Report questions state ambulance policy

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A recent report from a Louisville-based policy think tank calls for the phasing out of the certificate of need requirement for ground ambulance services statewide and the immediate suspension of the requirement in Kentucky’s most populous counties.

Issued by the Pegasus Institute, the report – “Certificate of Need: Kentucky’s CON Regulations and Their Impact on Ambulance Care” – argues that the Certificate of Need application process, overseen in Kentucky by the state Cabinet for Health and Family Services, leaves counties with fewer ambulance providers relative to neighboring states and causes long wait times for ambulance service and emergency care in the state’s more highly-populated counties.

The state should also order an immediate comprehensive review of its entire certificate of need system, the report recommends.

“Measured against our neighboring states and regional peers, Kentucky residents have access to fewer providers, on average, at every county population level across the state,” the report states in its conclusion. “Wait times in Kentucky’s largest metro areas, which are the most underserved by the existing CON regime, reinforce that Kentucky’s ambulance CON laws, like most others tested by researchers and long ago recognized by the federal government, are not living up to their claims for justification.”

The report mentions that Warren County is served by one ambulance provider, which is owned by The Medical Center, and cites statistics showing an average wait time of 55 minutes for emergency services and an average wait time of 96 minutes for pain related to broken bones at The Medical Center, compared to respective wait times of 8 and 32 minutes at TriStar Greenview Regional Hospital.

Neighboring Logan County has three ground ambulance providers, and Daviess (Owensboro) and McCracken (Paducah) counties also have three providers.

“There is no community in Kentucky that appears more underserved than Warren County, whose EMS situation could easily enable a call for action across the entire state,” the Pegasus Institute report states.

A certificate of need issued by a state health care agency is required in 35 states for the approval of a host of medical services and facilities.

Several factors brought the regulatory system into place, including efforts to ensure adequate health resources, foster rural community access to health care, increase quality of care and keep costs manageable.

In Kentucky, 21 different services require state approval through a certificate of need, the 10th most in the country, but the state is one of only four regulating ground ambulance service through the certificate of need process.

The Cabinet for Health and Family Services reviews certificate of need applications.

Large projects are subject to a formal review to determine if the project is consistent with the Kentucky State Health Plan and also meets several other requirements, including financial feasibility, accessibility, impact on the costs of providing care and relationships with other services and facilities in the region impacted by the proposal.

Regarding ambulance care, the Pegasus Institute report relies on publicly available data, news reports and a survey of more than 20 mayors around the state to support its position.

Of the mayors surveyed, 41 percent responded that they believed their cities needed more EMS or ambulance services, according to the report. More than 70 percent of mayors polled said residents have complained about high costs of ambulance services, while paramedic shortages are a concern in western Kentucky.

The Medical Center EMS receives no public subsidies.

Wade Stone, executive vice president for The Medical Center, disagrees with the report’s conclusions.

Stone notes that the average response time for an EMS run by one of the hospital’s ambulances is 7 minutes, 21 seconds, comparing favorably to the national average response time of 8 minutes.

A third-party survey of Medical Center patients who have received EMS service showed that 97 percent of patients felt that EMS responded in a timely manner, Stone said.

“There’s an assumption in the study that the level of service meeting the needs of the community by an ambulance service is a product of the number of providers offering service in the community,” Stone said. “Our opinion is that it’s not a function of the number of agencies you have in the community, but a function of the scope of services provided in the community and the scope of resources they have to provide.”

The Medical Center EMS is one of six agencies in the state participating in a pilot program in community paramedicine, in which paramedics in the field see patients in their homes.

The agency also collaborates with ambulance services in neighboring counties by providing them with equipment that enables them to transmit to the emergency room vital information about heart attack and stroke victims in the field, Stone said.

“We feel very strongly that The Medical Center EMS provides a tremendous service recognized nationally and at the state level for its quality of service,” Stone said. “We don’t run our ambulance service to meet basic expectations.”

Elizabeth Cobb, vice president of health policy with the Kentucky Hospital Association, said the state health plan, which details how medical services are determined to be needed and figures prominently in the certificate of need application review process, is reviewed and updated annually.

The certificate of need program is also subject to frequent review based on quality of care metrics, updates in technology and other factors, Cobb said.

“From our standpoint, in regard to the certificate of need and state health plan, we believe that Kentucky has a moderate certificate of need program here in the state,” Cobb said. “We certainly don’t have the most services covered and it’s not considered one of the more onerous application processes at all in comparison with other states because we are updating it annually.”

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