Lisa Tofil, a partner at the law firm Holland & Knight in Washington, D.C., is gaining a reputation as one of EMS’s most effective advocates on Capitol Hill. Tofil got her start as a legislative assistant on health care is- sues to Sen. John H. Chafee (R-R.I.). She later became vice president of government relations for the Caroli- nas Healthcare System in Charlotte, N.C., before join- ing Holland & Knight in 2002.
Today, Tofil is a lobbyist for Advocates for EMS, a nonprofit sponsored by the National Association of State EMS Officials, the National Association of EMS Physicians, the National Association of EMS Educa- tors and the National Association of Emergency Med- ical Technicians, which is working to move H.R. 6528, the Field EMS Quality, Innovation and Cost-Effective- ness Improvement Act, through Congress.
H.R. 6528, known as the Field EMS Bill, is biparti- san legislation that was introduced by Rep. Tim Walz (D-Minn.) and Rep. Sue Myrick (R-N.C.) in December 2010. Because bills die at the end of each congressional session, the Field EMS Bill will likely be re-introduced soon, Tofil says.
In addition to her work with Advocates, Tofil also represents the Association for Critical Care Transport; the Trauma Center Association of America; hospital systems in Florida, Illinois and California; and hospi- tal associations, including the Florida Hospital Associa- tion and the Metropolitan Chicago Healthcare Council.
Tofil spoke with Best Practices about the need for EMS to have a lobbyist in Washington and the impor- tance of EMS being willing to speak with a unified voice in order to get the federal support it needs to thrive.
Lobbyists and “special interests” are often depicted negatively. Why is it important for EMS to have a lobbyist in Washington?
There are many voices on Capitol Hill, and not having a presence and a voice would make it more difficult for EMS to get heard. That was what the founders of Advocates saw. Following 9-11 and the anthrax attacks, Congress started moving legislation on bio-terrorism and prepared- ness, and EMS got largely left behind. That hasalottodowithalackofavoice.The purpose of Advocates is to provide a voice for all of EMS on Capitol Hill.
Do you think the criticism of lobbyists and special interests is fair?
Do I think it’s really important for folks to have a professional lobbyist who lives and breathes how the Congress works, how the administrative agencies work and who can help them navigate that process? Absolutely. But I’ve never met a member
of Congress who would rather talk to a lobbyist than to a constituent.
As a lobbyist, I work very hard with my clients to encourage their active participa- tion in communicating with their mem- bers of Congress directly. A very good example of that, something that I wasn’t involved in the planning of, is NAEMT’s EMS Day on the Hill. Hats off to them for providing the leadership to have a day where people come in from around the country, go up to the Hill and share their views with members of Congress.
As a lobbyist, I can walk in and I’m going to understand the process better than the average person, but I’m not going to understand what that congressional district needs better than the constituent will. What the needs are back home is always best articulated by a constituent. Mem- bers of Congress want to hear their views and know what they think. Part of my job is to help facilitate that and help people understand how the process works.
Holland & Knight is one of the largest law firms in the world. How did it happen to get involved in EMS issues?
We have a number of folks doing work around health care. Some focus on the FDA, others on bioethics, hospitals or physicians. I was a hospital attorney, and my focus when I came here was on hos- pitals. Hospitals led me to trauma, which led me to critical care transport, which led me to EMS.
It’s also by choice. I love it. I like to say I’ve made a career representing the good guys. The work I’m doing for all of my clients—it’s for people who make a difference. I’ve never put my hands on a patient, but if I can help at a macro-level to make things better for those who are putting their hands on patients so that they have more tools in their toolbox— more financing, more support, high- er levels of safety for themselves as well as patients—I will continue to go home and sleep at night and feel I’ve done somethinghelpfulandpositiveforwhat they’re doing every day.
How does your work as a hos- pital lawyer help your work with EMS?
It helps a tremendous amount. I’m look-ing at the big picture. EMS is one compo- nent of one very large health care system. It’s a critical and very important compo- nent and one that has not yet garnered the amount of federal attention that it needs and deserves; nor has the larger health care system quite recognized that yet.
Whether you love or hate the Affordable Care Act [health care reform], what it’s focused on is getting the biggest bang for the buck. How do we get higher quality and lower costs?
In terms of EMS, say you have some one with heart failure—at some point that patient is going to be transported by ambulance. They are going to go back and forth to the hospital. There is connectivity with EMS that the larger health care community hasn’t quite seen yet, but they are going to. One of the main reasons they’re going to is because of the development of Accountable Care Organizations (ACOs), which will put doctors and hospitals on the hook for the quality of care they deliver.
What is an ACO?
You can ask 20 different brilliant health care experts and they will give you 20 different answers. The Medicare structure of an ACO is that it’s an organization constructed at least of physicians, but most will include hospitals and physicians coming together, who will get paid a fee for service, but if they can save Medicare money, they will be able to share in those savings as long as they reach certain quality benchmarks. The hospitals and the physicians take responsibility for care.
When you put them on the hook fi- nancially for reducing costs, they’re going to start looking beyond their own doors and they will inevitably start looking at EMS on the prehospital side. They are going to be dinged for unnecessary readmis- sions. They will have incentives to pro- vide better transitions out of the hospitals so patients don’t come back. The financial incentives are shifting dramatically and rapidly, and it will impact EMS.
Learn more about the Field EMS Bill at advocatesforems.org/ uploads/H.R._6528_Field_EMS_Bill_Section_by_Section.pdf.
As an industry, how is EMS different from others you’ve worked with?
It’s very fragmented. It has struggled to have a unified voice, and that has held its progression back greatly. If you look at some of the other industries—clinical lab associations, hospital associations, physician associations and the specialty societies—they typically come together on the big issues. When you have a big-ticket issue, every hospital association puts their name and their insignia on the same letter and sends it up to the Hill. EMS just hasn’t developed to that point.
One example from trauma land: The trauma centers, surgeons and a variety of other organizations worked together to get $224 million for trauma and regionalization of emergency medical care programs. It was because of the unified effort that they succeeded. There was one voice advocating for the exact same thing, which goes a really, really long way. If EMS can progress to the point where there is a good amount of consensus, EMS is going to get much, much, much further than if they are headed in a variety of different directions.
It’s getting better in EMS, though. EMS is maturing as an industry, as an enterprise, and hopefully, the Field EMS Bill will continue to facilitate that. We are working really hard to build as much consensus as we can through the development of the Field EMS Bill, but historically that has been a real problem. That doesn’t mean you will always have agreement, but the more you can get, the better off you are.
Do you think it’s possible for EMS to speak with a common voice?
I do think it’s possible. I think part of this is maturing as a segment of health care and as an industry. The more experience EMS has in terms of what it takes to get legislation enacted and what it takes to get laws funded, the better off it will be. There is an increasing recognition that finding that united voice is going to be necessary even if the legislation is not exactly what
you want. When different organizations work together, they have a much better opportunity to accomplish something.
Why has it been so hard to change they way in which EMS is reimbursed?
The Field Bill calls for doing an evaluation of alternatives and demonstration projects to test them. But change is scary. People want to ensure they are not going to go from a situation in which they’re getting paid to transport to not getting paid at all. Medicare payments for transport are below what it costs to deliver the service, and there is no recognition for readiness costs. We think alternatives ought to be evaluated and demonstrated to see if there is a better way to meet the needs of patients.
We’ve heard a lot of thought went into the name of the Field EMS Bill? Why is the name important?
One of the things we wanted to do was to begin to distinguish between EMS in the field and the rest of EMS. It gets con- fusing to folks on Capitol Hill when you talk about EMS. They often think you’re talking about EMS provided to a hospital in-patient. We just decided the simplest thing to do was focus on out-of-hospital EMS, not just prehospital, which assumes every patient is going to the hospital.
What are some of the misconceptions the public—and, by extension, members of Congress— have about EMS?
There is this public assumption that you call 911 and you’re going to have that ambulance show up wherever you are to deal with whatever you need and it’s going to have all the right capabilities. The public doesn’t understand, and as a result Congress doesn’t understand, all of the complexities and challenges that face EMS in meeting those public expectations.
What EMS folks are doing every day is pretty amazing. My job is to get the members of Congress to understand those challenges, and that federal support is essential to help them understand what’s needed.
One example we often use is the 12-lead. There are a lot of data that show they are very important, but not every EMS agency has them. We also use NEMSAC’s “EMS Makes a Difference.” That’s a very helpful document, as well as the Institute of Medicine Report, “EMS at the Crossroads,” from 2006, which makes very clear that EMS needs a lead federal agency and an infusion of federal funding. It needs recogni- tion and support at the federal level that it’s not getting right now.
If the Field EMS Bill passes, what would EMS potentially look like in 10 years?
It would mean greater recognition and integration of EMS into the larger health care system. If the bill were enacted, and understand
it’s going through a lot of revision, EMS will have a voice in the federal government and a home in the federal government that everybody can identify. It will have champions within the administration that will fund it and fight for it. And it will have the opportunity to continue to grow and develop and be much more responsive to the needs of the agencies, practitioners, chiefs and everybody in the community. We are getting ready to reintroduce the bill, possibly in the next few weeks, and we are working as hard as we can to generate as much consensus as possible on those revisions. I can’t say what the revisions to the bill are. They haven’t been agreed upon yet, but we are having a lot of conversations
Lisa Tofil is the keynote speaker at the Pinnacle EMS Leadership Forum, July 25-29, Miami Beach, FL. For more information visit pinnacle-ems.com.
