I have monitored the proceedings at the National EMS Advisory Council (NEMSAC) for years and will continue to do so. Its recent history and re-set last year prompted me to write about the new NEMSAC and my hopes for continued good work and great oversight of EMS in all its forms continue.
While I was tuned into the November NEMSAC meeting, I was prepared for the usual report outs and signs of progress. They were all there, but what got my attention wasn’t the staff reports of grant funding to support prehospital blood or the general enthusiasm for the subject, but the fact that three of America’s leading blood organizations have called for changes to federal reimbursement policy to support the nationwide expansion of prehospital blood transfusion, warning that existing Medicare ambulance payments do not adequately cover the costs of administering blood in the field.
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In a joint statement presented during the meeting, the Association for the Advancement of Blood and Biotherapies (AABB), America’s Blood Centers and the American Red Cross urged the federal government to establish dedicated reimbursement, strengthen national blood supply coordination and promote recognized standards for prehospital transfusion. The recommendations were delivered by Leah Mendelsohn Stone, JD, vice president of public policy and advocacy at AABB. A healthcare policy and advocacy attorney with more than a decade of private practice experience, Stone leads AABB’s efforts to advance policies supporting access to safe blood, transfusion medicine and biotherapies.
Speaking on behalf of organizations representing the nation’s blood collectors, transfusion services and transfusion medicine professionals, Stone outlined four priorities necessary for sustainable national implementation. Her remarks represent a significant contribution to a policy discussion largely focused on clinical implementation and the expansion of EMS blood programs.
Medicare reimbursement in the spotlight
Perhaps the most consequential recommendation concerned Medicare ambulance reimbursement.
“Medicare does not pay separately for blood or transfusion in the field,” Stone told the council.
She explained that these costs are bundled into the Advanced Life Support Level 2 (ALS2) ambulance payment, which the organizations contend is insufficient to cover the expense of providing the service.
The organizations recommended that the Centers for Medicare & Medicaid Services (CMS) establish a separate add-on payment, building on the TRICARE demonstration scheduled to begin in January 2027. They also encouraged state Medicaid programs to cover prehospital transfusion.
This is a significant recommendation from organizations outside the traditional ambulance reimbursement advocacy community. It acknowledges that expanding EMS clinical capabilities creates additional costs that existing payment structures may not adequately recognize.
A blood transfusion program requires more than purchasing blood. Storage, temperature monitoring, inventory management, clinician training, quality assurance and clinical oversight create ongoing financial obligations, regardless of how frequently an agency administers blood.
Stone also recommended continued federal grant support, including programs offered by the Department of Defense and the National Highway Traffic Safety Administration (NHTSA), with funding that recognizes implementation costs.
However, grants that help establish programs do not necessarily provide the dependable funding required to sustain them. For ambulance providers and their associations, the statement provides an important additional voice in the continuing debate over whether Medicare reimbursement adequately reflects the cost and complexity of modern prehospital medicine.
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The blood supply must be part of the plan
The organizations’ next major concern was the national blood supply itself.
“Prehospital transfusion cannot function as a standalone EMS intervention,” Stone warned.
Expanding prehospital programs creates demands extending beyond individual ambulance agencies. Donor recruitment, manufacturing restrictions, supply chain limitations, inventory management and product availability all influence the ability to support expansion. The organizations recommended that the federal government assess the impact of increased prehospital transfusion on the national blood supply and support regional inventory stewardship.
Increasing the number of EMS agencies carrying blood does not automatically establish that sufficient supplies will be available, appropriately distributed or efficiently used. Blood collectors, hospitals and EMS agencies must work together to determine how products are allocated, managed and replenished. Regional partnerships may also help reduce waste while maintaining access for patients who need transfusion.
The statement positions prehospital transfusion as part of a broader healthcare supply system rather than simply another clinical capability individual ambulance agencies can introduce independently.
National standards and accountability
The organizations also called for nationally recognized transfusion standards, consistent education, independent accreditation and stronger systems for traceability and hemovigilance.
Stone also recommended incorporating internationally standardized blood product identifiers, known as ISBT 128, into national EMS data reporting. This would improve the ability to track blood products from donation through prehospital administration to the receiving hospital, supporting patient safety, accountability and the investigation of transfusion-related complications.
The organizations also recommended that federal grants recognize accreditation, standards and transfusion education as allowable expenses.
Their message reinforces the principle that safe implementation requires more than equipment and protocols. It requires accountability connecting EMS agencies with hospitals, blood collectors and transfusion services.
One size will not fit every EMS system
Another important recommendation was flexibility in blood product selection.
Rather than promoting an approach focused exclusively on low-titer group O whole blood, the organizations supported access to all FDA-approved blood and blood components appropriate for prehospital use, allowing programs to reflect local clinical needs and available supplies.
This position echoed concerns raised earlier during the NEMSAC discussion.
Council member Dr. Dustin Calhoun, representing emergency management officials, questioned whether enthusiasm for expanding prehospital transfusion was moving ahead of the evidence needed to demonstrate benefit.
Calhoun warned about EMS’s tendency toward “shiny object syndrome,” citing previous interventions adopted enthusiastically before subsequent research challenged their value.
He questioned whether national targets should measure the number of programs established or instead focus on patients with appropriate clinical indications receiving transfusions and achieving better outcomes.
NEMSAC Vice Chair Dr. Nicholas Cozzi, representing EMS physicians, supported moving away from terminology focused exclusively on whole blood toward the broader concept of prehospital blood products.
Cozzi emphasized data-driven implementation, equitable regional access and sustainable reimbursement. His argument was not that every ambulance should carry blood, but that systems should develop capabilities appropriate to their communities and supported by meaningful outcome measures.
The council discussion and joint statement demonstrated considerable alignment around clinical evidence, responsible resource utilization and flexible implementation.
A national preparedness issue
Stone’s remarks extended beyond routine EMS operations to national preparedness. The organizations emphasized that the civilian blood supply is a national security resource and recommended stronger military-civilian collaboration.
They highlighted opportunities to develop products with longer shelf lives or fewer cold-chain limitations, including dried plasma and cryopreserved products, subject to regulatory approval. They also recommended joint preparedness exercises involving military organizations, blood collectors, hospitals and EMS agencies to evaluate supply capacity and operational arrangements during disasters and mass casualty incidents.
An opportunity for national EMS advocacy
The joint statement does not establish federal policy or mean CMS has agreed to change reimbursement. The organizations submitted recommendations for consideration by NEMSAC and federal agencies.
Nevertheless, their intervention creates an important opportunity for EMS.
Ambulance providers have long argued that reimbursement must evolve alongside their clinical responsibilities. A coordinated position from three major blood organizations adds another voice, specifically identifying the need for a separate payment mechanism supporting prehospital transfusion.
It also provides a potential foundation for collaboration among EMS associations, blood collectors, hospitals, clinicians and federal policymakers.
The immediate question is whether these recommendations will influence future federal advisories, reimbursement proposals and funding priorities. The broader question is whether the nation intends to fund prehospital transfusion as a sustainable healthcare capability or continue relying heavily on individual agency initiatives and temporary funding.
Prehospital blood transfusion offers the prospect of improving care for patients experiencing life-threatening hemorrhage. Its successful expansion, however, depends on more than enthusiasm, clinical protocols and equipment.
The blood community has made its position clear: if prehospital transfusion is to become a sustainable national capability, the systems responsible for supplying, safeguarding and paying for that blood must develop alongside it.
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