County hospitals react to new ambulance transfer policy



The conversation of Marion County ambulance transfers has been going on for months now, particularly at the weekly Marion County Board of Commissioners meetings. Last week, the board approved a new policy regarding the topic, but the policy is not sitting well with local hospitals.

“We aren’t mad like some have said. We just want the public to know some of the concerns that we have,” said St. Luke Hospital and Living Center CEO Jeremy Ensey.

Ensey explained that the County Commissioners, County EMS and the residents of Marion County as a whole need to understand that both of the Marion County hospitals are critical access hospitals, and as such, at times, must transfer patients to facilities capable of providing a higher level of care and a much more extensive range of services.

“Our hospitals exist to provide essential care to our community, but our license limits the range of services that we can provide. In addition to licensing constraints, economics comes into play. It is simply not possible for us to obtain all of the specialists, facilities and equipment that would be necessary for us to treat all individuals who come to our facilities. Therefore, our ability to transfer patients from Marion County’s critical access hospitals to facilities in the region that offer more advanced or more specialized care is not an afterthought nor is it a meaningless option; it is an absolutely critical component to the continued success and viability of our regional healthcare system,” said Ensey.

Ensey stated that he and Hillsboro Hospital CEO Mark Rooker have been trying to have conversations with the county for months. The pair have sent letters via email and Federal Express on both Aug. 30 and Sept. 21.

“I did send a follow-up email on Nov. 7 since I had not heard back from the Sept. 21 letter. I ended that email with ‘If you would like to discuss or work together towards a solution, please contact me’,” said Ensey.

He said that he did get a reply on Nov. 7 which acknowledged the hospitals wanting to meet and come to a consensus on the transfer and billing questions but asked him to wait until the new director could meet and include his experience and input.

“That is the last communication I’ve had from any of the county commissioners,” said Ensey.

In the official letter to the Marion County EMS Interim Director Charles Kenney on August 30, the two CEOs expressed their concerns about, and opposition to, the Transfer and Hospital Assist Policies recently released at that time by Marion County EMS. The policies approved last Monday are even more rigid than the previous ones.

Ensey and Rooker pointed out in the letter that the Transfer Policy severely restricts the scope of “transfer” services that EMS will offer. They also explained that the policy states that EMS will determine whether to provide “transfers from facilities other than those in our county” on an “individual basis” and that, when EMS only has one staffed ambulance, all transfers will be declined except those for “immediate lifesaving surgical intervention.”

The term “transfer” is not defined in the policy which leaves much up to interpretation. Another issue is that the Transfer Policy states that EMS will refuse to ever transfer a patient over sixty miles, even when the patient’s life is in imminent danger and the nearest facility that could possibly treat that patient is over sixty miles away.

The letter highlights four main problems with the policies:

1) Hospital-to-hospital transfers are an essential part of critical access hospitals’ role in the healthcare system. For the two hospitals to be eligible to participate in the Medicare program, they must maintain at all times agreements with an acute care hospital concerning, among other things, patient referrals, transfers and emergency transportation. These agreements must include at least one acute care hospital that will provide treatment to patients who require services that are not available at the critical access hospital.

The letter explained that “in order to comply with these Medicare requirements, it is critical that our hospitals have the ability to move patients who may require acute services for an extended period of time to other facilities. The federal government has structured the critical access hospital program to ensure that hospitals like ours can readily transfer patients who require advanced, specialized or extended acute care to other hospitals. Accordingly, hospital-to-hospital transfers have become an essential and legally required component of our healthcare system, a fact that is recognized under federal law.”

2) The Transfer Policy will jeopardize the health of Marion County residents by making it significantly more difficult for them to receive specialized or higher levels of care.

“A policy that restricts or limits transfers from Marion County’s critical access hospitals to other hospitals that offer a higher level of care will put patients in jeopardy, whether by imposing arbitrary mile limits on transfers or by imposing ambiguous restrictions on when and where transfers may be taken. EMS, the County Commissioners and the residents of Marion County generally must note that the Transfer Policy, if fully implemented, will lead to patients being stranded in our emergency departments or in inpatient departments without access to the specialized care they need,” the letter stated.

3). The new policies do not comply with the spirit or the letter of applicable federal regulations.

One of the biggest concerns for Ensey and Rooker is that the new policies, in addition to putting patient health in danger, are inconsistent with federal law because transfers from one hospital facility to another unaffiliated hospital facility when necessary to provide a patient a higher level of care is a covered service under Medicare Part B.

Such transportation is a service of EMS, and of EMS only, and the hospitals are not responsible for that service. EMS, as a Medicare-participating provider, does not have the option of refusing to bill patients and their payers for the Medicare-covered transportation services that it performs. In order to comply with federal law EMS must bill Medicare for medically necessary hospital-to-hospital transfers performed for Medicare-covered patients. Under the Transfer Policy, EMS’s flat fee of $2,000.00 per transfer for hospitals over 30 miles away will be billed to the requesting hospital, regardless of how essential the transfer is and regardless of what insurer covers the patient to be transferred. So if EMS provides a necessary hospital-to-hospital transfer to a Medicare beneficiary, the policy would dictate that EMS would not bill Medicare for that service, which would clearly violate the Medicare mandatory claims submission rules.

4) EMS and the County Commissioners must work cooperatively with the hospitals to develop policies that best serve the residents of Marion County.

“It is absolutely essential that County EMS and the Commissioners work collaboratively with the hospitals to craft policies that will comply with applicable law and serve the best interests of County EMS, the hospitals, and, most importantly, our patients. We are all ultimately on the same team here: we are all working to protect the health and wellness of the residents of Marion County. Implementing policies that are punitive or detrimental to the hospitals and that limit access to care for the people of Marion County will not advance the mission of the Commissioners or County EMS,” the letter stated.

Alex W. Schulte of Foulston Siefkin LLP, legal counsel for St. Luke Hospital, sent a letter to Kenney on Aug. 12 stating that the hospital had “significant concerns about the proposed policies and had asked their firm to conduct a thorough legal review of applicable state and federal statutory, regulatory and ethical requirements in connection with the Policies that Marion County EMS is attempting to impose”. The letter also stated that the hospital had not accepted or agreed to be bound by the terms of the policies, including the fees, and they would not consent to or be subject to the terms of the policies unless the policies comply with all applicable law and are consistent with the best interests of patients.

Neither Schulte nor Ensey heard anything back from the county.

New EMS Director Curt Hasart emailed Ensey on Friday, Dec. 9 and the two met on Wednesday, Dec. 14.

“We had a good conversation, but there is still work to be done,” said Ensey.

Ensey and Rooker still have not had conversations with any commissioners.

The Free Press did reach out to the board and Hasart and received a comment from Marion County Board of Commissioners Chairman David Mueller.

“The County looks forward to meeting the challenges ahead of all of us as a team working with the hospitals. Health care and EMS have evolved and we need to look at new opportunities to best serve our communities. Now that our new EMS Director has his feet on the ground, we can move forward,” said Mueller.

Ensey remains optimistic that progress can be made regarding the policies.

“We have roughly around 120 transfers a year which isn’t even one per day. Granted sometimes we may have several in one day, but generally, we do not have transfers all that often,” said Ensey.

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