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Quick take: Keep up the external political pressure for the good of EMS

Funding, COVID-19, civil unrest: Resources from the Federal Interagency Committee on EMS Meeting for the challenges facing EMS


Nyasha Sarju sits as a Seattle Fire Department paramedic prepares to take a nasal swab sample to test for coronavirus at a testing site, Monday, June 8, 2020.

AP Photo/Elaine Thompson

EMS is a service that is controlled and delivered in several ways: fire-based, hospital-based, private and non-profit. Because of this, at the Federal level, EMS falls across several governmental controlling agencies. While the ultimate responsibility for EMS falls to NHTSA’s Office of EMS, many others are involved. Because of this, the Federal Interagency Committee on Emergency Medical Services (FICEMS) was established in 2005 and meets every six months to discuss all things EMS. Given the recent events in and developments, Rob Lawrence provides an overview of the meeting, items discussed and his interpretation of what it all means for us on the ground.

The Federal Interagency Committee on Emergency Medical Services (FICEMS) was established by congress in 2005 to ensure coordination among federal agencies supporting local, regional, state, tribal and territorial EMS and 911 systems. FICEMS was also created to improve the delivery of EMS throughout the nation with the Departments of Defense, Health (HHS), Homeland Security, Transport (Office of EMS), and the Federal Communications Commission represented as members.

FICEMS met recently for the first time in 2020 and since their last meeting, a lot of water (and pandemic and unrest) has passed under our bridge. Today’s EMS One-Stop column provides an update on what the folk at the FICEMS are saying about some of the most important EMS activities, policies and events across the nation.

The agenda provided briefings on strategic direction, ET3, COVID-19, as well as an address by James Owens, NHTSA deputy administrator, and FICEMS chair, who began by saying;

“The past few months have been perhaps some of the most difficult times our EMS community has ever faced. But you have risen to the challenge and then some. The selflessness, dedication and resiliency of our nation’s EMS personnel are humbling and our nation thanks you. We want you to know that your voices are heard and we are working to ensure the safety and resiliency of EMS professionals. We remain committed to supporting our stakeholders and partners as we navigate this unprecedented event.”

Folowing are 5 takeaways from the FICEMS meeting.

1. COVID-19 and proving the ET3 model

Janelle Gingold, director of the Division of Health Integration; and Brenda Staffan, team advisor, Center for Medicare & Medicaid Innovation, provided an update on the Emergency Triage, Treat and Transport Model (ET3). CMMI houses the ET3 model as part of the prevention population health models group.

As we are aware, the ET3 model includes 3 interventions that will provide additional services to Medicare beneficiaries and additional patients:

  1. Alternative destination transport
  2. Treatment in place in person, or via telehealth
  3. The medical triage line

ET3 was formally paused with the arrival of the pandemic. Director Gould reported that the arrival of COVID 19 caused an operational pause in the ET3 rollout and may restart later in the year.

The pandemic has caused us to deliver many of the aspects of ET3, so perhaps we can either immediately adopt the program or change the pilot based on what we have learned. Gingold noted;

“In early April, we announced a delay of the model, the start of a model from May 1 to follow 2020 and at that time rescinded the model participation agreement. We did not execute any of those participation agreements at that time. We are currently assessing the model especially considering the flexibilities made available under the public health emergency which we are aware may still be in effect in the fall. and are working on additional implementation and operationalization of different model elements in the meantime.”

Could this perhaps be that affirmation that, as we have been delivering the ET3 concept to fight COVID-19, so we have indeed proven the concept? To my mind, the pandemic has certainly disrupted the original model, proven the theory and perhaps we can now roll out reimbursement for all – not just the appointed test sites? Let us hope so as I suspect it will be difficult to try to stuff this now-proven healthcare delivery genie back into the bottle. Time will tell.

2. Response to civil unrest

Director of the NHTSA Office of EMS, Dr. Jon Krohmer, discussed the current civil unrest and highlighted EMS experiences. He reported that both the Office of EMS and the U.S. Fire Administration have prepared a brief document to reinforce preparations for personnel, stations, equipment, apparatus and the community for emergency response considerations during civil unrest.

The documents feature sections on Mitigation of Occupational Violence to Firefighters and EMS Responders, and Preparing for Civil Unrest, describing the current state of fire and EMS civil unrest preparedness activities and guidance to assist with preparing standard operating procedures that establish a standardized approach to the safety of personnel at incidents that involve violence, unrest or civil disturbance.

3. COVID-19 response

Krohmer reviewed the EMS response to the pandemic at the federal level, including the formation of the Healthcare Resiliency Task Force and its subordinate group, the EMS Pre-Hospital Working Group (of which I am honored to be a member representing the American Ambulance Association), that was established to address EMS and 911 issues. The prehospital group has been working throughout the response and has developed several documents and resources that have been distributed to the EMS community via the website.

4. Sub-standard and counterfeit PPE

Duane Caneva MD, chief medical officer, DHS, discussed substandard and counterfeit PPE and the investigative work of Operation STOLEN PROMISE, which has been working with interagency, state, local and industry partners to look at the concerns on substandard and counterfeit PPE. Operation STOLEN PROMISE is looking at manufacturers and vendors importing counterfeit PPE or substandard PPE not manufactured to standards.

Caneva reported that many agencies, including CDC, NIOSH and the National Personal Protective Technology Laboratory are looking at ways to validate PPE entering the country to ensure it complies. Caneva said;

“They are routinely finding that 60% of [PPE] does not – and we have spoken to other industry experts who estimate up to 90% of the PPE that’s coming in through sort of not secure federal government sources – may be substandard or counterfeit so we are trying to understand the scope and scale of the problem.”

The issue for many EMS organizations comes back to supply chain and PPE issue priority. Organizations, particularly in the private sector, are still doing all it takes to acquire equipment to protect staff and need to step outside of normal channels to at least get some PPE. But, as Caneva notes, it’s very risky business and definitely a case of buyer beware.

The public comment period saw several important issues raised. American Ambulance Association President, Arron Reinert, posed the important question of PPE and the place of EMS on the national priority list. Reinert noted that first responders remain third on the priority list for PPE and that many localities were unable to acquire PPE to meet current needs, let alone future waves. The response identified that PPE has been challenging to address throughout the public health emergency, and that early on in the pandemic, hospital providers were prioritized. Subsequently, it has been possible to get first responders included in, and moved up the priority list.

Krohmer noted:

“It is unfortunate that we are in a situation where we have to do prioritization and do allocation, everybody that we engage with realizes the critical role that first responders play and the importance of the need for them to continue to respond.”

He explained that when faced with a limited supply, the risk assessment identified that there is a little bit higher risk for those that are currently providing care in hospitals and nursing homes. EMS resides in third place on the PPE priority list and this does not sit well with many as the challenge of responding to a call or into a household where there is little choice but to assume the patient is COVID-19-positive until proven otherwise accelerates the consumption rate of an agency. This situation is less than optimal or acceptable and more must be done, both inside government and by us on the outside to rectify this situation.

5. EMS funding advocacy

Dave Mitchell, president, International Association of EMS Chiefs (IAEMSC), asked if there was there an opportunity to continue to explore and advocate for the funding of EMS systems by ways other than the old mechanism of transporting then billing. Krohmer responded that there are opportunities to look at additional funding and additional funding needs, and that much discussion had taken place on this issue internally at the federal level and amongst external stakeholders. He concluded by offering;

“I think that it would be valuable for the stakeholder organizations to not only continue the discussions they have had but probably to expand the constituents with which they have had those conversations.”

Krohmer makes a valid point and could be the biggest take away from their meeting – EMS change will only come about rapidly via the external political lobbying that is currently being delivered collaboratively by such organizations as AAA, NAEMT, IAFC and others. And perhaps the subliminal message delivered here is to keep up this good work but step up the tempo and range of our legislative efforts.

Another question focused on emergency relief funding under the Stafford Act and CARES Act and the ability for all EMS of all types to gain access to FEMA funding. All were referred to the upcoming webinar to be delivered by USFA Administrator G. Keith Bryant and Star Black, FEMA Public Assistance Program SME. The webinar will discuss reimbursement and cost recovery issues.

It is important to track the activities of work of NHTSA, Office of EMS, FICEMS and NEMSAC – the National EMS Advisory Council. All sit at the national level of our profession and can advance ideas and initiatives up into government, but we must also continue the twin, and sometimes faster, track of keeping up the external political pressure for the good and benefit of EMS.

Keep up the external political pressure for the good of EMS: EMS One-Stop With Rob Lawrence

Listen to an audio version of this article below.

Additional resources for ET3, civil unrest and COVID-19 issues

Learn more about the challenges facing EMS with these resources:

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.

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