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FOR RELE/\SEONDELIVERY [XPECTCD AT 9: 30 A .ti. EST JANUARY ?.3, 1976 DIRKS[IJ SEtlAlE OFFICE BUILDIIIG
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GREGO~YJ. J\IIART, DIRECTOR MANPOv'ERAtlD\•;[LFARE DIVISION
B[FOR[ SUECOMMJTlEEOtl HE/\L T:I CO~'.liiITT[E Oil LM30R /\NO
PUBLI C v/[LFARE U.S. srnATE
ON THE EMERGENCY MEDICAL SERVICES
SYSTEMS ACT OF1973
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.._:·.-<· .-· . Mr. Chair man and members of the Subcommittee, I am pleas ed to
appear here today to participate in your hearin gs on S. 2548, S. 2673,
and S. 2011 to extend the authority for the emergency medi cal services
: (EMS) program, \llhich was authorized by the Emergency Medica l Services
Act of 1973. vJe have just completed our field work on a revie1,,1 of the
program and plan to is sue a report to the Congress on progress and
problems being experienced in developing re~io nal EMS systems.
Our review covered the activ iti es of 12 EMS grantees who received
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syste ms in their geographicnl areas. Three of the 1?. 9rantr.es were
[MS dc111onstrationproject~ funded prior to enactment of the 1973 act.
Our field work at grantee locations was completed in December.
FEOERJ\L ROLF.1N [MS
provided to local communities on a fragmented basis. Eleven Federal
programs, primarily in the Department of Transportation (DOT)and
th e Department of Health, Education, and Welf are (HHJ), provided
fundi ng of over $122 milli on between 1966 and 1973 for various EMS
components, such as ambulances, communicationsequipment, and training
. of attendants. In additi on, several other Federa l programs have
indir ectly supported EMScomponents. However, the Federal programs
had not been coordinated for development of comprehensive regiona l
EMS sys-';ems. . .
.. The Congress enacted the 1973 act to specifically provide assis -
:·tance for and encourage the development of comprehensive area emergency
medica l services systems. Program appropriations were $27 milli on in
.,.fi scal year 1974, and $37 mill ion in fiscal year 1975. Under continuing
· re sol ution funding authority , $37 milli on is available for fisca l ~ar
,1976. To date , more than 200 grants have been awarded for planning,
establishing, and expanding ms systems.
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I :. Suffici ent data is available t.o sh01·1 that , \'lith the aid of Federal
funds authorized under the act, communities t hroughout the country have
been abl e to upgrade tr.ei r EMSresources. Better equipped an•bul ances
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have been purchusec.l,hospi ta l e111ergencydepartments and other treat men
cente rs have procured equirm~nt to l,cttcr diagnose and tr e«t those in
need of emergencymedical services, ond more people have been better
tr ained to provide emergency medical services . He believe it ·i s fai r
to assume -that the increased capability to provide EMS has resulted in ~
some decrease in mortality and dis ability . In addi tion , through the
fede rall y funded programs, there appears to be i ncreased awareness of
· and i nterest in EMSthroughout the Nati on.
PR08L[l1S
However , probl ems are being experienced in estab l ishing and
operat'ing systems on a regiona l basis and HEWneeds to imrrove
coordination amongFedera l agencies th at have orograms concerned with
EMSsystems. Problems being experi enced ' by th~ regional ~ management ~
·· ent it ies will become more crit i cal when Federa..l funding , as call ed for
in th e act , stops . .
. . : . The systems being pl anned and developed encompass various local
governmental jur i sdictions and provider service areas. The act and
implementing guidelines provide for ~ringing together existing
resources i nto a regiona l syste m operated direct ly or indirec tl y by
a s ingl e management entity. The act requires that the n@nagemententity
have sufficient authority and resources to provide effective syst em
admi ni str ation . Either pr ivate nonprofit groups are being organized,
or exist in g governmental administr ative entities, such as State
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or county health depart ments or councils of government arc being
dcs iunuted as the management entity.
Lack of regional control ove-r-·systemf i nanc 1nq
Regional management entities are havi ng difficulty i dentifying
fir m sources of permanent financ ing of administrative and operating
costs that are being initia ll y borne by Federal grant funds. - In - _addi tio n, they have l ittle contro l over the l evel of emergency medica l
services being provided by loca l governments and EMS provi ders .
The act provides for E~S systems to be administered by public or
nonprof i t private entities which have the rescurces to provi de effective
system administration for the estab l ished regi on. The reg ional systems
shoul d be of adequate size to provide the financia l base for the establish­
ment and conti nued operation of services ~lithout cont i nued Federa l
fin ancia l support . ·'
Most of the admini strative costs for these entit ies are being initia ll y
fin anced wit h HEW grant funds. Most of t he costs of providing EMSser­
vices are being borne by local governments and private EMS providers .
However, some of the operati ng costs to achieve regionalization of EMS
deli very and upgrading of services (centra l communications li nes or towers ,
prin t i ng of standard record forms, equipment purchases , etc . ) are being
· fin anced with Hn/ grant funds .
Under the program a grantee can receive up to 5 years of support .
The regional EMS management entities must re ly pr imaril y on local governn:ents
for conti nued f i n,1ncia l support for thei r recurr i ng administrat i ve costs
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and costs for operating the system at tile level planned or estab li shed
with grant support. Firm co,mnitments of such support are not being
obtain ed. Without such com111it ments, advances made in the development
of EMS systems \ttith Federal funds could be l ost .
At one of the projects visit ed, a primary objectiv e was to establ~sh ' an advanced li fe support rescue syst em. Rescue teams were to be train ed ·
and equipped throughout the region. Operating costs .for the rescue teams
··were to be borne by the 1 oca 1 governments or providers . Whi 1 e we were
vi siting this project, a ref erendum on whether to support the operat ing
costs of the rescue teams was defeated in the l argest city in the region.
Another project, which received HEH funds through an [MS demonstration
contract as well as the EMS Act, subsidized the costs of (1) hospital
emergency depart me;nts and co1M11.mity ambulance ser vices, (2) .a regional
-·t el ephone communications system, and (3) regiorial system admini stration,
in clu di ng data collection . •·. ! ,
When the demonstration contr act ended, the county governments .
appropriated sufficient local funds to cont i nue operating the emergency
departments and ambul ance serv i ces ~t the l evel achi eved under the
demonstration contract. EMS grant funds were made ava i1 ab 1 e to continue
the regional telephone communication system, dat a collection, and system
management. The l ocal governments have made no commitments to fund
such activitie s , even though the project is in its final year of
eligibilit y for grant support under th i s program. These components are
essenti al for maintaining a regional syst em as call ed f6r in the act.
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Regional mana~enient entities are finding it difficult to control
the manner in which EMS systems are being planned, established, or
expanded. Most r egional management entities are assuming a coordinating
a·nd advi sory role rath er than the strong regional management and
operational role envisioned in the act and HEW guidelines. Because of
. t heir responsibility for, and financia l i nterest in, the provision of
emergency health services, loca l governments and EMS providers are
rel uctant to re l inquish management and operational control of their
resources to the system' s designated management entity . Problems
simil ar to the following are bei ng encountered in controlling trans­
portation, facilities, and communication systems.
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s t andards relating to design, perforn~nce, and equipment. Local
governments and E~S providers are reluctant to relinquish any control
over their transportation resources to regional management entities .
Consequently, except for vehicl es purchased with HEW funds, the regional
management entit ies have had little · influence over the numbers and
placement of vehicl es in the region . At one project visited , the
r egional management entity determined that , with proper placement
t hroughout the region, 69 emergency ambulances were needed to serve
the popul ation. There were 125 ambulances scattered throughout the
region but the milnagement c:ntity has no authority to reduce in number
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or r el ocat e the ambulances. Similar ly , at other projects additiona l
ambulances were being purchased or pl anned for purchase ~Jithout con­
si der ing the need on a regional basis .
At another project, the devel opment pl an provided for a computer
aid ed dispatch system which woul d al low cent ral di spatching of the
closest , most appropriate emergencyvehicl e . Several provider s
objected to hdving their vehic1es centra l ly dispatched and one county ,
aft er l ear ni ng about the loss of resource contro l, withhel d payment
of it s fin ancia l pledge and refused to all ow i ts ambul ances to operate
outsi de county boundari es except in di saste r situat i ons. The reg ional
management entity incurred si gnificant impl err.entation delays whil e
atte mpting to r evise t he r egional plan to make it acceptab l e to the
parti ci pants .
Facili t i es: The act provides for EMSsystems to i ncl ude an
adequat e numberof eas il y accessib l e emergency faci li ties which are
coll ectiv ely capabl e of providing services on a continuous basi s wi thout
dupl i cati on and \'lhich meet appropriate standards r el ating to capacity ,
l ocati on, personnel, and equipment.
Since hospi ta l emergency faci liti es are controll ed by ei the r l ocal
governments or ot her publ ic and pr ivate organizations , the regiona l
management entities have done l itt l e to eliminate dupl ication of
faci l ities or to adjust the ty pes of available serv i ces. Also, few
regi onal managemententities have negotiated patient trans fer agreements
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as provided for in the act . Therefo•rc , they have no assurance that
all pat ients will rece i ve appropriate care and services as required.
Conmrunications: The act provides that the personnel, faci li t i es ,
and equi pment of the system be join ed by a centra l communications
syst em. The system should incl ude a command and contro l cente r ~hich
woul d be responsible for all ocating r esources for the most effect i ve
-del ivery of services in the regi on.
Most regional management entitie s are not proposing cent ra l
communicat ions systems which would include a centra l command and
contro l center th rough whi ch all system resources wi ll be control l ed. .............. . .
Several are i cat i ons system which will _.,·~proposing to estab li sh a commun ..,
li nk t ogether all system resources and other publi c safety agencies.
-Al though this i s an advance, system access, di spatc h, and resource
contr ol will remain a l ocal function and responsibi li ty , result ing
i n the benef it s of centra l communi cat ions not being ful ly real i zed.
Standard medi cal recordkcepin9 and patient outcome evaluation have not been implemented
Regional management enti ties have not been able to impl ement
stan dard recordkeeping systems. Consequently , pat i ent outcome
evaluat ion procedures \'ihich \'/Ould permit measurement of system impact,
have not been estab li shed.
HEW program guidelin es require that regiona l systems provide
for a st andardized pat i ent recordkeeping system \'1hic h cover s patient
tre atment fron1 initia l ent ry i nto the system t hrough di scharge .
Informati on coll ected through the standardized recordkeeping system i s
to be used i n eval uat ing system per for111ur.ce.
As di scussed previously , re9ional rnanagemer.tentities have l itt l e
control over EMSresourc es . Therefore, ambul ance services, emergency
rooms, and hospita l s are not required t o provide infor mation to the
regional managemententities. Someentiti es , however, have been abl e
to impl ement standard recordkeeping for ambul unce services and emergency
rooms thr ough (l) agreements required of the providers rece iv i ng HEH
funded EMSequipment, (2) vol untary provider partici patio n, and (3)
other persuas ion.
Noneof the projects visited have been abl e to imple ment standard
record keeping systems for hospit al tre atment beyond th e emergency '
depart ment. Few of the r egional management entit i es have been able
to get access t o pati ent records as part of a rout ine data coll ection
effort. Grant ees told us that hospit al adminfst rat ors and doctors
are very rel uct ant to r el ease patient records because of pati ent
confid entia li ty and because of fears of mal pract i ce suits which
mi ght result fr om subsequent data eval uation .
Data gathered from ambul ance run reports and emergencydepartment
record s are being used only to evaluate response ti mes and qualit y of
init i al care. Without trackin g patients through t hei r ent ire per iod
of care to determine the ir outcome, the effect of the EMS system cannot
be fully measured . Some grantees fee l that EMSoutcome evaluati on may be
impracti cal if not impossibl e because of (1) hi gh cost , (2) l ack of
base data, and (3) manyfactors other than emergency services th at can
affect patient outcome.
Because of grantees ' inability to obtain firm participant commit­
ment and exercise contro l over syste1n resources , regional EMS syste ms
as call ed for in the act are not being established. If firm participant
conmitment and contro l over system resources does not occur when the
EMS grants expire , regional systems development will stop and advances
_made i n developing regional systems may be l ost.
COORDIN/\TJON PROBLCMS AMONG FEDERAL AGENCIES
Vari ous Federal agencies administer programs whi ch relate to one
or more aspects of EMS system development. Coordinati on among these
agencies is limi ted . Therefo re , appli cants for devel opment assistance
may not be receiving the ful l range of Federal assistance avail able.
The act provides for HEWto take the l ead rol e in promoting
coordinat i on of system development efforts wi th Federal funds . It
provides for HHJ to estab l ish an lnteragency Committee on EMS. The
Committee is respons i ble for promoti_ng the exchange of information
necessa ry to maintai n a coordinated and effective devel opment program.
The act further provides for HEWto consi der the funding avail able to
applic ants fro m other Federal programs in making grants under the act .
~lth ough the EMS ftct was passed in November 1973, the lnteragency
Commit tee did not meet until December1974, and did not form working I
groups unt il March 1975. At the time of our f ield work, . t he Comnittee
had i ssued no coordination guidance or direction to the Federal regional
of f ices. Consequently, Federal regiona l personnel and potential grantees
are left to the i r own devices to identify and coordinate the use of
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Fed<:'ral funds for EMS. As pointed out by one grantee , l ack of a\'1are­
ness· of other programs 111ight huvc caused them to miss other funding
sources .
In addition t o th e EMS grantees , other organizations i n some
regions r eceived funds for EMSact i vities fro1n severa l Federal funding
sources. Use of Federal funds by many of these organi zations was not
•controll ed by or coordinated \'1ith the desi gnated [MS system management
·entit y and may impede rather than st imul ate regional systems development.
Coordinated use of Federal funds for EMS does not appear like ly ,
without support from the var ious Federal agenci es . .
Mr.Chairman, we have met with Subcommittee staff and discussed
severa l possib l e changes ir the legi sl ation which may help overcome
the probl ems \'te have discussed . Thi s concludes our state ment . We
shall be happy to answer any quest ions that you or other members of
.. . th e Subco1m1ittee mi ght have.
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