Elements. Jane H. Brice SECTION

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1 Jane H. Brice Elements D SECTION Emergency medical services lie at a critical intersection of the healthcare system. Providing seamless, patient-centered care depends on those involved with EMS systems understanding and collaborating with public safety and healthcare organizations. The ability of EMS systems to work closely and knowledgeably with public health systems, centers, and government is crucial. EMS medical directors must understand how communications, injury prevention, information systems, and managed-care systems function. It is also essential to understand pediatric, regionalization, and diversion issues. This section will provide medical directors with important information on how these systems function and how EMS intersects with them in the provision of patient care. 457

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3 CHAPTER 42 Finance Jerry Overton INTRODUCTION It was not all that long ago that an EMS medical director or administrator could testify before a city council or county commission, ask the question, What is a life worth? and receive a positive response in terms of increased fiscal appropriation. However, with today s increasing demands on government, from funding education to repairing crumbling roads, the need for increased EMS funding could be ignored, or worse, denied. To be taken seriously by policy makers and administrators, it is imperative that EMS medical directors understand the economic dynamics of an EMS system. This chapter will serve as an introduction to EMS finance, its relationship to economic efficiency, and its impacts on clinical and operational realities of the EMS system. SYSTEMS FUNDING VERSUS SYSTEM FINANCE There has long been a misconception that federal and state governments fund the ongoing operation of EMS systems in the United States. Nothing could be further from the truth. Although all levels of government agree that EMS is important and needs financial support, the responsibility for the development of a specific system and how it is funded has been historically local. As a result, the ongoing operation of an EMS system is dependent on limited financial mechanism options, including tax subsidization, third-party reimbursement, and in some systems, contracts. However, as these systems were developing, the federal government did provide financial grants to regions that continue to impact both planning and operation, which will be explored briefly in this chapter. FEDERAL SYSTEM FUNDING With the publication of Accidental Death and Disability: The Neglected Disease of Modern Society, federal funding for emergency care started to become a priority. 1 Initial funds from the U.S. Department of Transportation were provided by Public Law , the Highway Safety Act of 1966, which funded EMS services through matching grant provisions to states. Funding was made available for EMS components such as ambulances, communications, personnel, and special demonstration projects and studies (Section 403). The Highway Safety Act of 1966 did not, except for in a few cases, stimulate development of organized EMS systems. However, these funds continued to flow to states for the provision of EMS training. As interest in emergency care increased, it became apparent that medical, pediatric, and other subspecialty patients would also benefit from a regionalized approach to emergency care. The Emergency Medical Service Systems (EMSS) Act of 1973 became the first comprehensive federal approach to supporting regional development of EMS systems. This act enumerated 15 mandatory components of an EMS system and served as a template for program planners. The EMSS Act of 1973 was designed to promote development of systems that were able to meet the individual characteristics of each community. 2 Total funding of $185 million over three years was granted to regional lead agencies, which would 459

4 direct disbursement of funds. Each region would have an average population of 700,000. Some 303 regions were initially created, although not all received funding each year. Funding was disbursed in two-year increments for the following: Section 1202 Feasibility Studies and Planning Section 1203 Initial Operations (Basic Life Support) Section 1204 Expansion and Improvement (Advanced Life Support) Section 1205 Research The level of funding expected to be needed by each regional agency for development of a successful and viable program was $1.5 to $1.75 million. Funding was apportioned so that 25% of all monies went to rural areas. On a per capita basis, regions received $1 for urban areas, $3.50 for rural areas, and $10 for wilderness areas to address the unique complexities of EMS care provision in less densely populated regions. The EMSS Act was amended in 1976 and again in 1979 to take the program from its inception in 1974 until its termination in Emphasis was placed on securing other sources of funding so that services would continue when federal funding ceased. With a shift in federal priorities, the concept of federal block grant programs was introduced during the Reagan administration. EMS was only one component, along with other programs such as rodent control and water fluoridation, and the decision on how funds were to be dispersed was left to the states. 3 Since allocations were in the form of grants with very specific targets, few states applied and even fewer were successful. As a result of limited options, the shift in emphasis by the federal government, and a lack of involvement by local decision makers, the ongoing development of the local EMS system faltered. STATE FUNDING While states provide a myriad of EMS functions, including training, licensure, and data collection, they also regulate and monitor local EMS operations and personnel. To be effective, financial incentives and disincentives need to be attached to the state EMS activities, but these unfortunately are lacking. State EMS offices face the same budgetary constraints as those in local EMS systems, and with 87% of their funds coming from a state budget, they too often face crisis. 4 Several states do provide limited funding opportunities for local EMS agencies in the form of special funding programs. Vehicle or driving license fees, motor vehicle violations, and special taxes have all been used to a limited success, but in these forms of special funding there is neither the intent, nor the dollars, to continually fund EMS. 4 That responsibility is local. EMS SYSTEM FINANCE To fully understand EMS system finance, it is a requirement to understand costs. To understand costs, three myths must first be dispelled. 1. Price does not equal cost. All too often, price or charge is used interchangeably with cost, but it is an extremely rare situation in which they are the same. Charge refers to the rate charged by the EMS agency as it attempts to be reimbursed for its services. Both Medicare and Medicaid reimburse far below the actual cost of providing the service. In a high-performance EMS system in Virginia, the cost per transport in fiscal year 2008 was $364.11, but reimbursement from Medicaid, the state-funded program for the medically indigent, was only $75 if the transport was five miles or less, even for a patient in cardiac arrest. (Richmond Ambulance Authority Budget, Fiscal Year 2008) 2. Direct cost does not equal full cost. To fully understand the economics of an EMS system, all costs must be identified. While labor, fuel, and medical supplies can easily be calculated, such costs as legal support, external billing agency services, and even dispatch, if done by an ancillary agency, need to be included in the overall economic analysis. 3. Higher government support does not guarantee superior performance. System design, predetermined response time requirements, and defined clinical standards in an economically efficient environment often provide a higher level of overall performance. 5 THE COST OF EMS It is no myth that the cost of EMS is driven by the cost of labor. Approximately 60 65% of all costs associated with providing service were vested in the wages of the 460 SECTION C EMS Personnel

5 paramedics and EMTs in 1994, a time when shortage of personnel was not an issue. 6 It is now 14 years later, and today it is estimated that this amount approaches 80%. Employment of the workforce is one of only two major variables that drive cost; the other is the strategic deployment of resources. Every EMS system takes into consideration response times, whether there is a mandate to require a specific time, a goal, or only recognition that it is clinically significant. The cost of deploying those resources is the cost of readiness, and in this lies most of the cost of EMS. 7 Responsible EMS administrators and medical directors recognize that if an impact is to be made on morbidity and mortality, response time goals must be established and achieved. To accomplish this, a strategically deployed distribution network is established. This network is unique in that production capacity must always exceed demand. The reason is simple: EMS is a timedependent delivery service. Other time intervals of an EMS response and transport including the length of the trip, unless that EMS agency is rural have little impact. This was recognized by Medicare with the implementation of its fee schedule when it set the reimbursement level for emergencies approximately 60% higher than for interfacility transfers. 8 To fully understand costs, it is necessary to grasp several commonly used terms. The following will assist in accurately determining the full costs to the agency. Full Cost The total direct, indirect, and shared costs of a particular service or product. Direct Cost A cost that can be traced specifically to a particular service or product, including costs for items or services that are provided by or shared with a parent hospital, government agency, corporation, or other operating division. Direct costs include operations labor, vehicle and fleet maintenance, medical supplies and equipment, and medical communications center equipment. Indirect Cost A cost that cannot be traced specifically to a particular service or product, including costs for items or services that are provided by or shared with a parent hospital, government agency, corporation, or other operating division. Indirect costs include administrative labor, building and facilities, and administrative support functions such as accounting, legal, billing, payroll, purchasing, human resources, marketing, public education, quality improvement, training and education, risk management, information technology, taxes, interest, performance penalties, performance security, medical director fees, accreditation, and other administrative and operations costs. Shared Cost A cost that is provided by, or shared among, one or more operating divisions or departments of a hospital-based, governmentbased, or multi-jurisdictional provider. Shared direct costs include items or services such as loaned vehicles, loaned medical equipment, shared fleet maintenance services, and shared medical communications center services. Shared indirect costs include items or services such as shared facilities, shared management functions, and shared administrative support functions. Marginal Cost The direct cost of producing one additional unit of a particular service or product. 5 It is important that both the EMS administrator and medical director understand that direct costs for vehicles and medical equipment can be depreciated for what is termed useful life, or the predetermined replacement schedule. For example, if the clinical decision was made by the medical director to implement intraosseous infusion technology, it might appear expensive because of the initial outlay of money for the powered drill for each ambulance. However, when divided by the number of years the drill would be in service, that dollar amount drops significantly. When working with direct costs, planning and budgeting must be inextricably interlinked. ANALYZING COSTS AND THEIR IMPACT ON PRODUCTIVITY The old axiom, Nothing in life is free certainly is applicable to EMS. As the medical director and EMS administrator learn more about the costs of the system, it becomes easier to understand the concepts of productivity and economic efficiency. The concepts of cost, productivity, and efficiency and the formulas with which to calculate each follow. Cost Per Capita Cost per capita is determined by dividing the total system cost by the total population served. 10 Although cost per capita is not an indicator of efficiency, it is CHAPTER 42 Finance 461

6 considered key to policy makers as an indicator of overall costs to the community. Note, for example, the high cost per capita for Richmond, Virginia. In 2006, Richmond had a population of 200,000 but one of the highest per capita transport rates in the country. Unit Hour Utilization The basic measurement of efficiency in EMS is the Unit Hour Utilization (U/UH) ratio. This measurement has become the standard for determining effective deployment strategies, response patterns, unit and system productivity, and even scheduling practices. To understand the importance of U/UH, one is required to have a basic understanding of the unit hour concept. A unit hour is defined as a fully equipped and staffed ambulance on a response or waiting for a response for one hour. Direct labor costs comprise more than 75% of the total costs of the average unit hour. The other 25% consists of the system infrastructure, including dispatch, administration, vehicles, equipment, and overhead. As a result, the cost of a marginal unit hour, or adding a unit to the existing schedule, is approximately 50 60% of the total unit hour costs. Unit hour costs are affected powerfully by economies of scale. For that reason, they are a poor predictor of clinical quality and cost per transport. Only when the unit hour is productive does the cost to the system begin to decrease. That productivity is termed utilization and is defined as how frequently the unit hour is used. Unit Hour Utilization is the measurement that results from dividing the utilization by the number of unit hours produced in a given time period. The equation for U/UH is as follows: U (Utilization) Unit Hour Utilization UH (Unit Hours) High-performance EMS managers use this ratio to measure the productivity of different actions within the system. The most commonly measured action is FIGURE SECTION C EMS Personnel

7 transports, but the productivity of responses, patient contacts, post-to-post moves, and workload also can be calculated by this equation. The U/UH is higher in urban areas because more patients are served in a smaller geographic area. 11 Cost for Patient Transport After the U/UH for transports has been calculated, the cost per transport can be determined. By using the following equation and dividing the cost per unit hour by the U/UH, the true cost of transporting a patient, not the revenue received per transport, is yielded: Cost per Unit Hour Cost per Transport U / UH Such calculations are crucial in revealing the powerful impact of economic efficiency in EMS system design. For example, if the full cost of placing a fully equipped ambulance in service is $100 an hour (cost per unit hour) and a patient is transported once every three hours (U/UH), the cost per transport is approximately $300 ($100/0.33). If a patient is transported once every four hours, the cost climbs to $400 ($100/0.25). While it may be unrealistic to assume that productivity in any EMS system can increase from one patient every four hours to one patient every three hours, it is not unrealistic to assume that productivity can increase by eight minutes. If a patient were transported every three hours and 52 minutes, the cost per transport would decrease to $370 ($100/0.27). Although the $30 savings per transport might seem insignificant, the savings accumulate when multiplied over a large number of patients. For example, an EMS system would save $360,000 each year based on 12,000 patients transported annually. High-performance EMS managers not only understand the importance of these calculations and the power of results but study comparisons with similar systems to ensure that they are achieving at least equal or better service, at lower cost, as those systems. Table 42.1 provides such a comparison of the highestperforming systems in EMS. 11 Again examining Richmond, notice how it has now gone from having the highest per capital cost to having a per transport cost that equals the median. EMS in rural America presents a special challenge in examining costs. Clearly, because of their required geographic coverage, examining costs cannot be efficient. According to a study by the U.S. Government TABLE 42.1 Economic Efficiency System Cost per Unit Hour Accountability Office (GAO), volume, or the lack thereof, was the key factor driving costs. Contrary to urban EMS, which can add increased unit hours at marginal cost, any excess capacity must always be available, which means that the cost of readiness is funded by fixed costs. With fewer responses and transports, costs cannot be spread (as was discussed previously with the Richmond system) and the average cost per trip is much higher. The GAO found that a rural system with three or fewer transports per day had almost double the cost of a system with nine to twelve transports per day. 12 (Table 42.2) THE CHALLENGE OF REVENUES Unit Hour Utilization Cost per Transport Clark Co. $ $ Davenport $ $ Ft. Wayne $ $ Ft. Worth $ $ Kansas City $ $ Little Rock $ $ Mecklenberg Co. $ $ Nova Scotia $ $ Oklahoma City $ $ Pinellas Co. $ $ Reno $ $ Richmond $ $ Tulsa $ $ Mean $ $ Median $ $ When patients are injured or sick and require the services of emergency medical personnel, they give little thought as to how the providers will be compensated for their care. However, reimbursement is a topic of considerable importance to EMS administrators and medical directors who must cope with a complex reimbursement environment that seems to change constantly, and ensure that patient clinical needs are met. EMS systems receive revenue from tax subsidization, third-party reimbursement, patient payment, or a combination of the three. The sources of reimbursement for EMS are finite and include Medicaid, Medicare, CHAPTER 42 Finance 463

8 TABLE 42.2 Relative Cost Per Trip for Full Cost Ambulance Providers, Providers average number of total trips per day (range) 3 or fewer to to Source: Project HOPE. Cost per trip relative to the average for providers with 9 to 12 trips per day private-paying patients, commercial insurance, and (in some systems) contracts with managed care payers or other payers. In systems responsible for responding to emergencies, patient demographics create an environment in which Medicaid and Medicare typically make up the bulk of reimbursement. Medicare Medicare is a federally authorized, regulated, and funded program that provides healthcare coverage for persons age 65 and older, which is administered by Medicare carriers. Established by the Social Security Act of 1965 (also known as the Medicare Act), its purpose was to pay for medically necessary ambulance transportation only, unless contraindicated by other means. Modern EMS systems, clinically relevant response times, and life-saving clinical interventions had not yet been anticipated, as it was not until the next year (1966) that the landmark document Accidental Death and Disability was published. As a result, the Medicare Act did not anticipate the need of coverage for the cost of readiness, paramedics and the training of paramedics, advanced life support, medications, and the sophisticated equipment that are now all integral parts of EMS. This funds insufficiency has become exacerbated by the rapidly rising population of the elderly, as Medicare can represent more than 50% of the revenues required of an EMS system. 7 The greatest recent impact on EMS reimbursement was the implementation of the Medicare fee schedule for EMS transports. This fee schedule was, in part, the result of the rapid increase in Medicare expenditures for basic and advanced life support that had occurred over the past 15 years. Another catalyst for changing Medicare fees was a series of GAO reports on the potential for fraud and abuse in EMS and private ambulance systems, focusing on the use of ambulance transportation for medically unnecessary, nonemergency cases. A third reason for change was the lack of uniformity among Medicare carriers in program administration and reimbursement rates. Finally, for many years, ambulance transportation was the only service not on a Medicare fee schedule; it was reimbursed at fee-for-service rates, which varied widely across the country. In the Medicare fee schedule, national relative value units (RVUs) have been established, which vary depending on the level of service provided, from basic life support (RVU 1.00) to advanced life support level 2 (RVU 2.75). The national reimbursement rate is then based on the RVU multiplied by a National Conversion Factor (NCF), which is a set dollar amount ($ for 2008) adjusted annually by inflation. A regional cost index is multiplied by the conversion factor to determine 70% of the local base rate, with the remainder being 30% of the national conversion factor. The actual national reimbursement for ambulance transport under the Medicare fee schedule, as of December 2007, is shown in Table Since mandatory assignment is part of the rule, EMS systems have no choice but to accept the proposed fees. As implemented, there were more losers than winners under the Medicare fee schedule. The large number of losers is primarily due to the high percentage of Medicare patients served by EMS. In a typical system, 40% of billings are for Medicare patients, 20% TABLE Ambulance Fee Schedule. Service Level NCF RVU Unadjusted Base ALS $ ALS-1E $ BLS $ BLS-E $ ALS $ SCT $ SECTION C EMS Personnel

9 for Medicaid, 25% for private pay, and 15% for commercial insurance or managed care. However, EMS providers, like other healthcare providers, have been shifting costs to make up for patients who cannot or do not pay. Thus, in a typical system, 55% of revenues come from Medicare patients, 15% from Medicaid, 5% from private pay, and 25% from commercial insurance or managed care. (Figure 42.2) The situation regarding the problems posed by the Medicare fee schedule was the subject of another GAO study, and the problems were validated. The GAO examined different levels of service and found that, compared to the definition of costs as formulated by the GAO, Medicare was failing to cover costs by an overall 6% margin. 14 (Table 42.4) Medicaid Medicaid is the other federal program that was established by the Social Security Act of Federally and state funded and administered by the states, the program is designed to provide coverage for the medically indigent and special-case patients. Medicaid is typically lumped with other transportation providers and lacks constituency. Whether it is used for EMS or eligible recipients other medical needs, Medicaid is not a priority for funding by state governments. The service is in danger of state budget cuts as deficits rise and the need for infrastructure improvements increases. The rates are set by the individual states and often are less than one half of the full cost of providing an EMS transport. 15 FIGURE 42.2 Payor Mix by Billings (left) and Payor Mix by Collections (right). TABLE 42.4 Expected Average Medicare Margins under the National Fee Schedule for Providers without Shared Costs in 2004 Dollars. Providers predominate service area Payment under national fee schedule Average cost (95 percent confidence interval) Providers average Medicare margins in percentage (95 percent confidence interval) Urban $350 $370-6 (326 to 414) (-18 to 6) Rural (354 to 465) (-13 to 12) Super-rural (448 to 628) (-35 to 2) All (381 to 450) (-14 to 2) Sources: GAO analysis of 2005 GAO Survey of Ambulance Services and 2004 Medicare claims. CHAPTER 42 Finance 465

10 Commercial Insurance Commercial insurance is the third major category of payers and provides varying rates of reimbursement. Some companies and policies provide full coverage, but others do not recognize the sophistication of care or the impact of EMS and reimburse for transportation only. Uninsured and Uncompensated Care With more than 45 million Americans uninsured, uncompensated care represents a tremendous challenge to the prehospital care community. 4 With limited ability to shift costs, a moral and legal responsibility to respond, and the increase in gatekeeping activities, it becomes imperative that EMS administrators responsibilities include sharing an accurate calculation of uncompensated care with decision makers as they determine the amount of tax support, if any, the EMS system is to receive. FIGURE 42.3 System Cost/Ambulance Fee Tradeoff Analysis. A TOOL FOR DECISION MAKERS Once all costs have been identified, a useful tool for EMS administrators and medical directors is the System Cost/Ambulance Fee Trade-off Analysis tool. 5 The purpose of the tool is to provide policy makers a visual understanding of the system s financing and to allow them the option of determining the payment mechanism for the current system, projecting the future impact of any improvements, and anticipating how those improvements will be paid for. To plot the subsidy-price trade-off line for the ambulance component of a system, obtain or estimate total payments for all emergency and nonemergency ambulance service costs from all sources (local tax support, patient payments, private third-party and HMO contract payments, Medicare, Medicaid, contributed services). Divide that total by the population of the primary service area (that is, find the total system cost per capita regardless of how the system is financed) and plot the result along the horizontal axis at the bottom of the chart. This point one of two points along the system s analysis tool line defines the amount of annual subsidy per capita that would sustain the system without revenue from any other source. Next, estimate the current total average bill, or fee, for ambulance service in the service area. Note that number. Next, estimate the current per capita per year local tax support of the system s ambulance service component. Using these two numbers (the current total average bill and the current per capita per year tax support), locate where the current total average fee intersects the current per capita tax support and plot the spot within the chart. This point defines the system s current actual position on its support/fee line, the second of the two points required to draw the system s current tax support/fee line. Connect the two marks, extending the left end beyond the plotted point so that it intersects the vertical axis. The result is the System Cost/Ambulance Fee Trade-off. Figure 42.3 provides data from six highper for mance EMS systems. This chart will assist EMS system leaders as they make comparisons and develop their own System Cost/Ambulance Fee Trade-off Analyses. The line represents the financial decision that must be addressed by policy makers. At any point along that line, the decision can, or must, be made as to how much the local government will contribute to EMS as compared to how high the rate must be to cover expenses. With both Medicare and Medicaid reimbursement now fixed by assignment requirements, rates will rise much higher to cover costs as insurance becomes the only payer to which the system can shift costs. 466 SECTION C EMS Personnel

11 THE FUTURE AND ECONOMIC EFFICIENCY This chapter began with the dismissal of the question, What is a life worth? in the search for funding of EMS systems. With the rapid state of change in EMS and an uncertain future looming ahead, EMS medical directors and administrators must understand two important points. First, EMS systems are in trouble. This was recognized and documented in the recent Institute of Medicine (IOM) report, EMS at the Crossroads. Understanding both the cost of coverage concept and the archaic funding mechanism under Medicare, the IOM recommended that the Centers for Medicare and Medicaid Services convene an ad hoc working group with expertise in emergency care, trauma, and EMS systems to evaluate the reimbursement of emergency medical services and make recommendations with regard to including readiness costs and permitting payment without transport. 4 Second, systems must change. This chapter referred several times to high-performance EMS systems, which according to Stout and Gunderson, are defined as systems that share key features of system design rarely associated with less cost-effective systems: Sole provider Control center operations Accountability Revenue maximization Flexible production strategy System Status Management (SSM) All high-performance EMS systems share the understanding that economic efficiency, response-time reliability, and clinical performance are directly interdependent. 11 Those systems, along with several other system designs, focus on performance; that will be key if EMS is to survive. Options are limited. One option that is not available is raising rates. Mandated assignment for Medicare and Medicaid mean rate increases are essentially meaningless, because systems are limited in the ability to shift costs to other third-party payers. Additional Subsidization For some systems, additional subsidization is an option. This option may be rare, however, as local governments are finding tax levies at the maximum, infrastructures crumbling, and services dwindling in the face of competing budgetary priorities. Service Alternatives To stay afloat, systems may need to explore various service alternatives. Since personnel costs account for about 75% of the total unit hour in a system, administrators will be looking at ways to cut these costs, perhaps by staffing the ambulance with one paramedic and one emergency medical technician, rather than with two paramedics. Integrated transportation models that shift nonemergency patients to less costly modes of transportation or allow treatment of a patient at home are an option, but they might not be feasible if providers are paid only when the patient is transported. Administrators are likely to focus on decreasing the number of nonemergency transports while increasing emergency response times. To save money, an increase in the emergency response time is likely to be considerable. However, deviating from a nationally recognized standard may be detrimental to patient care and clearly jeopardizes the possibility of a positive outcome for those in emergency situations, such as cardiac arrest patients. Deferring capital purchases is another costsaving mechanism, but it is one that would force providers to work with older and less sophisticated equipment. Improved Productivity Efficiencies Changes in the systems, with an emphasis on functioning more economically, are needed. Improved efficiency is a goal that should be a joint effort of both administrators and medical directors. However, it will be incumbent upon the EMS administrator to secure the confidence of local governmental officials, which will allow the reinvestment of any system savings back into the system. SUMMARY While EMS finance is perhaps not the most interesting of topics to the EMS medical director, it is one of the most important. Today s EMS systems are facing numerous and diverse priorities and expectations, many of which are in competition with one another. Whether directly or indirectly, these priorities will involve financial resolution. The medical director needs to be an informed decision maker who is ready to handle any proposed or implemented solution. CHAPTER 42 Finance 467

12 REFERENCES 1. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: Division of Medical Sciences, National Academy of Sciences-National Research Council; Sept Boyd DR. The History of Emergency Medical Services Systems in the United States of America. In Boyd DR, Edlich RF, Micik S: Systems Approach to Emergency Medical Care. Norwalk, VA: Appleton-Century-Croft; Swor, RA. System Funding. In Kuehl AE, ed: Prehospital Systems and Medical Oversight, ed. 3. Dubuque, IA: Kendall/Hunt; Emergency Medical Services at the Crossroads. Washington, DC: Institute of Medicine of the National Academies; Community Guide to Ensure High-Performance Emergency Ambulance Service. McLean, VA: American Ambulance Association; Stout JL. System financing. In: Roush WR, editor: Principles of EMS Systems, 2nd ed., Dallas, Texas, American College of Physicians; 1994, pp Mohr P, Cheng M, Mueller C, Good C. Findings From the 1999 National Survey of Ambulance Providers. Bethesda, MD: Project Hope Center for Health Affairs; March Centers for Medicare and Medicaid Services. Medicare Program; Fee Schedule for Payment of Ambulance Services and Revisions to the Physician Certification Requirements for Coverage of Non-emergency Ambulance Services; Final Rule. Washington, DC: Department of Health and Human Services. In Federal Register 67, no. 39 (2002 Feb 27): Overton J, Dean S, Edwards D, Andresen D. The International EMS Benchmarking Study: A Comparison of System Design and Performance. With Krafft T, Fischer M, Garcia-Castrillo Riesgo L, Lippert F, Overton J and Robertson-Steel I: European Emergency Data (EED) Project. Richmond, VA: Coalition of Advanced Emergency Medical Systems; Overton J, Stout J. System design. In Kuehl AE, ed: Prehospital Systems and Medical Oversight. National Association of EMS Physicians, ed 3. Dubuque, IA: Kendall/Hunt; United States Government Accountability Office. Ambulance Services. Medicare Payments Can Be Better Targeted to Trips in Less Densely Populated Rural Areas (GAO Report GAO ). Washington, DC; United States Government Accountability Office. Ambulance Providers. Costs and Expected Medicare Margins Vary Greatly (GAO Report GAO ). Washington, DC; Werfel D Medicaid rate survey. McLean, VA: American Ambulance Association; 2002: SECTION C EMS Personnel