Shorthanded Kentucky May Ditch Certificate of Need Requirement

Lexington Herald-Leader

On February 18, a patient arrived at the St. Claire Regional Medical Center emergency department with a ruptured blood vessel in his esophagus.

He was hemorrhaging and "bleeding out significantly," St. Claire CEO Donald Lloyd remembers. With help from additional hospital personnel, emergency room staff stabilized the patient, but he needed complex, immediate surgery. As is often the case at this Eastern Kentucky regional hospital, patients in need of specialized surgeries are often transported by an ambulance to University of Kentucky HealthCare, an hour away in Lexington.

The patient arrived at St. Claire around 10 a.m. When it became clear he needed emergency surgery, "We tried desperately to find any available EMS service that could take him to UK," Lloyd said.

Staff had tried to arrange to fly the patient, but rain that day wouldn't allow it. So, as is most often the case, "we had to rely on ground transportation," Lloyd said.

But there were no available ambulances.

Staff frantically phoned seven different EMS providers across Eastern and Central Kentucky, but "nobody had available resources."

Five and a half hours lapsed, and still no ambulance. Desperate, St. Claire opted for a route "not permitted, but we thought it was necessary," Lloyd said: they found an ambulance provider across the river in Ohio, who then transported the patient to Lexington.

The "frequent" lack of ambulances, Lloyd said — a persistent issue a bill before the General Assembly this session aims to correct — doesn't just affect patients in medical emergencies.

At Masonic Homes of Kentucky's Louisville and Shelbyville skilled nursing homes, more than 70% of new residents arrive after dark, as late as 3 and 4 a.m., said Conjuna Collier, vice president of risk management.

This is the opposite of what Collier wants for her new elders, many of whom have dementia and come to Masonic Homes from the hospital, where they've gone to seek care after an accident or illness. Many cannot drive themselves, so they need an ambulance to transport them.

But, like with staff at St. Claire, ambulances are frequently hard to come by. Like nurses and social workers, Kentucky has for years struggled with a shortage of emergency medical technicians to staff ambulances — a problem made worse by the COVID-19 pandemic. When there is availability, EMS tends to prioritize emergency situations, which means nonemergency patients, like Collier's elderly residents, are sidelined.

It's not uncommon for patients to wait at hospitals for hours, she said, sometimes a full day.

Other times, an ambulance just simply won't come. When that happens, "they may show up in a taxi cab," said Collier, who like Lloyd at St. Claire is frustrated with how the dearth of ambulances negatively impacts her patients.

"If you're needing a skilled level of care, it's probably not a safe transition to go in a taxi," she said.

Eight-Hour Waits

These troubling predicaments at St. Claire and Masonic Homes are fairly common, according to the Kentucky Hospital Association and Kentucky Association of Health Care Facilities/Center for Assisted Living, whose membership bases are statewide.

Nancy Galvagni, president of KHA, said she started getting calls and emails about issues with timely ambulance responses in 2019. Enough complaints piled up that later that year she and other stakeholders, including EMS providers, formed a task force to study the extent of the problem.

KHA asked its member hospitals to, for one month, track the amount of time it took for an ambulance to arrive once it was called, and the reason why a patient needed ambulance transport.

"What we found was the average wait time for patients to be transported was 7–8 hours," and roughly 90% of those requests were to transfer a patient to a higher level of care, Galvagni said last month.

It's very clear that "patients aren't getting the services they need. It's not just a matter of waiting around," she said. "If you don't get the care you need, you can die, and in some cases, patients have actually died."

But because of how Kentucky regulates its ambulance services, for years health care providers like Collier and Lloyd have been limited in their recourse.

House Bill 777, from Rep. Ken Fleming, R-Louisville, seeks to change that. After it received approval in the House earlier this month, members of the Senate Health and Welfare Committee advanced the bill unanimously on Wednesday morning.

"Waiting does not work in an emergency, and it does not work when patients need a different level of care," bill co-sponsor Rep. Kim Moser, R-Taylor Mill, said on the House floor earlier this month. "This bill is really about transporting patients to the appropriate level of care."

'We've Got Problems'

Kentucky and Hawaii are the only states that regulate ambulance services under a Certificate of Need provision — outside of the Cabinet for Health and Family Services umbrella and under the purview of its own independent board, the Kentucky Board of Emergency Medical Services, which is comprised only of EMS personnel.

Fleming's bill would remove EMS from the Certificate of Need status, a designation that bill proponents say radically limits oversight and creates an unnecessarily cumbersome process for adding new ambulance services, even in regions that desperately need them.

House Bill 777 would also give the state greater oversight over EMS, first by bringing KBEMS under the umbrella of the Cabinet for Health and Family Services. The bill tasks the board with turning over its internal data to the Cabinet, to be published in public reports, and the Cabinet would be charged with investigating all complaints filed against ambulance services.

Under the current law, any new ambulance service must obtain a Certificate of Need, which requires approval from the independent ambulance board. But KBEMS has pushed back against most applications in recent years. Galvagni penned in a January letter to Inspector General Adam Mather in January, pleading for his help.

"Kentucky hospitals report that the current level of ambulance service providers has failed to keep pace with demand," she wrote, "resulting in denials of medical transport and lengthier wait times."

When rebuffing applications, the board often cites not enough EMTs to go around, as well as a need to avoid duplicating services — a move that stakeholders like the Kentucky Association of Counties (KACo) says would only further financially burden the roughly 80% of counties footing the bill for those services.

They worry that by opening the market for more EMS, counties would lose the already slim revenue margins they're earning now.

"We have a special ambulance taxing district in Madison County," Reagan Taylor, Madison County judge executive and past president of KACo, told the Senate Health and Welfare Committee last week. "Taxpayers are subsidizing this service because it isn't a profitable venture on its own. Why would we want more duplication?"

Adding more providers would make it even less profitable, Taylor said, asking lawmakers to "consider the cost shift" to the county, which may very well lead to raising taxes "just to continue offering 9-1-1 services."

But Jim Duke, president of the Kentucky Ambulance Providers Association, who said he's "very much concerned about the viability of our ambulance services across Kentucky," told the same committee that House Bill 777 is the only way forward.

"We've got problems with destination issues [and] with transport times," he said. "We see this bill as a cooperation between several different groups to help keep EMS viable."

The bill now heads to the Senate.