CONDITION CODES--FINALLY! - American Ambulance Association

A M E R I C A N A M B U L A N C E A S S O C I A T I O N
IN THIS
ISSUE
SPRING 2006
2 Freeze on Payments
3 Position on Preparation of EMS
for Pandemic Flu
4 “Starter Kit” of EMS Clinical
Performance Measures
Results of 2005 National Consensus
Meeting
7 The Coming Crisis in
Pre-Hospital Care
9 Paratech Goes Mobile with
New Mobile Data Terminal
10 Reflections on Crazy EMS
Driving
12 AAA Audio Conferences
15 Information and Upcoming
Events
16 2006 AAA Calendar of Events
CONDITION CODES--FINALLY!
By David M. Werfel, Esq.
On December 23, 2005, the Centers
for Medicare and Medicaid Services
(CMS) issued Transmittal 789 (C.R.
4221) which provides the condition
codes and the instructions for using
the condition codes. The Transmittal and
Instructions (which are now in the CMS
Internet Manual, Pub. 100-04, Chapter 15,
Section 30.3) provide the following
information:
• The codes are effective March 27, 2006.
• There is no change in coverage policy as a
result of implementing condition codes.
• The codes are to be used by Part A
providers as well as Part B suppliers.
• The codes will help to more accurately
report the condition of the patient as
reported to dispatch as well as on-scene.
• Use of the codes does not guarantee
coverage for the ambulance transport.
• Use of the codes does not guarantee
payment at a certain level (e.g. ALS).
• Documentation of dispatch information,
the condition of the patient and loaded
mileage must still be maintained by the
ambulance supplier/provider.
• Carriers and Intermediaries may continue
to have Local Coverage Determinations.
• While the first column is listed as “ICD-9”
and “primary”, think of this as “condition
code”.
• The first column on the Medical
Conditions List is for the on-scene
condition of the patient.
• Often, that is all that will be needed on the
claim (subject to Carrier/Intermediary
policies).
• When billing ALS-1 emergency, based on
an ALS assessment, two condition codes
will be needed -- the first is for the onscene
condition, the second is for the
condition reported to dispatch that required
the ALS response for the ALS assessment.
• Generally, additional codes and narrative are
optional, if you want to add more specific
information. However, if you do use
another code, in a few instances, you will
note a “PLUS” in the second column. In
these situations, you will need to use a code
from the list that is before the “PLUS” and
another code listed after the “PLUS”.
• In addition to the condition codes, there
are Transportation Indicators, for ground
and air ambulance.
• Transportation Indicators will be placed in
the Narrative on the claim -- not as a
modifier. The Transportation Indicators are:
8201 Greensboro Drive, Suite 300
McLean, Virginia 22102
703-610-9018 • 1-800-523-4447
703-610-9005 fax • www.the-aaa.org
• Carriers and Intermediaries may allow
additional ICD-9 codes.
Condition Codes • continued on page 2

OFFICERS
Bob Garner President
Jim McPartlon President Elect
Dale Berry Secretary
Jim Finger Treasurer
Jerry Overton Immediate Past President
STAFF
Maria Bianchi Executive Vice President
Tristan North Vice President,
Government Affairs
Erika Davis Manager, Meetings and
Education
Stacy Bromley Manager, Member
Services & Public Affairs
Association
Management Group
S PRING 2006
Design and Production
Ambulance Service Journal is published quarterly
by the American Ambulance Association, 8201
Greensboro Drive, Suite 300, McLean, VA 22102;
703-610-9018.
Advertising Information:
Rates are available upon request.
Copyright 2006, American Ambulance Association. No
material can be reproduced without the express written
permission of the publisher.
Condition Codes
continued from page 1
Ground Transports
• C1 – Interfacility, (read this as interhospital)
EMTALA transfer.
• C2 – Interfacility, (read this as interhospital)
transfer for higher level of service,
not EMTALA.
• C3 – Emergency, major incident, e.g.
trapped in machine, explosion, multivictim
possibilities -- but it turns out to be
only BLS on-scene.
• C4 – Mileage beyond the nearest
appropriate facility.
• C5 – BLS ambulance transports patient
with an ALS level condition, no ALS
assessment (e.g. when no ALS available).
• C6 – ALS response, BLS level patient, with
an ALS assessment.
• C7 – Non-emergency, IV medications
required (does not include crystalloid IV
fluids such as normal saline, Lactate
Ringers, 5% dextrose in water).
Air Transports (i.e. can not be safely
transported by ground)
• C1 – Interfacility, (read this as interhospital)
EMTALA transfer.
• C2 – Interfacility, (read this as interhospital)
transfer for higher level of service,
not EMTALA.
• C3 – Emergency, major incident, e.g.
trapped in machine, explosion, multivictim
possibilities -- but it turns out to be
only BLS on-scene.
• C4 – Mileage beyond the nearest
appropriate facility.
Freeze on Payments (September)
By: David M. Werfel, Esq.
Section 5203 of the Deficit Reduction
Act, signed into law on February 8, 2006,
requires a freeze on Medicare payments to
all physicians, suppliers and providers,
including ambulance services. This is a onetime
hold on payments and only affects
claims that would have been paid September
22-30, 2006.
Claims that would have been paid on one
of those days will be paid on October 1,
2006. This is being done simply to move
payments into the next Fiscal Year.
• D1 – Long distance.
• D2 – Traffic patterns.
• D3 – Time to closest appropriate hospital.
• D4 – Point of pick-up not accessible by
ground ambulance.
Carriers/Intermediaries must implement
condition codes, if the ambulance
suppliers/providers want to use them.
The list, as published by CMS, may seem
confusing, particularly until you are
comfortable using condition codes.
Therefore, the AAA has developed a
Simplified Condition Code List that
includes the condition codes (without the
“alternative” codes listed by CMS),
descriptions and crosswalk to the HCPCS
codes you use for billing. The AAA list can
be downloaded from the AAA website on
the “Condition Codes for Ambulance
Services” page under “Reimbursement
Issues”.
You should also contact your
Carrier/Intermediary, through your state
ambulance association, to ensure they are
ready to use the condition codes, to ask if
they will have any local condition codes, if
they will have any local policies, how they
will know you are using condition codes,
whether you can test a few claims, will they
be reading the Narrative (and make sure you
both have the same field in mind), etc.
The AAA has worked long and hard to
get these codes implemented. Now, we all
need to understand how to use them.
Therefore, the AAA has also set up a specific
e-mail address for you to submit questions.
That address is questions@the-aaa.org. The
AAA will then post the question and answer
on the “Condition Codes for Ambulance
Services” page of its website.
CMS notified its contractors of this
provision through Transmittal 847 on
February 10, 2006. This hold on claims
applies to paper as well as electronic claims.
Also, no interest or late penalty will be paid
on claims for these 9 days, as a result of the
law.
I thought it appropriate to give you this advance
notice now. The AAA will also give you a
reminder in late August or early September so that
you can plan accordingly.
2
AMBULANCE SERVICE JOURNAL

AMERICAN AMBULANCE ASSOCIATION
POSITION ON PREPARATION OF EMS FOR
PANDEMIC FLU
February 9, 2006
AAA Position
It is the position of the American
Ambulance Association (AAA) that all
ambulance service providers have access to
the necessary funding and resources to be
prepared and plan for the possibility of a
pandemic flu outbreak. As America’s first
response and safety net, ambulance services
across the country must be included in
federal, state and local government efforts to
plan and prepare for what may be
widespread infection involving H5N1
Influenza. The AAA will further act as a
clearinghouse for information to ambulance
service providers on preparing and planning
for a pandemic flu.
The following outline provides ambulance
service providers across the country with the
first steps in preparedness and awareness of
the issue. While not intended to be a
comprehensive pre-plan, this document
provides the basic guidance and suggested
references to assist providers in their
preparations. Special thanks and recognition
is given to the members of the Professional
Standards Committee who worked so
diligently to provide their professional input
and expertise for this document.
Introduction and Background
Public health officials have recognized
pandemic flu as a significant public health
threat for several years; it is just now coming
to the attention of politicians, media, and the
public.The Professional Standards committee
of the American Ambulance Association will
update the EMS community on current
issues and assist in proactive planning for a
highly contagious respiratory pathogen
pandemic, be it avian flu or other contagion.
Pandemics are common to the history of
man, causing and ending wars, affecting the
intellectual growth of societies, and causing
some of the very first efforts at public
health. Pandemic plague was the reason that
Venetian authorities invented quarantine in
the 1460s. This quarantine required
incoming ships to remain idle for 40 days.
The seamen were not allowed to disembark,
load or unload cargo during that time.
Spanish Flu in 1918 is now considered as
much a cause to the end of World War I as
was military strategy.
In epidemiology, an epidemic is defined as
a disease that appears as new cases in a given
population, during a given period, at a rate
that substantially exceeds what is expected,
based on recent experience. Defining an
epidemic can be subjective, depending in
part on what is "expected." An epidemic
may be restricted to one locale (an
outbreak), more general (an epidemic) or
even global (a pandemic). Common diseases
that occur at a constant but relatively high
rate in the population are said to be
endemic.
Pandemics are dramatic events with
profound consequences for which
communities must prepare.The last
significant influenza pandemic in the United
States occurred in 1968 when approximately
34,000 people died.Why then all of the
concern with the current H5N1 avian
influenza outbreak This subtype of avian
influenza has the potential to act like the
great Spanish Flu pandemic of 1918 when
550,000 deaths were attributed to the flu in
a single season. Philadelphia alone recorded
11,000 deaths over an eight week period.
H5N1 Influenza
Avian influenza is common, with at least
144 known subtypes of which H5N1 is one.
What seems to set H5N1 apart has been its
profound pathogenicity, or its ability to cause
extreme illness in birds and ease of
transmission to other birds.The first
appearance was thought to have occurred in
wild birds with mutation and dissemination
to domestic bird stocks throughout Asia and
now part of the Middle East. Of particular
concern is the apparent re-infection of wild
migratory bird flocks with subsequent spread
among the continents being likely. Other
animal hosts infected include swine and cats.
With wide-spread disease occurring in
birds, the likelihood of human contact
increases and consequently the likelihood of
human infection. For an influenza virus to
become a pandemic flu pathogen, three
things must occur; it must infect humans
whose immune systems are naive to the
virus; it must be virulent or cause illness; and
it must be able to spread from human to
human. H5N1 has shown itself to have
accomplished the first two requirements. It
has infected humans, it is virulent, and may
only be one or two mutations away from
spreading from human to human.
Like other influenza viruses, H5N1 infects
humans through the respiratory tract.We
must breathe it in, or from contaminated
hands, introduce the virus to the respiratory
mucosa via the eye, nose, or mouth.The
symptoms of the disease include rapid onset
of severe illness signaled by a fever spike
greater than 101 degrees Fahrenheit with
subsequent respiratory symptoms and
respiratory distress. GI symptoms of
vomiting and diarrhea have been reported.
The World Health Organization (WHO)
tracks each reported case of human H5N1
disease. As of January 23, 2006 WHO
reports 151 cases with 82 deaths.
Pandemic Planning
Much of the current planning and
preparedness activities surrounding EMS
involves an “all-hazard” approach to mass
casualty incidents, hazardous materials spills,
tornadoes, multiple vehicle crashes, weapons
of mass destruction and many other natural
AAA Position • continued on page 11
S PRING 2006
3

MedicareUpdate
“Starter Kit” of EMS Clinical Performance Measures:
Results of the 2005 National Consensus Meeting
By Gary Wingrove, Debbie Gillquist, Frank Gresh, Joe Hansen, Todd Hatley, Annette Kritzler, Tami Lichtenberg, Kevin McGinnis and Nels Sanddal
Summary
In June, 2005, the North Central EMS
Institute and its partners, the American
Ambulance Association, the National EMS
Management Association, the National Rural
Health Resource Center and the Rural EMS
& Trauma Technical Assistance Center, hosted
a one-day session to form the EMS industry’s
pilot set of clinical performance indicators.
There is a lot of federal activity in the
health arena surrounding performance
improvement, quality improvement,
benchmarking and indicator development.
There is also some activity within EMS in
these arenas with development of the
National EMS Information System
(NEMSIS), the Open Source EMS Initiative’s
Performance Indicator Development Project,
and the National EMS Performance
Measures Project. However, EMS is behind
the curve in relationship to other sectors of
the healthcare community.
In March 2005, the Medicare Payment
Advisory Commission (MedPAC) advised
Congress that it needs to adopt “pay for
performance” programs for hospitals and
other specified care providers, stating
“Medicare payment systems are neutral and
sometimes negative toward quality.” It advises
Congress to support methods that measure
quality-enhancing activities that are
supported by information technology.
It is a good thing MedPAC did not
include the EMS industry within the list of
providers to move to pay for performance,
because EMS isn’t ready.As organizations
representing the major facets of the EMS
industry, we need to lead this process
ourselves in a pro-active manner rather than
have it developed in haste under a future
mandate that affects our federal funding and
reimbursement.
The 2005 meeting focused on identifying
a limited set of performance measures for the
EMS industry.A pilot set of indicators that
can be derived from the data elements
June 2005 National Consensus Meeting on EMS
Clinical Performance Indicators Participants
Federal Partners:
HHS
HRSA Office of Rural Health Policy
HHS
HRSA Trauma National Resource Center
HHS
HRSA EMS-C National Resource Center
DOT
National Highway Traffic Safety
Administration – EMS Division
Organizations:
American Ambulance Association,
Association of Air Medical Services,
Coalition of Advanced Emergency
Medical Systems, National Ambulance
Coalition, National Association of EMS
included in the NEMSIS data set was
established.We encourage the National EMS
Performance Measures Project, the Open
Source EMS Initiative and other similar
efforts continue to develop EMS industry
consensus on additional clinical and
operational performance indicators.
Background
There are a wide variety of public
reporting methods on health care quality.
Public quality reporting for some health
sectors has recently been demanded by
payers, purchasers and the government.
Medicare has required public quality
reporting by health plans since 1998, endstage
renal dialysis facilities since 2001,
nursing homes since 2002, and home health
agencies since 2003. Hospitals began public
reporting of quality data in 2005 and
reporting for clinics is in the planning stages.
There are good reasons for payers
Educators, National Association of EMS
Physicians, National Association of State
EMS Officials, National EMS
Management Association, National
Organization of State Offices of Rural
Health, National Registry of Emergency
Medical Technicians, the National Rural
Health Association, the North Central
EMS Institute, the Rural EMS & Trauma
Technical Assistance Center, the Rural
Health Resource Center, Stratis Health
QIO and the University of Minnesota
5Rural Health Research Center.
Software Vendors:
Med-Media, Medtronic, Ortivus North
America, and Zoll.
(including state and federal governments) and
purchasers to demand quality reporting.
Informed consumers can be participants in
their health care.As the cost of health care
skyrockets, government can force
acceleration of the pace of improvement,
leading to transformational changes in the
way health care is delivered, to slow the pace
of inflation. High performing providers
should be rewarded for exceptional
performance – for their part in leading the
transformational changes that are necessary.
In the past, either transformational changes
have led to payment policy changes, or
payment policy changes have forced
transformational changes.A couple decades
ago, Congress began experimenting with cost
control measures on the payment side. Fee
schedules and prospective payment systems
began replacing fee-for-service as the
dominant payment mechanism.Those
payment policy changes, which in the case of
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AMBULANCE SERVICE JOURNAL

hospitals favored outpatient care, led to
dramatic shifts in how care was delivered.
Eventually, Congress required a completely
unprepared EMS industry to shift from feefor-service
to a fee schedule.
The next wave of change has already
begun.The EMS industry cannot afford to
wait. It must engage in the process to have a
seat at the table. It must have a seat at the
table to assure the next payment overhaul
accounts for its unique characteristics.
Quality – Variations on a Theme
Quality Assurance involves measuring to
assure adherence to processes or controls to
meet performance standards. Significant
efforts toward Quality Assurance (QA) began
strongly in the 1970s and 1980s. During that
time, Medicare established Peer Review
Organizations (PROs) which are now
known as Quality Improvement
Organizations (QIOs) under a regulatory
model to identify outliers in care in the
hospital and physician health care sectors.
Often these efforts served as punitive tools.
In the 1990s, the focus of quality was on
the Quality Improvement (QI) model. PROs
were focused on offering and supporting
focused QI projects in hospitals. Inside the
health care world, the reason for early QI
efforts were finances; measuring encounters
and procedures, with an expected outcome
of reducing internal costs. It is anticipated
that QI will continue to be a focus for the
foreseeable future.
In this third phase of quality, however the
emphasis is shifting from the internal to
external world. External forces will dictate
QI activities and reporting.There will be
statewide quality improvement efforts across
the continuum of care, including public
reporting of quality measures.
The shift to an external focus is breeding
new terminology which is currently
concerning to health care providers.This year
MedPAC advised Congress that it needs to
take the next Medicare payment shift to
more uncharted territory, Pay for
Performance (P4P).There are a number of
health care experiments already underway,
purporting to use P4P. In reality, P4P is still
undefined, but there are enough experiments
occurring that some standard consensus will
emerge yet this decade.
What’s Happening Today
Those parts of healthcare (physicians and
hospitals) that were early targets of Medicare
are going through another shift.There are
major public reporting activities emerging.
Congress has tied the full hospital annual
payment updates (APU) for 2005-2007 to a
requirement that hospitals submit data for 10
quality measures. Medicare is publishing data
from these hospitals that are receiving the full
APU.
Medicare is again modifying the focus and
charge of QIOs.The QIO 8th Scope of
Work began August 1, 2005. Its new
emphasis is on improving healthcare quality
culture and increasing information
technology. For the first time, it also includes
a specific rural component.
The National Rural Health Association
(NRHA) and the Medicare Hospital
Flexibility Grant Program (FLEX) program
are embracing the focus on rural health
quality.The Technical Assistance Center for
the FLEX program has been leading efforts
for rural hospitals to increase their activity
“Quality of care is the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent
with current professional knowledge.” Institute of Medicine, 1990
and capacity for quality reporting, primarily
by promoting the balanced scorecard
approach.The NRHA has fully embraced
the quality mandate, sending messages that
not only can rural healthcare providers fit
into a quality system; they can lead the
transformational change for all of healthcare.
There are some important distinctions
between urban and rural healthcare
providers.The measures Medicare put in
place for its early efforts in quality reporting
were structured around high volume
inpatient care. Consequently, most rural
hospitals do not fit into the system, because
they don’t achieve enough volume and
because rural hospitals treat in their
emergency rooms and transfer to larger
tertiary hospitals, particularly with chest pain
patients. The current measures do not
include emergency room care, thus rural
hospitals are usually not able to report on the
care they provide chest pain patients. In the
mean time, the Office of Rural Health Policy
has convened a Rural Quality Advisory Panel
that will draw on an interdisciplinary
knowledge base to develop measures and
improvement strategies across the rural
continuum of care.
Current Hospital Public Reporting
There is a number of voluntary and
mandatory quality reporting systems already
in place for hospitals. Many of these are
available to the public, although no one is
sure the tools are yet public-friendly, nor if
the public at large actually accesses them.
While some are highlighted here, others also
exist.
• The Joint Commission on the Accreditation
of Healthcare Organizations (www.jcaho.org)
– JCAHO features a “Quality Check”
program that reports data on hospitals,
nursing homes and other healthcare settings
• HealthGrades (www.healthgrades.com) –
Uses Medicare and state survey data to
calculate a 5-star rating system of hospitals
and nursing homes
• Leapfrog (www.leapfroggroup.org) –
Promotes and rates hospitals on 4 patient
safety “leaps” – computerized physician order
entry, use of intensivists, volume, and 27 safe
practices
• Healthcare Facts (www.bluecrossmn.com) –
Blue Cross of Minnesota reports care given
and safety information in nutrition label
format for large hospitals
• Hospital Compare
(www.hospitalcompare.hhs.gov) – Provides
public data on the hospital measures
collected by Medicare
• Hospital Quality Alliance (www.aha.org) –
a voluntary program sponsored by the
American Hospital Association that includes
a 10 measure starter set and 13 optional
measures, with more than 3,600 participating
hospitals
• Minnesota Health Information
(www.minnesotahealthinformation.org) –
Information about the cost and quality of
health care in Minnesota
• Adverse Event Reporting
(www.health.state.mn.us/patientsafety/) –
State mandated reporting of 27 “Never
Events”
The public tools referenced above and
others like them are powerful tools to direct
the attention of health care providers toward
quality improvement.While providers are
Starter Kit • continued on page 6
S PRING 2006
5

Starter Kit
continued from page 6
paying attention, consumers are not yet, but
may begin to with education.The sponsors
of the tools are also beginning to learn
which work and which don’t, and will use
this information to refine their processes.
What’s Happening in EMS
There are a number of benchmarking and
performance measure projects underway in
the US.All of these programs are worthwhile
and should be encouraged to continue.The
existing programs, however, are geared
toward system and business performance, or
they are stuck in the quality assurance phase
of the previous decade.To date, there is no
known organization sponsoring measures
that would integrate with the current public
reporting tools used in other parts of the
healthcare industry.
The EMS Division of the National
Highway Traffic Safety Administration has
financed a forum on EMS performance
measures.The National Association of State
EMS Officials and the National Association
of EMS Physicians are coordinating the
project under contract with NHTSA.The
project has brought the various agencies
working on performance measures together
to share their ideas and to attempt to achieve
consensus on one standard set of measures.A
host of organizations are participating in the
program, which is now in Phase II. 138
measures have been identified and the
steering committee is refining the list to 25.
The advantage to NHTSA’s project is that
all of the major organizations interested in
EMS performance measures are seeking
common ground. One disadvantage to the
project is that the various players are
developing measures for their own various
reasons and to meet their individual goals.
There has been no project oriented directly
at inserting EMS into the healthcare quality
measures discussion. NHTSA and the EMS
Performance Measures project participated in
our national consensus meeting.The EMS
Performance Measures project will include
the consensus of the meeting in its
continuing work to gain a national
consensus.
In addition to sponsoring work to bring
the divergent organizations together on EMS
Performance Measures, NHTSA (in
cooperation with other federal partners) has
been busy updating the standardized
National EMS Information System
(NEMSIS) data set.This is also a consensus
driven project, but is geared toward global
EMS data. One distinct advantage to this
project is that instead of just focusing on the
data needs at a US level, this second EMS
data set has data items that will provide
useful information at the local, regional, state
and national level.The original federal EMS
data set contained only 83 items, the new set
will have standardized definitions on over
xxx.The program is also being structured so
that it will be Information Technology ready,
reducing the burden for ambulance services
to participate. Congress is supportive of this
approach and has earmarked funds to
continue its development.
The National Consensus Meeting’s Pilot
Set of EMS Measures
While all of the individual programs and
the EMS Performance Measures project are
worthwhile and should continue their work,
our goal was to create consensus on an initial
“pilot set” of EMS quality measures –
measures that will fit within the framework
in use by private and public payers.
At our national consensus meeting we
wanted to meet the following objectives:
• Simple: consider this the “EMS Starter Kit”
• For Everyone: target the least common
denominator
• Ease: consider those that can be measured
from NEMSIS
• Useful: for the local, regional, state and
national level
The participants identified measures from
the clinical, operational and educational
arenas. Of these, the agreed upon starter set
would include measures in these categories:
1 Time
• System issue: time of symptom onset to
911 access
• Benchmark issue: time of dispatch to arrival
at patient’s location
2. Respiratory
• The percentage of patients who require
respiratory support that receive it
• How long did it take to provide respiratory
support
About the authors:
Gary Wingrove is the Manager of Government Relations for Gold
Cross/Mayo Medical Transport; past president of the North Central
EMS Institute; chairs the AAA Small Providers Committee; and is
vice-chair of the AAA Government Affairs Committee.
Debbie Gillquist is the Director of Clinical Services at Allina
Medical Transportation in Minneapolis/St. Paul, MN.
Frank Gresh is Chief Information Officer at the Emergency
Medical Services Authority in Tulsa, OK.
Joe Hansen is the Executive Director of the Critical Illness and
Trauma Foundation in Bozeman, MT.
Annette Kritzler is a Project Manager with Stratis Health QIO
and works with hospitals on public reporting and quality
improvement.
Tami Lichtenberg is a Program Manager at the Rural Health
Resource Center in Duluth, MN.
Kevin McGinnis is Program Advisor for the National Association
of State EMS Officials.
Nels Sanddal is Director of the Rural EMS & Trauma Technical
Assistance Center in Bozeman, MT.
Todd Hatley is Chief Executive Officer of Integral Performance
Solutions, LLC.
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AMBULANCE SERVICE JOURNAL

3.Accuracy
• Accuracy score of PCR
• ALS Subset: the percentage of patients
whose condition indicated ALS that actually
received it
• BLS Subset: time to defibrillation
A workgroup of the consensus meeting
met to assure these measures can be
identified in the NEMSIS data set and to
write the indicator formatting.The measures
are provided in JCAHO format at the end of
this article.A five state trial coordinated by
REMSTTAC and NOSORH is planned for
2006.
Where We Go From Here
P4P is coming to healthcare, both in the
public and private sectors.The evidence for
this is clear and unmistakable with MedPAC
pushing Congress and Medicare restructuring
QIO focus.The last major changes in health
care payment centered on prospective
payment and fee schedules. During that
wave, the ambulance industry was absent in
the discussion and was caught off guard
when Congress announced the establishment
of the Medicare ambulance fee schedule in
1997.
Ambulance services cannot afford to sit
back and watch how P4P rolls out. In order
to survive, regardless of size or location,
ambulance services must get engaged in the
process that will determine our future for
2010 and beyond. Performance improvement
must start at the local level with changes in
attitude and with leadership commitment.
There are a number of things ambulance
services can do now to help secure their
future.
• Develop internal quality improvement
projects in your agency.There is almost an
infinite amount of information available on
the internet on how to start QI projects.
• Develop participative management practices
in your agency.The EMTs and paramedics
must be an integral part of the efforts to
improve your operation. Get them started
thinking quality and reporting, and spend
extra effort on patient documentation
• Find out if there are any interdisciplinary
care teams already functioning in your area,
and where appropriate, insist on
participating. EMS must be at the table for
every discussion
• Embrace and engage in the evolution of
the National EMS Information System and
state EMS data collection efforts
• Develop or participate in collaborative
projects in your healthcare community, make
them truly interdisciplinary, by including the
discipline of EMS
• Find out if it is possible to work with your
QIO.While ambulance services are not
currently in the QIO scope of work, two
Congressional bills, if passed, would require
CMS to change the scope. In the mean time,
learn what the QIO is doing with the
segments of healthcare they are working with
to see what you can learn about what your
future might look like
• Think beyond the ambulance.What can
your EMS agency do, what expertise can you
share, that can contribute to continuous care
in addition to episodic care.
Resources
• National EMS Management Association:
Six Sigma QI course specific to EMS and
Fire.
• National Highway Traffic Safety
Administration – EMS Division:A
Leadership Guide to Quality Improvement
for EMS Systems
• State of Nebraska EMS Office: EMS
System Quality Improvement Model
• Rural & Frontier EMS Agenda for the
Future
The Coming CRISIS in Pre-Hospital CARE
Brown County Democrat, August 28th 2005
A Brown County, Indiana Commissioner
suggests eliminating ambulance service from
2006 budget.A second commissioner, while
not endorsing the idea, did note that
ambulance service is one of the “biggest line
items” in the budget and the county needs to
look at “high ticket items.”
Wabash Plain Dealer, September 9, 2005
The County Council begins rethinking its
commitment to funding ambulance service for
the northern third of the county. "I don't know
how the county can continue to fund the
(ambulance service) in North Manchester,"
President Paul Sites said. "I don't know how we
can do that and I'm looking for an answer."
The first rule I learned in EMS was this one:
“All EMS is Local.” That is hard to dispute
now as local, and county governments scramble
for money. Strapped for cash and ways to pay
the bills for all the services they have promised
and citizens have come to demand,
governments at all levels are looking at ways to
“economize” and where they are looking
should not come as a great surprise to us in the
pre-hospital care industry. It’s beginning to
happen in Indiana. It will be coming soon to
your neighborhood if it is not already there.
The reason governments are looking in our
direction is a combination of ignorance of what
we first responders and ambulance responders
are expected to know, to do and to accomplish
and how we are paid to do it. That lack of
knowledge reflects a lack of respect for what
we do.These perceptions have many
underlying reasons and some of them are
fiercely intertwined.
The first reason is financial. It has long been
the financial secret of this industry that
Medicare underwrites 911 Emergency Medical
Services. Granted, it doesn’t underwrite them
well, but it provides a base of reimbursement
from which 911 services can operate and cover
costs that could not be recovered in the
provision of those services. But then came the
Medicare Fee Schedule and all of its
ramifications – the most impacting of which
was the slow reduction in reimbursement rates
for pre-hospital care while costs – and
expectations in the wake of 9/11 – were
greatly enlarged. No one in local or county
government has ever understood who really
pays for the 911 EMS services its citizens are
getting. And that is our industry’s fault because
of competition, because of complacency, and
because of politics and competition and distrust
between paid and volunteer fire services,
private services, not for profit services and
volunteer departments..
This ignorance of the economic realities of
the business epitomizes lack of respect for what
EMS services are in the form of lack of money
and proper funding.
Crisis • continued on page 8
S PRING 2006
7

Crisis
continued from page 7
The second reason is increased expectation.
This is especially so since 9/11.Whose service
now does not have to deal with hazmat
response and training of its personnel Whose
service now does not have to train in antiterrorism
response, both chemical and
biological Public or private, for-profit or notfor-profit,
municipal or fire – it doesn’t matter
anymore.We are all being expected to pitch in
to meet the needs of “homeland security” and
the public.The drum beat sounds: train more,
understand more, cooperate more and just
plain do more.Yes, some money is available to
do some of it.That is, it’s available if you know
where to get it; or if you have a grant writer
on staff; or if you want it for equipment that is
of no use in the provision of 911 Emergency
Services for the general public. But the average
small ambulance service hasn’t seen a dime of
it and won’t under the current disbursement
policies. These increased expectations and
requirements are a further indication of lack of
respect due to ignorance of what it monetarily
takes to get to these heightened levels of
expectation.
The third reason is lack of understanding of
what we do and how we do it, even from the
very people we work with day in and day out
– emergency room doctors, nurses, and
hospital social service workers. Often treated as
fast taxicabs rather than medical professionals,
ER’s daily ask us to transport patients for
reasons and at levels of care that do not require
our skills, just our wheels – and as quickly as
you can get there, please; with red lights and
siren blaring, thank you very much. Turn on
the red lights and siren and the chance of an
accident involving the ambulance or someone
around that ambulance increases by a factor of
ten. Last week, we attempted to explain to an
ER nurse why it might be unwise to run an
ambulance with red lights to her facility for
the transfer of a patient who was in no danger
of losing life or limb and the answer was,“I
don’t care. Just get them here and now ‘cause
we want this patient out of here.” A similar
refrain came from an ER physician who said,
“Every patient I need transported is ‘stat.’”
There is no consideration given to the risk to
the life and limb of the ambulance technician
in these requests, only to the convenience of
the facility, nurse or physician.
This ignorance of the consequences of what
we do and how we do is just another sign of
the lack of respect – or worse, indifference of
what we do, even among those who should be
cooperating with us as peers.
The fourth reason is an image problem
with the public that translates into lack of
respect for who we are and what we do.
Like the Israelites, we have wandered in the
desert for years looking for an identity, a
place in the public’s view and a reason to be
proud beyond the satisfaction we get in
doing our jobs.We thought we might get
some of that respect after 9/11 when
paramedics – both from public services and
private ones – lost their lives along with
firemen and policemen. But then the
newscasters didn’t even know what to call us
settling for,“and those other, uh... EMS
people.” The American Ambulance
Association has recognized this problem and
pushed to have us called,“Medics” regardless
of the level of EMT or service.That was an
identity that sound-bite America could
understand. But its only now beginning to
catch on and it is not an identity that
explains what we really do, the differences in
levels of skill among us, and how or why we
really do it.
Respect is shown in many ways, but the
chief of those is money or funding.We know
what Medicare thinks of us because they came
out with a sure-fire way to reimburse us below
the cost of providing ambulance services to
our elderly and call it a “Fee Schedule.”
Private insurance carriers took a look at that
and are saying in increasing numbers,‘if it’s
good enough for Medicare, it’s good enough
for us.’The public thinks ambulance services –
even private ones – are included in their taxes
and just don’t pay the bill at a nationwide rate
equal to less than 50% collections of billed
charges.What we are paid for what we do is a
mark of the esteem and respect in which we
are held. Most EMTs labor at or just above
minimum wage and if they have a family, they
are often eligible for food stamps. Paramedics
take jobs in hospitals and as industrial safety
officers because there is neither financial
reward nor upward mobility in 911 systems.
Whose service now does not have to deal
with the more than 40% rise in fuel costs since
before Katrina and the astronomical ones
afterward And yet, fewer than 30 of 435
congressmen have agreed to sponsor legislation
designed to help ambulance services and first
responders in these times.They are probably
the same ones who are so indignant over the
reported failures of FEMA in responding to
Katrina.Their questions of former Director
Brown certainly reflected that ignorance of
what first responders do. But that is a subject
for another article at another time.The issue
here is that, like the late great Rodney
Dangerfield,“we don’t get no respect.”The
issue here is simply that no one except first
responders and their agencies – whoever and
wherever they are – understand what they do
and why they do it. Put all this together and it
is a formula for eventual meltdown of the
system.And that meltdown may be coming
very soon.
This year in Indiana, three ambulance
services with 911 contracts went bankrupt or
decided to give up and just close up.Trained
paramedics, with nowhere to go but
“elsewhere” will go elsewhere. It has already
begun. EMTs at minimum wage will find
other jobs that can lead to a career as EMS
does not.And the turnover will drive training
and staffing costs beyond the ability of
individual services to compensate.
The day is here when we are being paid
less than it costs to provide ambulance
services.The day is coming soon when all
the costs of providing emergency first
responder and ambulance services will
exceed the capability to find efficiencies – to
do more or better with less or the same – in
order to keep them going.
Who and what will suffer Inevitably, those
items individual services can control.That
means equipment, communications, supplies,
personnel; in short, quality. For all other costs
and revenues like insurance and fuel,
reimbursement from government agencies are
beyond our control.
Everyone wants these services. Governments
want them, private agencies want them,
hospitals want them, citizens want them. But
no one yet – not federal nor state nor local nor
the patients themselves -- has the will
necessary to pay for them.
That is the coming crisis: a deep and
desperate crisis whose root is lack of respect.
The looming financial crisis that this lack of
respect is bringing could cause fire and
volunteer services to cut back or restrict
services and less efficient private services to
fight for survival.
Who will come when 911 is dialed and the
tones drop in the station when funding is
gone Perhaps the public will cry out, but only
when an ambulance one day does not come
when called.And perhaps the politicians will
act, but not if the public does not cry out.
Things will get worse before they get better.
That is often the nature of life. It is becoming
the nature of EMS.
8
AMBULANCE SERVICE JOURNAL

PARATECH GOES MOBILE
By Lawrence Knuth, Vice President
Paratech Ambulance Service
with NEW Mobile Data Terminal
Milwaukee –
How mobile is your Mobile Data
Terminal (MDT) We asked this question
to ourselves and found that even though
they were mobile when the vehicle was
moving that was as mobile as they got.We
began to investigate the options for
alternative ways to get the information to
the units in the field with the same
benefits of the mounted MDT system we
currently had but had the ability to stay
with the crewmembers.What we found
was an MDT that works on PDA style
phones.
Paratech first went to a MDT system in
2004 after researching what was available
on the market at that time and went with
a hard mounted MDT system that was
already integrated with our CAD system.
That system included a modem, a
Windows CE device (i.e. NEC 900
Mobile Pro) and an external cellular and
GPS antenna, not to mention several feet
of wire. From the start, we had issues with
installations and software performance.To
make a long story short we were not
happy with the software solution.The
mapping system on the MDT never
worked and because of the mobile device
being Windows CE based, if the unit lost
power for a certain period of time, the
software had to be reloaded and with a
fleet spread out over a large area,
reinstallation was a problem.That is just a
short list of issues we were dealing with.
Beginning Middle of last year, Paratech
began using PDA’s among the
management staff. After a meeting one
day, one of the owners of the company
started asking if using a PDA in the field
would be possible to facilitate the transfer
of data between the communications
center and the units in the field.That
conversation led to researching what
software was available for the PDA that
would allow us to accomplish this goal.
We found a Milwaukee Wisconsinbased
software company that had
developed a GPS solution that works on
GPS-enabled phones.We met with the
representatives from that company and
talked to them about what we wanted.
They came back with a modified version
of their GPS solution that would integrate
with our CAD system and give the same
benefits than our existing MDT solution
plus more. All of which runs on a PDA
with its integrated GPS.
I know what some of you are thinking,
a PDA Are they rugged enough for use
in the field What happens if one gets lost
or damaged We asked the same questions.
The PDA model that we used has proven
rugged enough for field use. Since the
cost of the hardware is significantly less
than that of other MDT hardware we are
able to have spares on hand in case of
damage to a unit or if one potentially
lost. And if one is potentially lost, with
the built in GPS we will have the last
known location of the phone. Also if the
phone is lost the software has a built in
kill feature that allows you to remotely
kill the software so no patient information
is able to be seen by others.
Here are some of the benefits of the
MDT system that we like:
• Portability.The crews can take the
information with them when outside the
unit and also receive updated information
while on the call.
• Routing. Besides having general map
views, the MDT has Routing maps and
text directions that guide the unit from
their current location to the call location.
Can even be used for drop off destinations
as well.
• All In One Communications. Since this
is a phone and with the company’s direct
connect feature, we were able to
consolidate out communications into one
device and one bill.
• Easily Updated. Deployment and
updates are easily accomplished with the
MDT’s built in over the air update
feature.We are able to update the units in
the field with the push of a button. No
need to take a unit out of service for
software updates.
After a couple of months of planning
and testing, we were satisfied with what
we saw and deployed the solution
throughout our entire fleet. Because this
solution does run on a PDA, it is easily
transferred from one unit to another. We
went from having 24 MDT’s mounted in
the units to 18 MDT’s that are portable.
Since moving to the new MDT, we have
seen a great improvement in reliability of
the software as well as the GPS tracking.
The integration to our CAD system is
seamless and no extra work is required by
the dispatchers to get the information to
the units in the field. Our productivity in
the field and in the communications
center has improved greatly since the
transfer.
If you would like more information, please
email me at larryk@wi.rr.com or call 414-
365-8900 Ext. 320.
S PRING 2006
9

REFLECTIONS ON CRAZY EMS DRIVING
By Steve Frisbie, Director of Operations, LifeCare Ambulance Service, Battle Creek, Michigan
“OK Steve, we’re going to put the car into a
skid and see if you can react and correct the
skid” YEE HAW! Ed Schidell taught my first
driver-training course during my medic
education at Davenport College in 1982. What
a blast! However, the Defensive Driving course
should have been more aptly labeled Offensive
Driving.
Skip forward five years.“Medic 4, respond to
a possible overdose, priority 1”. That was the
first radio transmission for the call. One of the
next radio transmissions included,“We’ve been
involved in an accident, my partner is injured,
send help”. Soon, my phone was ringing at
home. A manager’s nightmare had unfolded
and now landed in my lap.
In October of 1987 that is what we
experienced at LifeCare Ambulance Service.
Our crew never made it to the original call; we
had to rely on mutual aid. One medic, the
driver, had a significant arm injury, the other
uninjured. The ambulance, which was now on
its side, and some pieces of ALS equipment
were destroyed.The car that our ambulance hit
was totaled and the driver was slightly injured.
But when the car which the ambulance had
struck while running through the yield sign
spun out of control and struck the child on a
bicycle who was on the sidewalk, the event
rapidly compounded. The child suffered a
serious leg injury from which he will endure a
life-long disability.
Way too often this scenario is carried out
across the world. If you subscribe to any EMS
press clipping service you find that ambulances
and other emergency vehicles kill and injure
people at a frightening pace. Although no
official statistics are compiled, it is believed that
ambulances are involved in around 10,000
crashes each year in the U.S. that involve injury
or death to staff, patients and citizens. That
figure does not include non-injury accidents. If
those figures did not make you gulp for air
then you should stop reading right now.
What are you or your organization doing to
address this growing and acknowledged
problem Approximately two years ago the
USA Today and the Detroit Free Press covered
this issue in a series of articles. Lawyers read
newspaper too! Unfortunately, many in our
industry chose to ignore or even challenge the
facts. Nobody demands perfection but they
(your employees, patients and the public) do
expect all avenues of prevention to be taken.
Rightfully so, we as EMS managers and
administrators worry about preventing needle
sticks, airborne exposures, workplace injuries,
and providing high quality medical care.
Unfortunately, we often ignore the most
dangerous part of the job, driving. Driving
incidents and dropping patients provide our
most litigious events in EMS, not patient care.
Policies and procedures are only one
component of a driving program. Education,
prioritization of calls to determine the need for
lights and siren responses, preventative vehicle
maintenance and driver monitoring help round
out a well-managed program.
After the 1987 ambulance crash our
organization said enough was enough. We
researched several solutions including
education. We decided on a driver-monitoring
product. The company focused on an
educational component along with a driver
monitoring system. After the “crash” it was not
difficult to gain the acceptance of the
employees. Instead of just installing the
monitoring device and telling them to drive
safely, we educated and trained all the staff on
how to safely operate within the parameters of
the system; all the while focusing on their safety
at work and how the system would make it
easier to care for patients in the back of a
moving ambulance.The mindset of our staff
soon turned away from speed and toward
safety.
We have not eliminated crashes nor did we
believe we could, after all, perfection is not
achievable. However, we have greatly reduced
crashes and their severity and have saved
ourselves from many near misses on the
roadways because of our focus on safety. As a
medic, the stable platform of a safely driven
vehicle is much easier to perform your job
within than a platform of hard corners, quick
stops, and jackrabbit starts.
The system monitors vehicle performance
relating to forces being applied to the vehicle
while starting and stopping, cornering and
speed. Obviously, stopping a 10,700-pound
vehicle (Ford E350) is not like stopping a midsized
passenger vehicle. How much distance
does it require to stop a 10,700 pound vehicle
you ask 32 feet when traveling only 25 mph
and conditions are perfect is the correct answer
(see formula below).Traveling 80 mph means
your braking distance is 328 feet. Add reaction
time (generally 1.5 seconds and another 180
feet) to that and you are now getting a clear
picture. Now add a time frame for a
perception that you need to react and you have
traveled 450+ feet. Speed kills and there is no
ability to overcome the affects of speed.
LifeCare set the top-end speed allowed at
72mph. If anyone travels over that speed, the
monitoring system captures that event along
with immediately notifying the driver. Making
it safely to the call and back to the hospital is
our goal. Issues such as out-of-chute times,
proper vehicle positioning, and taking the
shortest routes are the best methods to
overcome response time issues, not speed.
The initial system purchased in 1987 cost
$1800 per vehicle.The cost of the system was
recouped in about 8 months because of vehicle
maintenance savings. Cracked rotors became a
thing of the past. Our brake pad life
quadrupled to over 21,000 miles. Our
insurance carrier in 1987 rewarded us with a
30% decrease in vehicle premiums. The
company’s newest and most sophisticated
monitoring system now costs approximately
$3300 per vehicle so paybacks will take an
extended amount of time. However, the
immediate payback of a stable platform for a
Medic or EMT providing care and the
reduction of unsafe driving will be priceless.
In 2004, the American Ambulance
Association (AAA) adopted a “Best Practice
Model” for safe driving. Larry Anderson,
LifeCare’s CEO, helped craft this policy and
worked tirelessly within AAA to see its passage.
At LifeCare Ambulance we spend a minimum
of 16 hours (8 classroom and 8 driving hours)
in driver training call Collision Avoidance
Training (C.A.T.) with all new employees
during orientation. We constantly monitor
driver performance and have even terminated
employment of personnel who refused to
comply with safe driving techniques.
Performance within the system is also a
component of the employee’s performance
evaluation. Most often, the rest of the staff will
voice displeasure with the unsafe driving of a
coworker before we discover an issue within
the monitoring system.
The keys of safe driving are extended
following distances (4-5 seconds), looking
ahead down the road (20 seconds), clearing of
intersections one lane at a time, and driving
only as fast as conditions allow. Policies and
procedures only go so far. Training and the use
of a driver monitoring system will greatly
reduce your crashes and liability.
Braking Distance = MPH squared
30 x .65 (drag factor)
Source:Thomas Case, Union City Police Chief,
Accident Investigator and Reconstruction
10
AMBULANCE SERVICE JOURNAL

AAA Position
continued from page 3
and man-made disasters.These events are
rarely ongoing, and are generally
geographically contained. A cornerstone of
this planning has been the ability to call on
EMS resources from neighboring areas to
bolster the needed response. Unlike other
mass casualty incidents, pandemic planning
requires community plans to be selfsufficient.
In essence, when the whole world
is sick, there is no one to call for additional
help. It is, of course, just this problem that
makes pandemic planning difficult.
Luckily EMS has a few models and lessons
to refer to in preparation for a pandemic.
Most pandemics are caused by respiratory
pathogens. We can therefore look at past
preparations and rules relating to our past
experience with SARS and tuberculosis as
our starting points. Mass relief efforts and
shelter operations such as those associated
with past natural disasters provide a reference
point for planning quarantine, isolation, and
contingency health care facilities.
It is beyond the scope of this article to
describe the community planning needs for
a pandemic. However, the Centers for
Disease Control and U.S. Department of
Health have published a guide to
community planning available at
http://pandemicflu.gov/plan/statelocalchecklist.html
to assist the EMS community and other first
responders in this endeavor. Suffice it to say
that ambulance services and EMS agencies
must be engaged at the local level planning
meetings. It is suggested that every
ambulance service administrator be familiar
with the contents of the Centers for Disease
Control and U.S. Department of Health
community planning guide.
Specific modeling tools to help EMS
agencies grasp potential patient numbers are
available at
http://pandemicflu.gov/plan/tools.html. Of
particular interest is Flu Surge, a modeling
tool that predicts hospitalization and fatality
rates.
Business level planning is critical for all
EMS and first responder agencies. A good
starting point is the planning guide and
checklist from the Centers for Disease
Control available at
http://www.cdc.gov/flu/pandemic/checklists.htm.
It is estimated that up to 40% of EMS staff
and first responders will be stricken with the
disease and unavailable to work for an
unknown period of time. Contingency
staffing plans must be anticipated and readily
available prior to any need.With this basic
tenet in mind the following issues must be
considered:
1. Can dispatch protocols be modified to
provide specific healthcare instructions to
callers that may have the flu and not need an
ambulance During an outbreak of
respiratory disease, patients that should be
treated without transport, and those that
truly need ambulance transportation must be
identified early in the dispatch process.
Identifying the “worried-well” must also be
included early in the dispatch process.This is
the first step in reducing the spread of
disease and maximizing appropriate use of
community resources.
2. Is there an effective infection control
policy and procedure for the service Do all
employees know what and where this policy
is Is there an equipment and vehicle
decontamination procedure in place The
use of appropriate personal protective
equipment is paramount during an outbreak
of respiratory disease, much less a pandemic.
Minimally, each employee involved in
patient care must have a N95 mask, gloves,
eye protection, and isolation gown for each
point of contact. Planning for supply
stockpiles and re-supply must be considered
in the plan. Are those supplies easily available
and accessible to crews Special
consideration should be given to supply loss
as a result of spoilage, and theft. Count on
some supplies to suddenly turn up missing.
Consider how many pairs of gloves an
agency buys compared to the number of
patient transports per year and you can easily
understand the point.
3.What, if any, emergency expanded scope
of practice rules exist for your area EMS
agencies could, and probably will, be called
on to help in mass immunization programs
or mass distribution of medications. Are your
personnel capable of these tasks and are they
permitted to perform these tasks Under
which circumstances What legal authority
exists to assist your agency in carrying out
these duties
4. Have employees been informed of the
need for personal and family preparation
Are your employees able and willing to
potentially come to work for days on end
and not see family, either due to workload
or the need to remain isolated to prevent the
spread of disease from work force to family
5.What are the personnel policies regarding
illness obtained at work and the
continuation of a paycheck due to being in
isolation or quarantine What does your
Workers Compensation plan say about the
issue
6. Is there a local quarantine and isolation
authority How does it work Will your
agency be involved in the staffing of such a
facility either by demand or contract The
same questions may also apply to
contingency health care facilities and must
be considered.
7. Do you have an established working
relationship with your local public health
department or authority They will likely be
the agency calling the shots during a
pandemic. Planning, practicing and
becoming familiar with these individuals
now will help your agencies response and
operational effectiveness when a pandemic
occur in the future.
8. It is imperative that planning continue and
not be set aside simply because there is no
current “crisis” to deal with. Failure to plan
now will most likely have significant
consequences should a pandemic event
begin to materialize.
Personal and family preparation for any
disruptive health event is highly suggested
and strongly encouraged. Information about
personal disaster and pandemic preparedness
is available from the Centers for Disease
Control and Department of Homeland
Security as well as non-governmental
agencies such as the Red Cross.
S PRING 2006
11

Information and
Upcoming Events
Do your vehicles have tinted windows
If so, please email us at sbromley@the-aaa.org or call Stacy Bromley at 703-610-0247. We will be ordering new membership
decals that can be placed externally on your vehicles so they can be seen! The current decals are difficult to read with tinted
windows as they are placed inside. Please let us know if you need external decals so we can place an order by May 15, 2006.
Stars of Life Celebration
May 7-10, 2006
Omni Shoreham Hotel
Washington, DC
The AAA is preparing to honor many of those individual paramedics and other emergency medical service personnel from all
over the nation at the 13th Annual Stars of Life Celebration. The three-day event involves the “Stars” being inspired and
presented with Gold Medals by 2006 Winter Olympian Emily Cook, in a Kick-Off and Orientation. Stars will engage in face-toface
meetings with their Members of Congress on Capitol Hill, where they deliver important information to their U.S
Representatives and Senators on the value of quality ambulance service as a key component of an effective and efficient
health care delivery system.
Summer Reimbursement Conference
July 11-15, 2006
Indianapolis Marriott Downtown
Indianapolis, IN
This is the conference that addresses "hot" reimbursement issues from the industry experts.
Annual Convention and Tradeshow
October 1-7, 2006
Caribe Royale Orlando All-Suites Resort and Convention Center
Orlando, FL
Come to the conference that has the largest gathering of ambulance and pre-hospital care leaders, that gives you the tools
you need to promote the growth and development of both new and established business!
S PRING 2006
15

2006 AAA Calendar of Events
Mark your calendars for these events!
May 7-10, 2006
Stars of Life Celebration
Washington, DC- Omni Shoreham Hotel
July 11 - July 15, 2006
Summer Healthcare Reimbursement
Conference
Indianapolis, IN – Indianapolis Marriott
Downtown
October 1 – 7, 2006
Annual Convention and Tradeshow
Orlando, FL – CaribeRoyale All-Suites
and Resort
Visit www.the-aaa.org for more information.