Final Ambulance Data Collection Rule

The Centers for Medicare and Medicaid Services (CMS) released its calendar year (CY) 2020 final payment rule for the Physician Fee Schedule (PFS) on November 1, 2019, and it included the final requirements for Medicare’s new ambulance cost data collection program.

To review:

The proposal was introduced on July 29, 2019.
TEMSA has held two seminars on the subject, and TEMSA’s next seminar will be Monday, November 25 in Fort Worth.
In exchange for renewing the ambulance extender payment policy, Congress included a provision in the Balance Budget Act of 2018 that will require ground ambulances to submit to a cost data collection program to collect cost, revenue, utilization, and other information determined appropriate by the Secretary of Health and Human Services (HHS).
According to CMS: “Such system must be designed to collect information: (1) needed to evaluate the extent to which reported costs relate to payment rates under the AFS; (2) on the utilization of capital equipment and ambulance capacity, including information consistent with the type of information described in section 1121(a) of the Act; and (3) on different types of ground ambulance services furnished in different geographic locations…”

This long-awaited final rule provides the framework that EMS agencies will need to study. Click here to read the final rule, which begins on page 926. Click here to read this summer’s proposed rule, which is referenced in this summary.

This summary is provided for informational purposes only. The American Ambulance Association will present another seminar with TEMSA on Monday, November 25 in Fort Worth. Click here for details.

TEMSA provided a lengthy summary of the proposed rule for TEMSA members this summer, and many of those proposals were finalized by CMS in the final rule. Therefore, much of TEMSA’s following summary comes from TEMSA’s summary of the proposed rule.

In its final rule, CMS published 58 stakeholder comments on the ground ambulance provisions and 11 public comments from air medical organizations. (CMS indicated that a recently-formed advisory committee will be examining air ambulance rates, but CMS does not have legislative authority to collect air ambulance data.)

CMS’s responses to commenters typically include CMS’s final decision on the proposals, and many of those comments have been included in this summary. However, remember that the American Ambulance Association’s seminar on November 25 in Fort Worth will include a much more thorough summary.

Click here to view the Texas EMS agencies that will be required to participate in the first round.

Key Dates
The following is an overview of the key dates.

HHS is required to specify the data collection system by December 31, 2019, and to identify the ground ambulance providers and suppliers that would be required to submit information.
“[Not] later than December 31, 2019, for the data collection for the first year and each subsequent year through 2024, the Secretary must determine a representative sample to submit information under the data collection system.
Beginning January 1, 2022, HHS is required to apply a 10 percent payment reduction to Medicare payments for the applicable period to a ground ambulance provider or supplier that is required to submit information under the data collection system and fails to do so.
The Medicare Payment Advisory Commission (MedPAC) is directed to submit reports to Congress no later than March 15, 2023. The law allows HHS to revise the data collection system as appropriate after taking into consideration the report(s) that MedPAC will submit to Congress.
The law requires ground ambulance providers and suppliers to submit information for years after 2024, but in no case less often than once every three years, as determined appropriate by HHS.
CMS finalized the data collection period to serve as a continuous 12-month period of time, “which is either the calendar year aligning with the data collection year, or when an organization uses another fiscal year for accounting purposes…”
The proposed rule featured a typo. CMS made the following statement in the final rule: “We note that we correctly stated the dates of the first data collection period throughout the remainder of the proposed rule and confirm again here that the correct dates of the first data collection period are January 1, 2020 through December 31, 2020.”
CMS will give EMS agencies up to five months to report data to CMS.

Finalized: Who Must Submit Data? 25 Percent of EMS Agencies
CMS’s final rule regarding the sample can be found beginning on page 1014.

Per CMS on page 1034 of the final rule:

After consideration of the comments, we are finalizing our sampling proposals to implement a 25 percent stratified sample in each of the first 4 years of data collection. We are also finalizing our proposal to codify the representative sample requirements at § 414.626(c).

Per CMS on page 1038:

While we understand that system changes may be necessary for some ground ambulance organizations who are sampled in the first data collection period, we believe that most ground ambulance organizations will be able to complete the data collection requirements within the specified timeframe.

After consideration of the comments, we are finalizing the data collection period as a continuous 12-month period of time, which is either the calendar year aligning with the data collection year, or the organization’s 12-month fiscal year that begins during the data collection year when an organization uses fiscal year for accounting purposes and elects to collect and report data over this period rather than the calendar year. We are also finalizing our proposal to allow a ground ambulance organization 5 months to report the data collected during data collection period. We are also finalizing our proposals to codify the data collection and reporting requirements for selected ground ambulance organizations at § 414.626(b).

The following comes from TEMSA’s summary of this summer’s proposed rule.

CMS provided the following commentary in its proposed rule on page 533:

Under section 1834(l)(17)(B)(ii) of the Act, not later than December 31, 2019, for the data collection for the first year and for each subsequent year through 2024, the Secretary must determine a representative sample to submit information under the data collection system. The sample must be representative of different types of ground ambulance providers and suppliers (such as those providers and suppliers that are part of an emergency service or part of a government organization) and the geographic locations in which ground ambulance services are furnished (such as urban, rural, and low population density areas), and not include an individual ground ambulance provider or supplier in the sample for 2 consecutive years, to the extent practicable.

CMS went on in this summer’s proposal to indicate:

We are also proposing that 25 percent of ground ambulance organizations be sampled from all strata (as described below) in each of the first 4 years of reporting without replacement; that is, if an organization is sampled in Year 1, it would not be eligible for sampling again in the subsequent 3 years of data collection. We are proposing a 25 percent sampling rate because if a lower sampling rate is used, estimates of cost, revenue, and utilization from the data collected via the instrument for subgroups of ground ambulance suppliers would be of inadequate precision as described in the following section. Furthermore, our analyses illustrated that using 50 percent sampling rate yielded only marginal gains in precision over a corresponding strategy that involves sampling NPIs at a 25 percent rate while doubling the response burden. In our view, these gains are not sufficient to merit the increased burden that would be imposed by implementing a higher sampling rate. Our proposal was informed by analyses regarding the alternative sampling rates in Chapter 7 of the CAMH report. We invite comments on the proposed sampling rate of 25 percent each year.

CMS also commented on the concept of proposing a stratified random sample on page 584. According to CMS, the top 10 percent of ground ambulance agencies by volume accounted for nearly 70 percent of total Medicare ground ambulance transports in 2016. Meanwhile, the bottom 50 percent of ambulance providers and suppliers by volume accounted for only 3 percent of total Medicare ground ambulance transports.

In the final rule, CMS reminded stakeholders about what it stated in the proposed rule:

We stated that as a result, we would use 2017 Medicare claims and enrollment data to determine the sample for the 2020 data collection period because 2018 Medicare claims data could not be considered complete in late 2019 when the sample for the 2020 data collection period would be selected.

To meet the law’s requirement to sample a wide variety of EMS agencies, CMS is proposing to use a stratified random sample:

We believe that use of a stratified random sample would comport with the statutory requirements. Therefore, we are proposing a stratified random sample approach. Specifically, we are proposing to sample from each strata at the same rate (25 percent, as described above). We believe that data collected from a sample of this type can be adjusted via statistical weighting to be representative of all ground ambulance organizations billing Medicare for ground ambulance services even if response rates vary across the characteristics used for stratification.

As TEMSA indicated in the beginning of this summary, HHS cannot include an individual ambulance provider and supplier in two consecutive years. CMS indicated on page 1038 of the final rule:

We proposed that 25 percent of ground ambulance organizations be sampled from all strata (as described below) in each of the first 4 years of reporting without replacement; that is, if an organization is sampled in Year 1, it would not be eligible for sampling again in the subsequent 3 years of data collection.

CMS is proposing to sample ground ambulance agencies that are enrolled in Medicare and that billed for at least one Medicare ambulance transport in the most recent year for which a full year of claims data prior to sampling is available.

Finalized: What Are the Non-Compliance Penalties?

CMS provided commentary on the law’s non-compliance penalties on page 534 of this summer’s proposed rule:

Section 1834(l)(17)(D) of the Act requires that beginning January 1, 2022, the Secretary apply a 10 percent payment reduction to payments made under section 1834(l) of the Act for the applicable period to a ground ambulance provider or supplier that is required to submit information under the data collection system and does not sufficiently submit such information. The term “applicable period” is defined under section 1834(l)(17)(D)(ii) of the Act to mean, for a ground ambulance provider or supplier, a year specified by the Secretary not more than 2 years after the end of the period for which the Secretary has made a determination that the ground ambulance provider or supplier has failed to sufficiently submit information under the data collection system.

A hardship exemption is available, and the form can be found here:

https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html

CMS provided the following commentary on page 1911 of its final rule:

While we expect that few, if any, ground ambulance organizations will request a hardship exception, we do not have experience in collecting data from ground ambulance organizations that could be used to develop an estimate, so we based our estimate on the total number of organizations being surveyed. As a result, we estimated that a total of 2,690 ground ambulance organizations would apply for a hardship exemption, and that it would take 15 minutes for each of these ground ambulance organizations 15 minutes to complete and submit the request form.

We assumed for purposes of this estimate that the mix of staff responsible for completing this form would have the same blended hourly wage used to estimate the data collection and data reporting costs. We also calculated the cost of overhead, including fringe benefits, at 100 percent of the mean hourly wage, as we did above. As a result, we estimated that the total cost burden associated with the completion and submission of the hardship exemption request form would be approximately $38,884.

In addition, the law directs HHS to establish an informal review process under which a ground ambulance provider or supplier may seek an informal review of a determination that it is subject to the payment reduction.

What Will MedPAC report to Congress?
MedPAC will be required to report on the following items to Congress:

An analysis of information submitted through the data collection system;
An analysis of any burden on ground ambulance providers and suppliers associated with the data collection system;
A recommendation as to whether information should continue to be submitted through such data collection system or if such system should be revised by the Secretary, as provided under section 1834(l)(17)(E)(i) of the Act; and
Other information determined appropriate by MedPAC.

What Resources Did CMS Use to Develop This Proposal?
CMS outlined the research that it utilized to develop this program on page 537 in this summer’s proposed rule. It included peer-reviewed literature, government and trade association reports, interviews with industry experts, and Medicare claims and enrollment data.

In addition, a contractor analyzed the following five data collection tools:

The Moran Company Statistical and Financial Data Survey. This was commissioned by the American Ambulance Association in 2012.
Ground Emergency Medical Transport Cost Report form and instructions from California’s Medicaid program.
The Emergency Medical Services Cost Analysis Project framework, which was funded by the National Highway Traffic Safety Administration in 2007.
A 2012 Government Accountability Office (GAO) ambulance survey, which examined ground ambulance suppliers’ costs for transports.
The Rural Ambulance Service Budget Model, which was developed by a task force of the Rural EMS and Trauma Technical Assistance Center.

Per CMS in the proposed rule:

Our contractor’s analysis of these tools revealed that while there was overlap of the broad cost categories collected (for example, labor, vehicles, and facilities costs) via these tools, there were significant differences in the more specific data collected within these broad categories. Overall, there was a large amount of variability regarding whether the tools allowed for detailed accounting of costs and whether the tools used respondent-defined or survey-defined categories for reporting. The five tools also differed in terms of their instructions, format, and design in terms of how a portion of organizations’ total costs were allocated to ground ambulance costs, the time frame for reporting, and the flexibility of reporting.

Based on these activities, our contractor prepared a report entitled, “Medicare Ground Ambulance Data Collection System –Sampling and Data Collection Instrument Considerations and Recommendations” (referred to as “the CAMH90 report”) which is referenced throughout this proposed rule. It is available at https://www.cms.gov/Center/Provider-Type/Ambulances- Services-Center.html and provides more detail on the research, findings and recommendations concerning the data collection instrument and sampling. This report, in addition to other considerations we describe below, informed our proposals for the data collection instrument.

Final Rule: Several commenters expressed concern that the data collection instruments and sampling methodology were not tested prior to the proposal.

CMS responded in the final rule:

While the data collection system and instrument was not widely tested prior to making our proposals, we conducted an extensive environmental scan as described above, consulted with as many stakeholders as possible throughout the tight timeframe between when the law was enacted and the statutory deadline for specifying the data collection system. This included meeting with all the major associations representing ground ambulance providers and suppliers, and conducting interviews with randomly selected ground ambulance organizations as described in our contractor’s report. Given the extensive effort that has gone into preparing the data collection instrument and sampling plan, as well as the overall positive feedback we received from commenters to the proposed rule, we believe the data collection instrument and sampling plan will achieve the requirements of the statute. We also plan to conduct extensive stakeholder outreach and develop educational materials to help respondents report accurate information, and will make revisions to the data collection instrument and sampling plan as expeditiously as possible to address any issues that are identified.

Finalized: CMS’s Proposal for the Data Collection Tool: Web-Based System

CMS proposed a web-based system to collection the data. CMS outlined its proposed data collection tool, which could be found on page 542 in this summer’s proposal:

Based on our analysis of the existing or previously used data collection instruments described above, we do not believe that any of them would be sufficient to adequately capture the data required by section 1834(l) of the Act. Therefore, we are proposing to collect ground ambulance organization data using a survey that we developed specifically for this purpose, which we will refer to from this point forward in this proposed rule as the data collection instrument, and which we would make available via a secure web-based system. We believe that the data collection instrument should be usable by all ground ambulance organizations, regardless of their size, scope of operations and services offered, and structure. The proposed data collection instrument includes screening questions and skip patterns that direct ground ambulance organizations to only view and respond to questions that apply to their specific type of organization. We also believe that the proposed data collection instrument is easier to navigate and less time consuming to complete than a cost report spreadsheet. The proposed secure web-based survey would be available before the start of the first data reporting period to allow time for users to register, receive their secure login information, and receive training from CMS on how to use the system.

Final Rule: CMS indicated on page 940 of the final rule that it is finalizing this proposal.

CMS commented in its final rule:

We thank the commenters for the overwhelming support of the proposed format of the data collection instrument and will implement many of the suggestions commenters provided to ensure the data collection system is user friendly and provides as many avenues for analysis as possible.

We understand the concern that upon first glance, the data collection instrument may appear complex, as well as the concern that it may suffer from a low response rate. However, we expect that ambulance organizations will find that the use of screening questions and skip patterns that direct them to only view and respond to questions that apply to their specific type of organization will be easier to navigate and less time consuming to complete than a cost report spreadsheet. We believe that the data collection instrument will be usable by all ground ambulance organizations regardless of their size or other characteristics, and do not believe it is necessary or beneficial to have a limited data collection instrument for low-volume ambulance organizations to complete. Our belief is that all ground ambulance organizations that are chosen to participate in the sample will work with CMS and their ambulance associations to receive the assistance they need to report the data required, not just because they will receive a 10 percent payment reduction for failure to report the data, but also because they believe their data is important so that those analyzing the data can accurately assess whether or not Medicare payment rates are adequate. We specifically designed the data collection instrument to leave as many doors open as possible for data analysis while also considering the burden associated with every question.

Finalized: CMS’s Proposal for Data Elements: Total Costs, Total Revenue & Total Utilization

CMS outlined the potential data elements to collection on page 543 of this summer’s proposed rule. CMS made the following data collection program this summer:

Therefore, we propose the first option as discussed above, which would require ground ambulance organizations to report on their: (1) total costs related to ground ambulance services; (2) total revenue from ground ambulance services; and (3) total ground ambulance service utilization. This approach would consider all ground ambulance costs, revenue, and utilization, regardless of whether the service was billable to Medicare or related to a Medicare beneficiary to collect total cost, total revenue, and total utilization data.

The proposed data collection instrument is available on CMS’s website at:

https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html.

The following chart was published in the final rule (page 952):

Final Rule: CMS provided commentary on its final decision beginning on page 950 in the final rule:

We agree that it is critical to collect data in such a way that ground ambulance costs can be separated from an organization’s total costs in cases where an organization performs ground ambulance and other activities. The approach that we proposed would collect information in such a way that analysts (rather than the respondent) would be able to allocate many costs to ground ambulance services.

We also do not agree with the commenter who suggested that we collect information on what they described as “hidden” costs. The statute requires us to collect information on actual costs, not on costs that would have occurred under certain circumstances. We believe that the proposed data collection instrument will provide the necessary data required by the statute, and collecting information on other costs or potential costs would be out of scope for this data collection.

After consideration of the comments, we are finalizing our proposals to collect data on total costs related to ground ambulance services, total revenue from ground ambulance services, and total ground ambulance service utilization. We are also finalizing our proposals regarding allocation of a share of organizations’ total costs and revenues unrelated to, partially related to, and entirely related to ground ambulance services.

Finalized: EMS Characteristics

Due to the variation in the training level of EMS professionals, geographic inconsistencies, and other characteristics, HHS proposed to collect additional information, such as:

Ownership information.
Volunteer labor.
The category that best describes the ambulance organization.
Shared operational costs with an entity of another type, including a fire department, hospital, or other entity.
Routinely responds to emergency calls for service.
Operates land, water, and air ambulances.
Has a staffing model that is static (that is, consistent staffing over the course of a day/week) or dynamic (that is, staffing varies over the course of a day/week) or combined deployment (certain times of the day have a fixed number of units, and other times are dynamic depending on need).
Provides continuous emergency services.
Provides paramedic or other emergency response staff to meet ambulances from other organizations in the course of a response.

Final Rule: Commenters provided feedback on the proposal to collect organizational data and volunteer labor.

Per the final rule:

Comment: Some commenters expressed concern that information on key organizational characteristics (such as organization type and use of volunteer labor) are being collected as part of this data collection effort, rather than in a separate data collection process that would occur before the collection of cost and revenue data. They stated this two-stage approach to data collection is needed to stratify the sample and ensure a representative sample.

Response: We recognize the desire that many commenters shared to have all of the organizational characteristic data prior to selecting samples to ensure that CMS has what

commenters believe would be a complete set of data to use to stratify the sample. As stated in the proposed rule, we believe that Medicare claims and enrollment data provide CMS with enough data to appropriately stratify the sample. We also continue to believe that multiple data collections would increase respondent burden and that the commenters’ suggestion to collect data from all ground ambulance organizations in the first data collection and then select a random sample to collect data from some ground ambulance organizations in that same year or the year after may not align with sections 1834(l)(17)(B) of the Act, which requires CMS to collect data from a random sample and prohibits data collection from the same ground ambulance organizations in 2 consecutive years, to the extent practicable. Furthermore, we believe that collecting data on organizational characteristics as part of one data collection effort will enable skip patterns within the survey to limit the number of questions organizations with certain characteristics will need to answer.

After consideration of the comments, we are finalizing our proposal to collect ground ambulance organization data using a single survey-based data collection instrument delivered via a secure web-based system. We made a few technical changes to our proposals to codify these policies at § 414.626 including adding a definition for Medicare Ground Ambulance Data Collection Instrument. We are finalizing our proposals to codify these policies at § 414.626.

CMS continued to provide more background on this issue in the final rule.

Defining the Primary Service Area
Per CMS on page 553 from this summer’s proposed rule:

We are proposing to require ground ambulance organizations that are selected during sampling to identify their primary service area by either: (1) providing a list of ZIP codes that constitute their primary service area; or (2) selecting a primary service area using pre-populated drop-down menus at the county and municipality level in question 1, section 3 of the data collection instrument. We are also proposing to require respondents to specify whether they have a “secondary” service area, which are areas where services are regularly provided under mutual aid, auto-aid, or other agreements in section 3, question 4 of the data collection instrument and if so, to identify the secondary service area using ZIP codes or other regions as described above for the primary service area (section 3, question 5). Mutual aid agreements are joint agreements with neighboring areas in which they can ask each other for assistance. Auto-aid arrangements allow a central dispatch to send the closest ambulance to the scene. We are not proposing to collect information on areas served only in exceptional circumstances, such as areas rarely served under mutual or auto-aid agreements or deployments in response to natural disasters or mass casualty events because we believe reporting on rarely-served areas would involve significant additional burden and would add to instrument complexity without generating data that would be useful for analysis.

CMS provides its reasoning for proposing the following questions to help study the EMS agency’s geographic region:

Whether the respondent is the primary emergency ambulance organization for at least one type of service in their primary service area.
Average trip time in primary and secondary service areas.
Average response time (for organizations responding to emergency calls for service) for primary and secondary service areas.
Whether the organization is required or incentivized to meet response time targets by contract or other arrangement (for organizations responding to emergency calls for service).

Finalized: Collecting Data on Ground Ambulance Utilization
The law requires CMS to collect information on the utilization of ground ambulance services.

CMS proposed a “two-pronged approach” to collect data on the volume and mix of services. To measure volume, CMS is proposing the following data elements:

Total responses, including those where a ground ambulance was not deployed.
Ground ambulance responses, that is, responses where a ground ambulance was deployed.
Ground ambulance responses that did not result in a transport.
Ground ambulance transports.
Paid ground ambulance transports, that is, ground ambulance transports where the ambulance provider or supplier was paid for a billed amount in part or in full.
Standby events.
Paramedic intercept services as defined by Medicare.
Other situations where paramedic staff contributes to a response where another organization provides the ground ambulance transport.

To account for EMS agencies that specialize in non-emergency transports or inter-facility transports, CMS is proposing the following data elements:

The share of responses that were emergency versus non-emergency.
The share of transports that were land versus water (asked only of organization reporting that they operate water ambulances).
The share of transports by service level.
The share of transports that were inter-facility transports.

CMS’s responses to commenters in the final rule can be found on page 973:

We appreciate the detailed comments to our proposals, but do not agree that respondents should be presented with an option to report service volume in terms of categorical “low,” “medium,” and “high” response options. Data collected using this categorical approach would considerably decrease the precision of estimated per-transport costs. We also believe that it would be challenging to combine data from ground ambulance organizations reporting specific counts of services with those opting to use the categorical response options. Reported counts of services can easily be described in terms of categories when the data is analyzed.

We agree that it is appropriate to use Medicare manual definitions for ground ambulance services, although some of the verbatim descriptions may need to be abridged due to their length. We appreciate commenters’ concerns that the specific Medicare definition of ground ambulance transport may not apply to transports paid by certain other payers. While we would generally prefer to use the Medicare definition of ground ambulance transports, we believe that the burden of asking respondents to distinguish between transports paid by other payers that would or would not have met Medicare requirements would be unreasonable compared to incremental benefit of using this narrower definition. We agree that the definition of interfacility transport in the data collection instrument needs to be clarified and revised. We agree that the commenters’ specific clarifications to the definitions of several service categories will be helpful to respondents.

In the data collection instrument, the term ‘ground ambulance response’ is defined as “a response by a fully equipped and staffed ground ambulance, scheduled or unscheduled, with or without a transport, and with or without payment. If more than one vehicle is sent to the scene, the instructions are to count this as one response.” For example, if three ambulances are sent to one incident, and only one ambulance transports a patient, then this example is counted as one response and one transport. Similarly, responses where another EMS vehicle arrives and cancels the ambulance would not be counted in the responses. While there may be some discrepancy between the number of responses, paid transports and responses that do not result in a transport, we do not agree with the suggestion to allow for multiple ambulances sent to one scene to be counted as multiple responses since we do not encourage ground ambulance organizations to send more than one ambulance on every call.

Emergency transfers would be counted in the number of emergency responses in Section 6, Question 1, and under their corresponding level of service in Question 3. Paid transports should only include those where a health insurer or patient paid for some or all of the billed charge. Any payments that are offset by tax revenue should not be counted in this section since tax revenue is reported separately in the revenue section.

We agree with commenters that it is important to collect information on the number of responses that do not result in a transport, and understand that some ground ambulance organizations many not currently track this information. Due to the importance of this information for determining cost, we do not believe that adding the response options to report that the information is not available or to allow respondents to estimate the share of responses where the patient is not transported is appropriate.

The proposed data collection instrument asks respondents to report the share of responses that do not result in a transport for any reason, including that the death of the patient. We are collecting information on all ground ambulance costs, regardless of whether the patient was transported. Given our overarching goal of minimizing burden while collecting the data necessary, we believe that existing items collecting information on the number of responses that did not result in a transport are sufficient.

After consideration of the comments, we used the Medicare manual definitions of Medicare ground ambulance services, clarified the definitions of other response and transport categories, and removed the Medicare medical necessity requirement from the definition of “ground ambulance transport.” We also refined the definition of “interfacility transport” in the data collection instrument to include transports where “the origin and destination are one of the following: a hospital or skilled nursing facility that participates in the Medicare program or a hospital-based facility that meets Medicare’s requirements for provider-based status. We also added an additional question to the data collection instrument that specifically asks for interfacility transports that are covered under Medicare Part A where the ambulance provider or supplier would seek payment from SNF, hospital, or hospice.

Finally, we clarified the instructions for the definitions of response and transports, incorporating the example of an emergency transfer.

Finalized: Collecting Data on Costs
CMS provided commentary on its final “collecting data on costs” provision beginning on page 976 in the final rule.

CMS provided the final response to commenters in the final rule (page 981):

The survey is designed to collect information on total costs, which implicitly captures all costs related to readiness, and therefore, we do not believe it necessary to include a separate question that requires ground ambulance organizations to calculate a readiness cost. We believe that while some commenters noted the lack of a standard approach to the allocation of costs between ambulance organizations and their parent organization or central office could potentially lead to differences in how these costs are reported, we do not believe that developing a specific, standardized allocation method for these costs is necessary, as we expect only a small share of reporting ground ambulance organizations to allocate parent organization costs in this way.

The questions for total costs and total revenue currently specify that services not related to ground ambulance services should be included, but we agree with the commenter suggesting the addition of a question on fees paid to other non-transporting organizations for their services, when there is an agreement in place to pay for these services. However, as we discuss elsewhere in these comments, we continue to believe that requiring ground ambulance organizations to report on the estimated costs of labor, supplies, vehicles, etc. for non-transport vehicles that are ‘in-kind’ donations would be extremely burdensome for ground ambulance organizations that do not currently pay for these services. However, if a cost that is borne directly by the ground ambulance organization or another entity that owns, operates, or manages the ground ambulance organization, then that cost is required to be reported.

We acknowledge that certain items such as depreciation will be difficult for some agencies to estimate and we will provide additional instructions on how to estimate depreciation in the survey instructions. However, we disagree with the commenter regarding collecting fair market value from respondents because we want to reduce any subjectivity and burden involved in asking respondents to report fair market value. We continue to believe fair market values could be imputed using publicly available sources of data to facilitate comparison of data between organizations that have donations and those that do not. We believe the data collected on the survey will allow end users to infer approximate costs for donated items.

After consideration of the comments, we added a question to the ‘other costs’ section for funds paid to other organizations for services (such as non-transporting organizations providing medical personnel).

Finalized: Collecting Data on Staffing and Labor Costs
CMS’s commentary on its final rule for collecting data on staffing and labor costs can be found beginning on page 982.

CMS provided a lengthy response to several comments about labor on page 989:

We thank commenters for their support. We considered several alternatives when developing our proposals for collecting information on staffing and labor costs, including approaches that would have allowed respondents to split reported hours and labor costs across multiple staff categories for individual staff with multiple responsibilities. While these alternatives could collect more detailed information, they would all increase response burden substantially. The proposed instructions ensure that all compensation costs are reported, and no compensation costs are double counted. The instructions accomplish this by aiming to direct respondents to assign each individual staff member to only one labor category. While CMS recognizes the instructions are lengthy, the aim is to minimize necessary calculations and complex data tracking by the respondent.

It appears that several commenters mistakenly assumed that we proposed to collect compensation costs over a typical week rather than over the entire annual reporting period.

While we did propose to collect information on staffing levels over a typical week, the data collection instrument collects compensation costs only on an annual basis. Collecting annual compensation minimizes some of the concerns raised by commenters related to under or overestimating labor costs in a particular category. The distinction between reporting staffing levels during a typical week and labor costs over the entire year may have introduced unnecessary complication, and therefore, we are removing the instruction to report staffing levels during a typical week and instead will ask respondents to report staffing levels in terms of hours over the entire annual reporting period.

The proposed data collection instrument instructions ask respondents to report costs associated with contracted medical director services in Section 11 of the data collection instrument as an “other cost.” We agree with commenters that separating questions related to medical directors is confusing particularly given the fact that contracted medical directors are so common.

In reporting the hours associated with volunteer labor, it was not our intention to capture hours on-call while volunteers are at other locations or jobs. We intended to capture the hours in service, which includes the time from which they receive a call or a page to the time they are finished with their call, as well as time spent in the station house performing duties as if they were being paid.

We agree that it would be possible to collect information that would help explain differences in staffing and deployment models, although collecting this information would add additional burden on respondents. The current labor questions collect what we believe is the most relevant information to assess how differences in labor inputs drive total costs – more specifically, the data collection instrument collects information on the total staff and total compensation. We agree that it is important to understand the extent to which other organizations contribute to responses, for example by providing paramedic or other staff to responses that are not paid by the organization submitting data. While the proposed data collection instrument collects costs related to these arrangements when a payment is made, the proposed data collection instrument does not otherwise collect information on when such arrangements exist, which we agree would be helpful information to include in the data collection instrument.

Finalized: Facility, Equipment, Supply & Vehicle Costs (page 993)
Commentary in the final rule regarding Medicare’s data collection for these elements can be found beginning on page 993.

CMS provided commentary on page 995 of the final regarding guidance related to facility costs:

We are not specifying a particular methodology for calculating the percent of square footage attributable to ground ambulance services, in order to reduce the burden on organizations who might have a particular method in place already. The instructions in Section 8 of the data collection instrument ask for the total square footage of the facility and the percentage of the facility related to ground ambulance services. The entire square footage of the facility should be reported in the first case.

After consideration of the comments, we provided additional examples for clarification on how a ground ambulance organization should report the percentage of the facility attributed to ground ambulance services in the data collection instrument.

On page 1000 of the final rule, CMS provided the following commentary related to vehicle costs:

We agree that it is important to balance burden on respondents with the level of detail of vehicle data reported in this section. While some data, for example licensing, registration, maintenance, fuel, insurance costs, could be collected in more detail in relation to ground ambulance services, we believe that alternatives to collect more detailed data would involve significant additional burden. Our intention is for organizations to report the ambulances that qualify as such in their jurisdiction. We expect that most of these ground ambulances would meet CMS’ definition of a ground ambulance.

It is our intention in the vehicles section to collect data on the costs of vehicles associated with the reporting organization only. This may include fire trucks if the fire trucks are sent to the scene with EMS personnel. If there are no firefighters co-trained as EMS personnel, then these fire trucks are not related to ground ambulance service and should not be included. If an organization is assisted by another organization at the scene (such as from a different fire department), the costs associated with these vehicles would not be included. We state elsewhere in these comments that we will add an additional question to the miscellaneous costs that allows organizations to report fees paid to other non-transporting organizations for their services. We believe that it would be too much additional burden to ask organizations to assess the costs of providing services for organizations other than their own.

For insurance, fuel or other vehicle-related costs, we ask that organizations ask the agency providing these items for an estimate of their cost.

After consideration of the comments, we added more general examples of non-ambulance vehicles, such as sport utility vehicles and pickup trucks used to support ground ambulance services, which should be included in reporting in this section. We also clarified in the data collection instrument that respondents should report on all ground ambulance vehicles that meet local and state requirements.

CMS’s commentary on other costs can be found on page 1004 of the final rule:

While there are many other potential equipment and supply categories that could have been added separately to this section, in the interest of balancing the level of detail collected in the data collection instrument with burden, we decided to limit this section to only a small number of specific types of supplies and equipment (such as drugs) for which we proposed to collect costs separately. We believe that the data collected through the data collection instrument may point to opportunities for additional refinement in this section in future years of data collection. For example, rather than collect information on all drugs in aggregate, reporting by category of drug or even for individual drugs may provide useful information. Still, given the fact that information on ground ambulance costs is limited, we believe the appropriate first step is to collect higher-level cost information. We also agree with the commenters that items such as nebulizers should be considered non-capital equipment as they are typically a single usage device when used by ground ambulance providers and suppliers. In the process of developing the survey, we heard from many organizations about the increasing cost of medications and as a result, we requested these items to be reported separately. We recognize that some organizations may not be able to separate their drug costs from other medical consumables, so this question is optional on the survey.

After consideration of the comments, we removed the example of nebulizers from the capital equipment section.

Collecting Revenue from Different Payers
CMS provided the final commentary in its final rule on page 1011:

Comment: Many commenters supported the collection of ground ambulance revenue from different types of payers, as well as the collection of other sources of revenue. These commenters asked that CMS divide Medicaid revenue by traditional Medicaid and Medicaid managed care, similar to the separate lines for Medicare fee-for-service and Medicare Advantage and recommend that CMS define the term “ambulance club,” which they stated is not a standard term.

Several commenters asked CMS to add a revenue category to Section 13, Question 5 in the data collection instrument to collect in-kind contributions (including labor, supplies, medications, etc.) provided by another agency which responds to calls for emergency service in conjunction with the ground ambulance organization completing the data collection instrument.

Commenters would like respondents to select yes or no, enter the dollar amount, and enter a percentage. They stated that fire departments often provide EMS care to patients, including at the ALS level, even when another agency provides the actual ground transportation services to a patient and when this occurs, the fire department’s ALS personnel often continue providing patient care inside the third-party ambulance during transportation to the hospital. They stated that this continuation of patient care by fire department personnel constitutes a significant savings to the third-party transportation company as they do not incur the costs associated with the fire department employee(s) such as salary, benefits, and insurance. They also stated that in many cases, the fire department never receives reimbursement for these costs by the third-party ground ambulance agency. They stated that since the data collection instrument only will apply to Medicare-enrolled ground ambulance agencies that they believe that the data collection instrument should count these services as in-kind contributions to the third-party ambulance agency. Commenters further stated that ground agencies selected for sampling by CMS each year can easily gain this information by requesting it from the agencies which commonly respond to calls for emergency service with the third-party ground ambulance agency.

Several commenters stated that Section 11, Question 5 seeks information from respondents on several revenue categories which may apply to an ambulance supplier or provider. They stated that since the goal of the data collection instrument is to assess the adequacy of CMS’ reimbursements for the cost of providing patient care, they believed that the inclusion of tax revenue for public agencies could lead to the inclusion of unrelated data. They stated that operating revenue that is derived from taxation and provided to public agencies represents the level of service expected by a community but is not expected to be a dollar-for-dollar coverage of patient care costs and that these funds should supplement, not supplant, CMS’ reimbursements to public agencies for the care that they provide to Medicare beneficiaries. They also stated that they believed that tax-derived subsidies should be reported by respondents when these funds are included in a larger contract between a local government and a private entity. They stated that in these cases, these subsidies are intertwined with the overall structure and terms of the contract but that they do support the requirement for respondents to report when revenue is received by any agency (public or private) through an EMS-specific tax and as a result, they recommend that CMS adopt changes to Section 13, question 5.

Another commenter suggested that donations to organizations that support volunteers should be considered in the revenue section. This same commenter also requested clarification as to whether patient self-pay includes the uninsured or uncovered transports.

Response: We agree that it would be informative to distinguish between traditional FFS Medicaid and Medicaid managed care revenue and will add that option to the instrument. We use the term ‘ambulance club’ to describe a membership organization where local residents pay a regular fee for ambulance service not provided by their local governments. We do not agree with the commenter suggesting to collect information on the in-kind subsidies provided by other, nontransporting agencies who assist the reporting organization at the scene or while transporting patients. We believe this additional question will add substantial burden for organizations who must collect it, as this requires valuing the other organization’s labor, supplies, vehicles, facilities, etc., and this information will be captured in the cost sections if there is a contract between the organizations for reimbursement.

The data collection instrument is designed to capture the costs of operating a ground ambulance service, consistent with our statutory requirements and we do not believe that including donations to other organizations would be appropriate to include. Donations, payment, or benefits made by other entities that support staff or other services that are out of scope for this data collection are also out of scope when reporting revenue. The patient self-pay revenue section is intended to capture payments patients made to the ambulance organization for a transport that was covered or not covered by their health insurer.

We are required to collect information on revenue received by ground ambulance organizations. Therefore, we do not agree that tax revenue for public agencies should be excluded from the data collection instrument because omitting questions related to this source of revenue from that data collection instrument would result in an incomplete picture of revenue across different types of ground ambulance organizations. The data collection instrument collects information separately on tax revenue for public agencies and from contracts between local governments and ground ambulance organizations.

After consideration of the comments, we clarified the meaning of an ambulance club and added an option to separately report Medicaid Managed care revenue. We also added an option to separately report contract revenue from local governments, as well as tax revenue from local governments, and clarified that self-pay refers to non-covered transports.

After consideration of the comments regarding the data collection instrument, we are finalizing our proposals regarding the format, scope, costs and revenue with several modifications or clarifications as described in the sections above.