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By Mike Williams
President, The Abaris Group
Walnut Creek, CA
The Office of Inspector General’s (OIG’s) published proposed safe harbor for ambulance restocking (Fed Reg 65(99):32060-32065 [May 22, 2000]) and a recent separate final safe harbor (Dec. 21, 2000, OIG Advisory Opinion 00-9) has created some controversy about its intent and limitation. I believe hospital emergency departments should be out of the business of resupplying ambulances.
The safe harbor makes it clear that the OIG considers it improper to restock ambulances at a discount or for free unless the arrangement meets seven very specific conditions set forth in this safe harbor. (There are several other safe harbors published by the OIG on this subject during the past two years). Not only is it considered improper by Medicare to restock ambulances at a discount or for free, it is unnecessary.
Hospitals began many years ago providing support services for ambulances and their staff. Some of the early support was necessary to establish and monitor prehospital programs. During the 1970s, early paramedic programs received key services from hospital coronary care units (CCUs) to mobile intensive care units. Yes, in these infancy days of paramedic programs, many paramedics received their training, medications, and even on-line direction from CCUs. Quickly, these programs matured to developing links with professionally run EDs, where the paramedics and some EMTs received instructions from ED physicians or mobile intensive care nurses.
In these early days, the only place a paramedic ambulance company could obtain its medications and supplies was from these EDs. Because these programs were so new, there was also a need to provide more direct supervision. Resupply was one way to do this.
I also remember when sandwiches and drinks were made available to me in the ED and resupply was another way to "attract" ambulances to use a particular ED when there was a choice. Frankly, it worked. During my early days in EMS, I, like many other EMTs, worked hard and got paid little. Often my lunch or dinner depended on whether the hospital ED had food for us. Ambulance resupply was just another excuse to go to that ED even if we did not have a patient.
A lot has changed since then, but I am sorry to say there are still EDs out there trying to attract ambulances to bring patients to them. I am not talking about good customer service or strong clinical links; I am referring to incentives designed to induce.
Paramedic and EMT-run ambulances have other ways to legitimately resupply themselves without relying on the hospital. These include purchasing the supplies and drugs directly from reputable medical supply companies or perhaps from a hospital but at fair market value.
It is also known that payers generally will reimburse ambulances for these costs. Even Medicare in most communities pays for most prehospital drugs and supplies and in others, the Medicare payment has been adjusted upward as these costs are considered "wrapped" into the base cost. Even the new draft Medicare fee schedule provides a global rate for all services to include supplies and drugs, and therefore the ambulances will be repaid for these costs. We might not agree that the proposed rate of payment by Medicare is sufficient, but the intent is there to cover these costs.
Getting resupplied by the hospital at no cost or below actual cost has the potential of allowing an ambulance provider to "double dip." Medicare’s new fee schedule, which is expected to begin in the spring of 2001 but will be phased in over four years, is still paying most ambulance companies based on specific drugs and supplies used.
Don’t get me wrong. A close working relationship between hospitals and all prehospital providers is an important and necessary feature of quality EMS systems. Rural providers that do not have the resources or the funds to conduct their own resupply now have a series of OIG safe harbors that provides guidance on how to structure a hospital resupply program without risk.
Hospital resupply has the potential to be an actual or potential inducement Ambulance providers have opportunities to be resupplied in other appropriate ways that don’t put quality-coordinated EMS systems at risk. Those that do not use these methods risk stiff fines and other penalties and put the local EMS system at risk. I recommend that the practice be eliminated in all but the most extreme circumstances.
[Contact Williams at The Abaris Group, 700 Ygnacio Valley Road, Suite 250, Walnut Creek, CA 94596. Telephone: (925) 933-0911. Fax: (925) 946-0911. E-mail: email@example.com.]