
health
patients,
yes
so
a
lot
of
times,
those
are
the
voluntary
holds,
so
the
patient
will
voluntarily
admit
themselves
to
a
mental
health
facility
and
really
and
honestly,
at
that
point
they
just
need
a
ride.
So
there's
really
no
medical
reason
for
them
to
be
in
the
back
of
an
ambulance.
The
problem
with
that
is
we
get
paid
if
there
is
a
medically
necessary
issue.
I
E
I
I
think,
that's
very
relevant
to
our
discussion
here
and
I
think
it's
a
problem,
especially
now
with
the
gray
area
between
drug
addiction
and
mental
illness
and
the
overlap
that
we
see
there,
but
also
the
the
authority
to
detain.
You
know,
of
course,
I'm
just
an
attorney,
I
mean:
do
you
want
that
potential
liability,
or
do
you
want
that
at
all?
I
think
that
too
is
is
worthy
to
note
and
put
on
the
record
here.
I
I
mean
I'll
speak
from
a
director
standpoint
and
I
would
say
no
for
one
you,
you
have
the
the
tren
the
burden
of
increased
transports,
but
then
also,
as
I
said,
my
number
one
responsibility
is
that
my
crews
go
home
in
the
same
shape
that
they
came
in
in
and
a
lot
of
times
that
puts
them
in
jeopardy.
So
I'll
always,
I
would
go
now.
Okay,.
B
I
think
it
is
very
concerning-
and
I
know,
there's
been
some
discussions
about
the
opportunity
or
the
possibility
of
moving
some
of
the
mental
health
transports
from
where
we
see
them
now
at
the
sheriff's
office
to
the
medical
or
the
ems
services,
one
you're
shifting
from
an
already
short
staffed
agency
to
another
short
staffed
agency,
so
you're
not
really
fixing
a
situation
you're
just
shifting
the
burden
around
and
the
other.
With
regard
to
the
detainee
issue,
I'm
going
to
give
you
a
real
world
example.
My
dad
work
is
still
a
licensed
dmt
to
this
day.
B
I
think
it's
been
15
20
years
ago
when
this
happened,
but
they
had
a
patient
who
got
up
off
the
gurney
and
literally
jumped
out
of
the
back
of
the
ambulance
as
they
were
driving
down
the
road
number
one
dad's,
not
in
a
position
at
that
point,
to
be
able
to
stop
him
without
injuring
or
hurting
himself,
and
two
has
no
ability
to
detain,
and
so
you
have
a
huge
liability
concern.
You
have
a
huge
situation
there.
It's
not
the
proper
situation
in
trying
to
deal
with
this.
B
A
I
They
walk
the
patient
out.
They
get
in
they're,
secure,
they're
transported
to
the
facility
they
get
out,
but
there's,
but
those
are
the
reimbursement
for
those
are
through
contracts
so
or
through
funding
from
the
state.
So
those
are
just
innovative
solutions
that
we
we've
kind
of
explored
and
have
actually
piloted
throughout
the
country.
D
Thank
you,
mr
chairman,
there's
a
distinct
difference
between
urban
and
rural
areas,
especially
in
not
only
other
fields,
but
in
ems
and
fire
field.
Amr
you
operate
agencies
in
both
of
them
arenas.
Could
you
maybe
give
us
some
examples
on
some
programs
that
you've
used
good
or
bad
whether
it
worked
or
didn't
work
on
how
you
tackled
recruitment
and
retention
in
the
rural
versus
the
urban
area?.
I
So
that
that
is
that's
the
20
billion
dollar
question
per
se,
but
we've
realized
that,
while
social
media
has
been
a
big
increase
for
recruitment
in
in
the
urban
areas
like
lexington,
louisville,
northern
kentucky
and
even
owensboro,
when
you
talk
about
the
eastern
kentucky
area,
connectivity
is
an
issue
down
there
and
maybe
not
everybody
has
access
to
as
much
connectivity
as
far
as
the
internet
goes.
So
we've
actually
found
that
newspaper
is
actually
a
viable
form
of
advertising
there.
I
Otherwise
it's
just
partnering
with
local
officials,
we're
approaching
and
working
with
actively
some
of
the
local
government
county
governments
in
that
area
to
partner
on
how
we
recruit
in
from
the
communities,
because
if
you
get
the
community
behind
the
program
the
people
will
come,
I
mean
because
they'll
it's
about
a
sense
of
belonging.
We
want
them
to
feel
like
they're
they're,
part
of
something
bigger
and
especially
within
those
those
counties.
Getting
those
county
officials
on
board
and
getting
them
to
endorse
it
is
is
a
major
step
in
that
direction.
Yeah.
G
We've
seen
we've
seen
success
with
partnering,
with
county
or
regional
workforce
solutions,
working
with
unemployment
offices
and
and
like
we
talked
about
before.
Actually
we
call
it
earn.
While
you
learn
program,
we
put
them
in
there
we
pay
for
it.
We
pay
them
a
full-time
salary
while
they're
in
there
and
we
get
them
successful
and
get
them
on
to
an
ambulance
in
some
other
areas.
We're
doing
we're
we're
backing
down
on
some
of
the
requirements
for
non-emergency
ambulance
services.
G
So,
for
example,
in
florida
we
just
passed
a
bill
that
will
allow
drivers
now.
These
are
somewhat
similar
to
emrs
to
work
with
a
paramedic
on
an
als
call
on
an
advanced
life
support
call
as
long
as
the
paramedic's
in
charge,
but
we're
looking
at
that
configuration
to
try
to
get
more
entry-level
folks
into
the
industry,
more
exposure
and
then
once
we
capture
them
and
they're
interested,
we
can
invest
in
their
education.
If
that
answers
good
question,
okay,.
J
He
talked
about
a
number
of
things
and-
and
I
I
know
earlier,
I
think
there
was
a
something
a
statistic
given
out,
or
at
least
the
number
given
out
about
40
of
the
calls
are
non-emergent
as
someone
who
actually
worked
as
an
emergency
room
physician
for
four
years,
that's
pretty
darn
close,
maybe
a
little
low
at
times,
but
but
you,
the
three
of
us,
are
looking
each
others
in
the
eyes
and
we're
saying
yeah
right,
one
of
the
one
of
the
things
I'd
like
to
know,
and
I'm
not
asking
for
that
for
that
data
here,
but
I
do
hope
I
can
get
it
at
some
time,
and
that
is
the
non-emerging
transports
as
they
relate
to
social
economic
status,
the
people
who
call
in
and
who,
who
who
want
to
who
need
a
ride.
J
Okay,
we're
talking
the
three
of
us
are
going
to
talk
real
world
here,
okay
and
then
some
of
the
data
on
rural
versus
urban
calls
again.
I
don't.
I
just
want
to
throw
this
out
because
we
need
to
move
on.
You
mentioned
the
things
in
the
workforce.
You
talked
about
lack
of
interest
and
maybe
a
20
to
30
percent
turnover
from
year
to
year,
and
then
even
what
we
all
know
is
mal
distribution.
But
the
other
thing
we
don't
talk
about
a
great
deal.
J
Is
the
motivation
there's
not
a
lot
of
motivation
for
people
to
get
off
their
butt
and
go
work
again,
I'm
the
bearer
of
bad
news
so
put
that
on
my
shoulders
and
so
what
we
really
have
to
try
to
do
to
help
not
just
your
area,
but
all
the
areas
that
we
have
in
the
commonwealth
is
we've
got
to
remove
some
of
the
things
that
inhibit
people
of
getting
into
the
workforce.
I
know
you
all
are
being
polite.
J
You
know
the
the
opioid
crisis
certainly
gives
us
a
lot
of
challenges.
It
pulls
a
lot
of
our
workers
out
of
the
workforce.
We
all
know
that
all
of
us
sitting
here
public
assistance
programs,
whether
we
want
to
talk
about
it
or
not
or
whether
we
want
to
say
it
out
loud,
is
telling
the
motivation.
Why
go
to
work
when
you
can
get
it
for
free
and
if
there's
not
enough
work
people
in
the
workforce
out
there,
it
is
very
difficult
for
you
all
to
maintain
a
business.
J
You
just
can't
you
can't
keep
paying
the
the
the
continually
continuing
elevation
of
salaries
that
people
are
are
asking
you
for
and
then
just
the
this
one
one
last
thing
here
we
look
at
some
of
our
education.
There
was
a
recent
study
that
came
out
and
I
wish
I
had
had
brought
that
here,
but
a
lot
of
young
people
who
are
graduating
from
college
now
are
getting
out
and
expecting
a
starting
salary
of
between
120
and
130
000
and
unfortunately
it's
about
46
or
47..
J
So
there's
that
big
disparaging
there's
a
there's
that
big
difference
in
what
the
expectation
is
and
what's
actually
out
there
and
therefore
we
lose
workforce
because
people
expect
more
than
what
the
economy
is
going
to
pay
them,
and
I
think
until
we
start
addressing
some
of
those
things
we're
all
all
our
businesses
are
going
to
continue
to
have
problems
in
the
workforce.
Thank
you,
mr
coach.
Here,
if.
J
G
You
you
talked
about
geographic
demographic
differences
and
how
folks
utilize
ems
and
we've
seen
that-
and
you
know
I
don't
have
the
statistics
here,
but
but
there
are,
but
there
are
differences
and
in
a
lot
of
places
across
the
rural
areas,
this
is
their
only
access
to
health
care.
So
if
you're
sick,
maybe
you
don't
have
a
primary
care
physician.
G
You
haven't
really
taken
care
of
yourself
for
whatever
reason,
but
then
it
culminates
all
the
way
up
until
the
emergency
and
that
that's
when
you
call
911,
because
that's
the
access
to
health
care
to
the
system.
What
we're
doing
is
looking
at
how
to
intervene
there
at
that
point.
So
we
don't
call
ourselves
a
transport
agency,
we're
ems
responders
right.
G
So
this
is
while,
while
everything's
a
lot
of
things
are
here
in
the
context
of
transport,
we're
looking
at
ways
of
how
we
can
intervene
into
that
request
for
care
and
and
provide
better
means,
for
example,
in
911
centers
across
the
country,
we're
now
implementing
nurses
that
can
triage
and
have
the
scope
of
practice
to
triage
these
patients
and
maybe
schedule
them
later,
not
send
an
ambulance.
So
we're
we're
moving
in
some
areas.
I
know
places
in
tennessee
are
doing
this
now
is
not
not.
G
Every
911
call
gets
an
ambulance
where
that
now,
what
every
911
call
will
get
care
or
will
get
coordinated
somewhere
in
a
system
to
make
sure
they're
finding
the
right
care.
So
those
are
the
changes
that
are
happening
in
terms
of
innovations
that
we're
looking
at
changing
the
model.
A
Gentlemen,
well
done,
thank
you
for
your
presentation,
insightful,
very
insightful
and
appreciate
you
being
here
today
and
certainly
welcome
you
to
stay
and
listen
to
the
final
presentation.
Thank
you
for
having
me.
Thank
you.
Our
final
presentation
today
is
is
going
to
be
most
interesting.
I
had
the
chance
to
preview
the
slides,
I'm
excited
about
inviting
the
international
association
of
firefighters
representatives
to
the
table
for
their
presentation
and
in
looking
at
your
slides
before
you
come
and
present
them.
A
C
Bartley
state
policy
and
legislative
representative
from
the
international
association
of
firefighters
represents
over
330
000,
firefighters,
paramedics,
emts
and.
C
Across
north
america,
also
retired
lexington
firefighter
paramedic
went
to
class
with
representative
hart.
I
won't
know,
don't
hold
that
against
me,
retired
from
lexington
last
year.
That's
the
guy,
got
the
beard
and
now
moved
over
to
virginia
so
good
to
be
back.
So
it's
been
a
few
years
since
I've
been
up
here.
Thank
you,
co-chair
and
committee
of
the
ems
task
force.
The
ems
field,
like
the
rest
of
health
care,
is
facing
critical
shortage.
C
But
the
recruiting
and
retention
of
ems
personnel
was
already
in
effect
before
the
pandemic,
and
it
just
exacerbated
it
and
probably
left
it
up
over
10
years,
and
it's
made
it
a
lot
worse.
There
are
some
outstanding
and
intelligent
people
in
the
ms
world.
They
work
in
a
blue-collar
job,
that
is,
they
are
highly
skilled,
but
usually
with
low-paying
benefits,
he's
throwing
the
pandemic,
and
now
the
workforce
has
been
beaten
down.
They
work
constantly
no
work-life
balance
and
they
are
mentally
and
physically
exhausted.
C
Going
to
go
over
the
history
of
the
ems
and
the
ms
and
the
fire
servers
trends
and
just
describe
what
firebase
dms
it's
good
to
know,
history.
I
know
a
lot
of
people
don't
understand.
I
get
calls
all
the
time.
Why
do
we
send
fire
trucks
to
ems?
Calls
we're
paramedics
too
emts,
and
you
know
it's
it's
for
manpower
or
staffing,
I
should
say
60
or
60
years
ago
there
was
no
real
ems
in
the
in
the
united
states.
C
Basically
over
time
through
the
world
wars,
korea
and
vietnam
basically
figured
out
you
had
better
survivability
rates
by
being
shot
or
called
shrapnel
overseas,
rather
than
a
car
wreck
on
I-75,
so
obviously
a
national
issue
in
the
60s
I
started
discussing
this.
The
white
paper,
the
accidental
death
and
disability,
came
out.
C
That
was
created
to
put
ems
under
the
committee
of
the
highway
traffic
safety
drafted
bls,
als
standards.
We'll
talk
a
little
bit
about
dr
nagle,
the
father
of
paramedicine
worked
for
the
who's
a
doctor
down
there.
C
Miami
worked
with
the
fire
department,
decided
to
say:
we've
got
this
army
here,
let's
put
them
into
ems
and
make
them
paramedics
and
emts
and,
and
so
that's
kind
of
where
that
came
from
ems
systems,
acts
was
put
in
1973,
it
was
put
in
the
national
highway
traffic
traffic
safety
administration,
which
kind
of
tends
to
be
some
of
our
funding
issues.
Don't
know
why
it's
under
transportation,
except
that's,
why
you're
just
transporting
people
you're,
not
caring,
and
it's.
C
Service
and
it
needs
to
be
again
worked
with
the
fire
department
in
miami
they
all
you
know,
kicked
and
streamed,
but
they
became
paramedics
lexington,
it's
not
well
known,
you've
got
seattle
and
miami
and
several
other
large
cities
in
the
country
that
started
the
firefighter
medic
programs.
C
Anybody
would
see
that
with
the
paramedics
they
got
in
the
ems
emergency.
I
don't
know
if
you
remember
that
show,
but
that
is
a
credit
that's
credited
with
where
firebase
dms
came
from
and
kind
of
pushed
it
nationally.
I
didn't.
I
couldn't
find
the
picture
of
me
back
when
I
was
like
four
years
old
had
like
a
little
doll
and
that's
test
scope
and
had
my
little
fire
helmet
on
so
I
didn't
have.
I
couldn't
find
that
picture,
but
you
know
just
a
little
relief
again.
C
Again,
paramedics
make
alternatives
to
nurses,
they're
hired
in
hospitals.
I
worked
in
a
hospital
for
a
little
bit
part
time,
probably
about
12
years
ago,
and
they
paid
much
higher
and
they
work
in
more
controlled
environments.
They're
not
under
a
flip
car
and
pouring
down
rain,
and
you
know
doing
cpr
on
somebody
or
trying
to
innovate.
Somebody
in
the
you
know
it's
it's
a
rough
job
trends
a
day
your
your
private
for-profit
companies
are
struggling
with
recruiting
entertainment,
just
like
we
are,
but
they're
they're
struggling
to
remain
profitable.
C
Volunteers
is
for
years
since
I've
been
here,
it's
always
been
a
trying
to
retain
volunteer
firefighters.
I
was
appointed
to
the
kentucky
fire
commission
under
governor
bevin,
and
we
fought
with
those
issues
for
that
time
that
I
was
on
there
and
it's
just
not
changing
rural
areas
continue
to
provide
service.
C
My
point
of
this
whole
conversation
is
firebase,
dms
was
there
in
the
beginning,
it
was
there
before
the
pandemic
and
it's
there
now
and
it's
already
trending
that
way.
Large
cities
kansas
city,
philadelphia,
orlando
made
the
move.
You've
got
small
towns
in
north
carolina
massachusetts,
small
rural
communities,
their
fire
departments,
your
volunteers
are
kind
of
going
away
and
some
locals
are
having
to
decide.
They
have
to
pay
their
their
departments,
they
have
to
become
part-time
or
fully
paid,
and
those
are
the
people
that
are
answering
the
calls.
C
C
What
we're
also
seeing
is
once
the
fire
departments
are
getting
becoming
the
ms
transport
for
their
communities,
they're
bridging
the
gap
by
hiring
from
the
private
for-profits
and
they're
they're,
bringing
them
in
single
role
medics.
They
can't
go
into
fires,
but
they
can
still
serve
as
paramedics,
so
we're
seeing
that
happen
as
well
until
basically
to
bridge
that
until
they.
C
Currently,
just
during
the
pandemic,
we've
seen
atlanta
go
away
from
their
private
service.
They've
still
got
they've
started
doing
their
own
ambulance
transports.
Small
towns
in
ohio
voted
the
city
council
to
contract
in
their
contract
with
smith
ambulance,
the
villages
florida
don't
know
if
you've
seen
those
in
the
news
large
community
down
in
florida.
That
accomplishes
three
counties,
helped
on
this
project
and
the
fact
that
the
citizens
got
tired
of
slow
response
times
and
ended
their
contract
with
amr,
and
they
voted
to
have
the
county
fire
department
in
the
city
of
the
villages.
C
I
C
Bought
12,
ambulances
all
actually
saw
him
at
fdic
in
indianapolis
in
the
spring,
so
it
was
good
to
work
on
that
project.
Blackjack,
mid-missouri,
small
suburb,
out
of
st
louis
again,
citizens
were
tired
of
waiting
on
9-1
calls.
C
C
Also
seen
in
the
state
with
jefferson
county
fire
districts,
they
have
moved
to
even
before
the
pandemic.
They
moved
to
merge,
crate
taxing
district
or
they
were
already
taxing
districts,
but
created
transport
units
because
of
the
service
provided
by
the
city,
and
it.
C
As
previous
stated
on
the
first
pres
presenter,
the
fire
service
is
the
predominant
provider
of
ems
transport
in
the
united
states,
not
here
in
kentucky
97
of
the
200,
most
populated
communities
use
the
firebase
dms
system
and
basically,
nearly
all
firefighters
have
some
level
of
ems
training.
C
We
have
a
built-in
infrastructure
every
all
our
stations
are
built
in
a
certain
community.
We
have
a
ready
army
to
go
to
war
basically
and
get
and
make
runs
and
make
ems
responses,
and
we
can
make
all
hazards
responses.
So
if
somebody
has
an
incident,
that's
a
car
wreck.
You
can
actually
start
treating
the
patient
and
you're
ready
to
go,
and
you
have
either
a
high
angle,
rescue
hazmat
situation
and
we
had
to
learn
how
to
start
ivs
and
hazmat
suits
in
our
training,
and
so
it
we
can
do
an
all
hazards
response.
C
It
is
again
more
robust
system.
It
provides
a
seamless
transition
to
care
through
all
stages
of
emergency
response
from
fires,
emergencies,
hazmat,
technical
rescues,
and
even
we
already
do
the
cr,
the
community
risk
reduction
programs,
fire
safety
programs.
We
get.
We
do
ems
reduction
programs
as
well.
It's
not
a
distraction
from
our
mission
to
core
service
provided
by
firefighters
and
paramedics
within
the
department.
C
C
C
Basically,
some
of
the
same
stuff
medicaid
reverses
approximately
ten
percent
of
the
actual
cost.
So
we
know
we
got
issues
there.
One
thing
that
we're
looking
for
is
the
treatment
in
place.
It
was
mentioned
before
in
the
last
couple
of
presenters.
C
H
C
Alternative
destinations
already
explored
a
little
bit.
There
needs
to
be
access
to
urgent
care
mental
health
providers
within
care
of
that,
but
reimbursement
needs
to
be
considered.
There
are
other
cities
around
the
country
that
are
considering
uber
and
lyft,
and
obviously
that
would
be
in
more
urban
areas.
C
Other
innovations
federal
we're
looking
at
federal
legislation
to
basically
the
reimbursements
happen,
every
they're
reauthorized
every
six
months
or
24
months,
we're
looking
at
extending
that
time
over
several
years.
So
ems
agencies
can
predict
more
assistance,
planning
and
ems
budgets.
Basically
so.
C
C
Let
me
go
back
here:
community
paramedicine
program
will
hit
on
that,
I'm
going
to
brag
on
lexington.
Again
I
don't
know
if
you
see
the
news,
it
helps
with
opioid
overdoses.
C
Your
chronic
illness
is
diabetes,
high
blood
pressure
and
keeps
people
out
of
the
hospital
and
saves
hospitals
a
lot
of
money
and
taxpayer
time
as
well.
But
that
program
that
was
okay.
D
C
D
H
C
I
hope
that
this
task
force
looks
forward
and
works
with
all
the
organizations,
all
the
fire
organizations,
fire
chiefs,
firefighters,
privates,
hospitals
and
and
basically
looks
at
what's
best
for
the
the
citizens
of
the
kentucky
and
their
911
response
times
and-
and
basically
you
know,
I
I'm
going
to
advocate
keeping
everything
local
control
at
the
county
or
city
level,
because
they're
the
ones
that
has
the
answer-
the
cause
of
complaints
and
and
and.
C
H
C
C
Tornado
in
mayfield
and
got
the
flood
going
on
it's
it's
been
a
tough
year
for
kentucky
tough
couple
years.
C
Funding
needs
to
be
available
for
all
these
telemedicine,
alternate
destinations,
training,
recruitment
and
one
of
the
things
that
we
looked
at
michigan
just
passed
a
budget
that
allocated
12.9
million
to
boost
medicaid
reimbursements
for
ems
when
combined
with
federal
match.
That
is
nearly
a
50
million
dollar
that
will
benefit
ems
and
michigan
at
all
agencies.
In
michigan
there
was
an
additional
5
million
dollar
grant
to
help
local
governments
recruit
and
train
first
responders
as
well.
C
A
Gentlemen,
thank
you
for
the
presentation.
I'm
I'm
confident.
Some
of
my
colleagues
on
the
panel
may
have
some
questions.
One
of
the
one
of
the
points
that
I
think
we've
heard
over
and
over
throughout
the
day
is
on
the
question
of
reimbursement
and
a
lot
of
conversations
about
workforce
retention
attraction.
A
A
Expert,
the
national
numbers
10
of
the
actual
cost,
so
not
not
to
diminish
your
presentation
in
any
way
whatsoever.
Movement
toward
a
privatization,
moving
away
from
privatization
toward
taxpayer
funded
operations
is
obviously
a
cost
shifting.
It's
got
to
be
paid
somewhere
if
medicaid
is
not
going
to
pay
it.
Am
I
wrong
in
my
thinking
that
moving
it
to
a
taxpayer,
you
mentioned
some
entity
had
had
imposed
a
tax
on
themselves
to
provide
for
fire
service
taking
over
the
the
emergency
medical
response,
so
we
can
pay
for
it
either
way
it's
got
to
be
paid
for.
C
J
C
C
So
it's
already
within
our
dna
to
make
these
runs
and
and
you're
you're
looking
at
what
is
the
needs
of
the
citizens
as
well?
If
you,
you
know,
we
looked
at
in
lexington,
there
was
a
battle
to
to
reduce
ems
cost
and
response
times
and
take
people
off
the
ambulances,
and
you
start
talking
about
that.
The
mayor
did
at
the
time
and
then
once
the
council
got
a
hold
of
us
like
not
in
my
district,
my
citizens
expect
proper
response
times
proper
care
and
that's
what
we
provided.
We
actually
had.
C
H
A
C
No
houses
they
get,
they
just
get
the
reimbursements
through
medicare
medicaid,
and
then
I
believe,
the
community
prime
medicine.
I
believe
the
hospital
systems
fund
some
of
that
to
subsidize
that
as
well.
A
B
B
Medicaid
is
only
paying
a
very
small
portion
of
what
the
medicaid
cost
is
and
if
you
look
in
our
taxing
districts
that
are
either
either
fire
and
ems
combined,
taxing
districts
in
places
like
jefferson,
county
or
in
your
smaller
communities
like
edmondson
county,
that
we
represent,
where
you
have
an
ambulance,
taxing
district,
it's
really
the
property
taxpayers
who
are
paying
that
tax
rate
that
are
subsidizing
the
ems
service.
That
is
not
being
covered
by
medicaid
rates
or
medicare
rates
and
private
insurance.
B
And
I
think
that
would
be
something
that
you
would
see
in
many
of
the
rural
communities
across
the
commonwealth,
because
I
think
you
know
that
you
have
the
the
for-profits
that
are
operating
in
some
areas.
You
have
hospital
based
in
in
some
rural
areas,
but
but
for
the
most
part
I
would.
I
would
think
that
the
state
is
covered
by
those
taxing
districts
like
that
that
are
subsidizing
through
a
property
tax
through
some
type
of
a
fees,
type
structure
or
or
the
local
government.
The
county
is
paying
it
somehow
out
of
the
general
fund.
E
Briefly
and
if
you
go
to
a
firebase
model,
what's
the
optimum
complement
like
per
shift
for
your
demographic?
Is
it
population
miles
covered,
I
mean?
Is
there
a
model
that
you're
familiar
with,
or
do
you
just
have
to
come
up
with
one
yourself
based
on
respective
community.
C
E
E
E
K
If
I,
if
I
may,
coming
from
your
senatorial
district
in
east
kentucky
basically
in
the
rural
areas
like
that
around
ashland,
where
I'm
from
it's,
they
do
the
best
they
can
with
what
they
have.
And
you
know
just
like
you
mentioned
the
the
lack
of
hospitals
in
in
greenhouse
county
and
in
carter
county
that
you
know
they're
constantly
transporting
patients
from
carter
county
into
ashland
to
king's
daughters,
which,
as
as
he
stated
earlier
as
well,
it
leaves
a
shortage
of
ems
protection
in
carter
county,
while
they're
spending
so
much
time
in
ashland.
K
So
you
know
I'm
sure
that
the
carter
county
ambulance
services
is
taxed
to
the
limit
as
well.
They
would
have
to
be
as
much
as
I
see
them
in
my
city
and
so,
as
I
said,
I
think
in
those
kind
of
communities
they
do
the
best
they
can
with
what
they
have
and
that's
why
we've
advocated
not
only
funding
for
for
the
metropolitan
areas
in
the
urban
areas,
but
but
there
needs
to
be
funding
provided
for
the
rural
areas
as
well.
C
So
I'm
so
I'm
also
helping
arizona
a
little
bit
there's
a
proposal
that
goes
to
all
the
voters
of
arizona
and
again
this
is
obviously
kentucky.
I
guess
doesn't
do
this,
but
would
allow
taxing
districts
a
certain
amount
that
would
sunset
over
20
years
and
it's
basically
for
those
rural
areas
of
arizona
that
aren't
covered
by
phoenix
or
tucson
that
aren't
really
cash
strapped.
So
it's
a
it's.
You
know,
there's
changes
that
got
to
be
looked
at
that
maybe
you
can
look
at
alternatives.
C
And
even
though
it
only
helps
probably
40
percent
of
the
population,
it's
there
for
everybody
to
vote
on
and
and
look
at
so
I'm
helping
with
their
tax
initiative.
There.
F
I
wanted
to
add,
ask
holly
brown,
quick
question
and
then
more
of
an
explanation
of
how
you'll
handle
something
I
got
a
pretty
good
background
from
chief
briscoe
this
past
spring,
on
how
y'all
operate
and
so
forth.
It's
very
very
helpful.
I
want
to
ask
in
terms
of
breaking
out
between
emergency
and
non-emergency.
Can
you
break
that
out,
particularly
for
kentucky
and
turns
your
runs.
C
E
C
F
F
That's,
I
guess
it
goes
back
to
having
good
data
collection
and
that's
one
thing.
We
need
to
work
on.
C
F
My
second
question:
could
you
explain
how
do
you
handle
mental
health
patients,
clients.
F
C
Uk
healthcare-
I'm
old
school,
a
police
officer-
would
have
to
ride
in
the
back
with
us,
because
I've
had
the
same
scenario
that
the.
C
Presenter
did
somebody
just
jumped
out
of
middle
alumni
drive
on
me
and
I
was
like
I'm
not
stopping
you,
but
I'm
calling
the
cops
to
stop
you
so
but
from
what
I've
been
told,
we're
because
of
the
shortage
in
the
police
department,
we're
we're
transporting
eastern
state
another.
F
D
You
know
going
off
of
representative
fleming's
last
comment:
what
might
be
beneficial
is
lexington
fire
department,
they're
working
with
eastern
state
and
they've
got
a
new
program
to
help
facilitate
better
mental
health
transports.
So
it
might
be
beneficial
to
this
committee
to
maybe
see
if
lexington
would
come
and
give
us
a
presentation
on
what
they're
doing.