WSR 04-07-179

PROPOSED RULES

DEPARTMENT OF HEALTH


[ Filed March 24, 2004, 9:27 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 03-21-117.

Title of Rule: WAC 246-976-935 Emergency medical services and trauma care system (EMS/TCS) trust account.

Purpose: The legislature appropriates money to both the Department of Health (DOH) and the Department of Social and Health Services (DSHS) as part of a spending plan to be dispersed to trauma verified prehospital agencies, designated level I-V acute facilities, designated trauma rehabilitation facilities, physicians and other clinicians. This section describes how the DOH disperses the money appropriated to them.

Other Identifying Information: As a result of the new budget appropriations adopted by the legislature for the 2003-2005 biennium for the EMS/TCS trust account, DOH and DSHS now have separate appropriations that no longer require the agencies to contract with one another. This requires new spending plans to be developed.

Statutory Authority for Adoption: Chapter 70.168 RCW.

Statute Being Implemented: Chapter 70.168 RCW.

Summary: Based on the new spending plans, the proposed rule identifies DOH's new grant distribution methods and removes language from methods that are no longer applicable or that have not met the intended goals and objectives.

Reasons Supporting Proposal: As a result of the new budget appropriations, the department has developed a new spending plan for the EMS/TCS trust account. The new spending plan includes new grant funding distribution methodologies that need to be added to WAC 246-976-935. The proposal will help prevent expenditures from exceeding appropriations.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Rebecca Pittman, 310 Israel Road S.E., Tumwater, WA 98501, (360) 236-2860.

Name of Proponent: Department of Health, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The EMS/TCS trust account was created under RCW 70.168.040. DOH distributes funds from this account for state trauma care system purposes, including emergency medical services, trauma care services, rehabilitation services, and the planning and development of related services. DSHS distributes funds from this same account for Medicaid trauma care services provided by designated trauma centers and their trauma physicians and clinical providers.

As a result of the new budget appropriations adopted by the legislature for the 2003-2005 biennium for the EMS/TCS trust account, DOH and DSHS now have separate appropriations that no longer require the agencies to contract with one another. A new spending plan was developed to distribute these funds according to the legislative intent and to assure that the state expenditures do not exceed the amount appropriated to each agency. For DOH, the new spending plan includes new grant distribution methods.

WAC 246-976-935 is based on RCW 70.168.135, which states that DOH shall establish by rule a grant program for trauma care services, and that the grants will be made from the EMS/TCS trust account. The proposed amendments include the new grant distribution methods and remove language for methods that are no longer applicable or that have not met the intended goals and objectives. The proposal will also help prevent expenditures from exceeding the department's appropriation.

Proposal Changes the Following Existing Rules: 1. The definition of "initial acute episode of injury" has been deleted.

2. All references to how DSHS allocates expenditures have been deleted.

3. Language has been added to define the methodology for allocating funds through the new uncompensated trauma care grants for level I-III acute designated services.

4. Language has been added to define the methodology for allocating funds through the new trauma care grants for level IV and V services, and/or CAH (critical access hospital).

5. Language has been deleted that would require DOH to provide partial reimbursement to physicians and other clinical providers for care of trauma patients who meet DOH criteria.

6. Language has been added to distribute trust account funds to physicians that are DOH-certified medical program directors (MPD).

7. Language has been deleted for partial reimbursement to designated trauma rehabilitation services.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

Small Business Economic Impact Statement

What Does the Rule Amendment Require? Emergency medical services and trauma care are provided to all residents of the state of Washington regardless of a person's ability to pay. In 1997 the Washington state legislature passed the trauma reimbursement fund legislation to provide funding to hospitals and health care providers for costs incurred while caring for uninsured or underinsured major trauma patients. The legislature appropriates money to both DOH and DSHS as part of a spending plan to be dispersed to trauma verified prehospital agencies, designated level I-V acute facilities, designated trauma rehabilitation facilities, physicians and other clinicians.

As a result of the new budget appropriations adopted by the legislature for the 2003-2005 biennium for the emergency medical services and trauma care system trust account, DOH and DSHS now have separate appropriations that no longer require the agencies to contract with one another. A new spending plan was developed to distribute these funds according to legislative intent and to assure that the state expenditures do not exceed the amount appropriated to each agency. For DOH, the new spending plan includes new grant distribution methods.

The trauma care fund (TCF) workgroup was established in January 2003 to develop new methodologies for distributing trauma care funds as stipulated by the legislature's appropriation of these funds. The group met six times in 2003, and will continue to meet to monitor the results of the implementation of the new methodologies, and to recommend changes as needed. The workgroup includes representatives from the Washington State Hospital Association, the Washington State Medical Association, a representative for each level (I-V) of designated trauma service, hospital financial representatives, physicians, trauma nurse coordinators, interested public parties, and state staff from both DOH and DSHS.

In creating the new trauma care grant methodologies, DOH staff presented options to the TCF workgroup for consideration. Additional options were created through discussion at the workgroup meetings. DOH staff modeled the grants under the various options, in some cases working with a smaller subgroup of financial people. The results were brought back to the TCF workgroup for discussion, and after thorough discussion of the pros and cons for each option, members would agree on a recommendation.

The TCF workgroup operates under the consensus model and strives to select fair methods that best meet the objectives for the EMS and trauma system as a whole. Their recommendations go before the EMS and Trauma Steering Committee for endorsement, and a final recommendation is made to the department.

DOH's existing rule (WAC 246-976-935) must be amended in order to include the new grant distribution methods, and to remove language for methods that are no longer applicable or that have not met the goals and objectives intended. These rules will also help prevent expenditures from exceeding the department's appropriation.

DOH, Office of Emergency Medical Services and Trauma System (OEMSTS) is proposing the following changes to the trauma care fund, WAC 246-976-935:

1. The definition of "initial acute episode of injury" has been deleted.

2. All references to how DSHS allocates expenditures have been deleted.

3. Language has been added to define the methodology for allocating funds through the new uncompensated trauma care grants for level I - III acute designated services.

4. Language has been added to define the methodology for allocating funds through the new trauma care grants for level IV and V services, and/or CAH (critical access hospital).

5. Language has been deleted to provide partial reimbursement to physicians and other clinical providers for care of trauma patients.

6. Language has been added to distribute trust account funds to physicians that are DOH-certified medical program directors (MPD).

7. Language has been deleted for partial reimbursement to designated trauma rehabilitation services.

Is a Small Business Economic Impact Statement (SBEIS) Required for This Rule? Yes.

What Industries are Affected? The following Standard Industrial Classification (SIC) Codes affected by this rule change encompass:

8011 Offices & Clinics of Medical Doctors

8031 Offices of Osteopathic Physicians

8049 Offices of Other Health Practitioners (Includes Nurses)

8062 General Medical & Surgical Hospitals

8069 Specialty Hospitals exc. Psychiatric (Includes Children's Hospitals)


SIC Total Units Total Employment Average Employment
Smallest 90% Largest 10%
8011 2,821 43,659 7.9 154.2
8031 120 680 3.5 13.2
8049 913 5,450 2.6 27.4
8062 146 78,593 11.1 2,027.7
8069 23 4,106 15.4 167.7

What are the Costs of Complying with this Rule for Small Businesses (Those with Fifty or Fewer Employees) and For the Largest 10% of Businesses affected? The proposed rule changes either reduce the burden on businesses, have minimal impact, or do not have any associated costs.

Does the Rule Impose a Disproportionate Impact on Small Businesses? The proposed rule changes do not have a disproportionate impact on small businesses. The proposed rule changes either reduce the burden on businesses, have minimal impact, or do not have any associated costs.

How are Small Businesses Involved in the Development of this Rule? DOH used the trauma care fund workgroup (as described above) to develop and come to a consensus on methods that are fair and administratively simple. In addition, this rule has been reviewed by the governor appointed EMS and Trauma System Steering Committee at open public meetings. The steering committee includes constituents representing: Designated trauma services, Association of Anesthesiologists - Washington Chapter, American College of Surgeons Committee on Trauma - Washington Chapter, Washington State Hospital Association, American College of Surgeons, Emergency Nurse's Association, Association of Neurological Surgeons, Washington State Medical Association Standards Committee, Washington State Association of Fire Chiefs, Washington State Fire Commissioner's Association, Washington Ambulance Association, Washington State Firefighter's Association, Washington State Law Enforcement, and the citizens of Washington state.

A copy of the statement may be obtained by writing to Department of Health, EMS and Trauma System, Tami Schweppe, P.O. Box 47853, Olympia, WA 98504-7853, phone (360) 236-2859, fax (360) 236-2829.

RCW 34.05.328 applies to this rule adoption. The proposed rule adopts substantive provisions of law pursuant to delegated legislative authority, the violation of which subjects a violator of such rule to a penalty or sanction (i.e., receiving or not receiving a grant issued by DOH).

Hearing Location: Department of Health, 20435 72nd Avenue South, Suite 200, Kent, WA 98032, on May 6, 2004, at 9:00 a.m.

Assistance for Persons with Disabilities: Tami Schweppe by April 22, 2004, TDD (800) 833-6388 or (360) 236-2859.

Submit Written Comments to: Contact Tami Schweppe, P.O. Box 47853, Olympia, WA 98504-7853, fax (360) 236-2829, by April 29, 2004.

Date of Intended Adoption: May 7, 2004.

March 19, 2004

Mary C. Selecky

Secretary

OTS-6437.2


AMENDATORY SECTION(Amending WSR 02-04-045, filed 1/29/02, effective 3/1/02)

WAC 246-976-935   Emergency medical services and trauma care system trust account.   RCW 70.168.040 establishes the emergency medical services and trauma care system trust account. With the advice of the EMS/TC steering committee, the department will develop a method to budget and distribute funds in the trust account. The department may use an injury severity score to define a major trauma patient. Initially, the method and budget will be based on the department's Trauma Care Cost Reimbursement Study, final report (October 1991). The committee and the department will review the method and the budget at least every two years.

(1) Definitions: The following phrases used in this section mean:

(a) (("Initial acute episode of injury" refers to care that is related to a major trauma. This can include prehospital care, resuscitation, stabilization, inpatient care and/or subsequent transfer, and rehabilitation. It does not include later readmission or outpatient care.

(b))) "Needs grant" is a trust account payment that is based on a demonstrated need to develop and maintain service that meets the trauma care standards of chapter 70.168 RCW and this chapter. Needs grants are awarded to verified trauma care ambulance or aid services. Services must be able to show that they have looked for other resources without success before they will be considered for a needs grant.

(((c))) (b) "Participation grant" refers to a trust account payment designed to compensate the recipient for participation in the state's comprehensive trauma care system. These grants are intended as a tool for assuring access to trauma care. Participation grants are awarded to:

(i) Verified trauma care ambulance or aid services;

(ii) Designated trauma care services; and

(iii) Designated trauma rehabilitation services.

(2) The department will distribute trust account funds to:

(a) Verified trauma care ambulance and aid services;

(b) Designated trauma care services:

(i) Levels I-V general; and

(ii) Levels I-III pediatric;

(c) ((Physicians and other clinical providers who:

(i) Are members of designated trauma care services;

(ii) Meet the response-time standards of this chapter;

(iii) Provide care for major trauma patients during the initial acute episode of injury. This includes physiatrists who consult on rehabilitation during the acute hospital stay, or who provide care in a designated trauma rehabilitation service;

(iv) Complete trauma records in a timely manner according to the trauma care services current requirements; and

(v) Participate in quality assurance activities;

(d))) Designated trauma rehabilitation services:

(i) Levels I-III; and

(ii) Level I-pediatric.

(3) The department's distribution method for verified trauma care ambulance and aid services will include at least:

(a) Participation grants, which will be awarded once a year to services that comply with verification standards((. Services that are eligible to receive Medicaid funds will have the option of either receiving the participation grant or receiving an increased payment by the department of social and health services for medical emergency transportation of medical assistance clients who meet trauma triage criteria));

(b) Needs grants, based on the service's ability to meet the standards of chapter 70.168 RCW and chapter 246-976 WAC (this chapter). The department may consider:

(i) Level of service (BLS, ILS, ALS);

(ii) Type of service (aid or ambulance);

(iii) Response area (rural, suburban, urban, wilderness);

(iv) Volume of service;

(v) Other factors that relate to trauma care;

(4) The department's distribution method for designated trauma care services((, levels I-V general and I-III-pediatric)) will include ((at least)):

(a) Participation grants to levels I-V general and I-III pediatric, which will be awarded once a year only to services that comply with designation standards. The department will review the compliance requirements annually. The department may consider:

(i) Level of designation;

(ii) Service area (rural, suburban, urban, wilderness);

(iii) Volume of service;

(iv) The percentage of uncompensated major trauma care;

(v) Other factors that relate to trauma care;

(b) ((Increased payment by the department of social and health services for major trauma care for medical assistance clients during the initial acute episode of injury;

(5) The department's distribution method for physicians and other clinical providers included in subsection (2)(c) of this section will include at least:

(a) Increased payment by the department of social and health services for trauma care of medical assistance clients and care provided within six months of the date of injury for inpatient surgical procedures related to the injury, which were planned during the initial acute episode of injury, using Medicare rates as a benchmark;

(b) Partial reimbursement for care of other major trauma patients who meet DOH eligibility criteria. The department's criteria will consider at least:

(i) The patient's ability to pay;

(ii) The patient's eligibility for other health insurance, such as medical assistance or Washington's basic health plan;

(iii) Other sources of payment.)) Trauma care grants, which will be awarded once a year to level I-III designated acute trauma services to subsidize uncompensated trauma care costs. To be eligible for the grants, trauma services must comply with Washington state's DOH trauma registry requirements per WAC 246-976-420 through 246-976-430 including submission of complete financial data and injury coding data. The grants will be calculated by multiplying a hospital's bad debt and charity care ratio times the sum of injury severity scores (ISS) for a specific period. The results for all eligible trauma services are summed, and each trauma service will receive a proportionate share of the available uncompensated trauma care grant allocation based on their percentage of the overall total. The bad debt and charity care ratio is calculated by summing a hospital's bad debt and charity care figures divided by the hospital's total patient revenue for the same period. These figures are from annual financial data reported to the department per chapters 246-453 and 246-454 WAC. Injury severity scores are extracted from trauma registry data for cases that:

(i) Meet the trauma registry inclusion criteria per WAC 246-976-420; and

(ii) Are admitted with an ISS of thirteen or greater for adults, nine or greater for pediatric patients less than fifteen years of age, or trauma patients received in transfer regardless of the ISS.

(c) Trauma care grants, which will be awarded once a year to designated acute trauma services levels IV, V, and/or critical access hospitals (CAH) to subsidize their costs for providing care to the trauma patients, and for stabilizing and transferring major trauma patients. The individual grant amounts are based on designation level.

(5) The department may issue grants to DOH-certified medical program directors (MPD) for their role in the EMS/TCS as described in WAC 246-976-920.

(6) The department's distribution method for designated trauma rehabilitation services, levels I-III and I-pediatric will include at least:

(((a))) Participation grants, which will be awarded once a year only to services that comply with designation standards. The department will review the compliance requirements annually. The department may consider:

(((i))) (a) Level of designation;

(((ii))) (b) Volume of service;

(((iii))) (c) Other factors that relate to trauma care((;

(b) Partial reimbursement for trauma rehabilitation provided during the initial acute episode of injury for major trauma patients who:

(i) Meet DOH eligibility criteria. The department's criteria will include at least:

(A) Residence in Washington at the time of injury;

(B) The patient's ability to pay;

(C) The patient's eligibility for other health insurance, such as medical assistance or Washington's basic health plan;

(D) Other sources of payment;

(ii) Were admitted for rehabilitation service within ninety days of the injury;

(c) The department will give priority to acute inpatient rehabilitation services.

(7) Chapter 70.168 RCW requires regional match of state funds from the emergency medical services and trauma care trust account. Contributions to regional matching funds may include:

(a) Hard match;

(b) Soft match:

(i) The value of services provided by volunteer prehospital agencies;

(ii) Local government support;

(iii) The cost of care by designated trauma care services which exceeds insurance or patient payment;

(iv) The value of volunteer time (excluding any expenses paid with state funds) to establish and operate:

(A) State EMS/TC committees and their subcommittees;

(B) Regional and local EMS/TC councils, and their committees and subcommittees;

(C) Regional and local quality assurance programs;

(D) Injury prevention and public education programs;

(E) EMS training and education programs;

(F) Trauma-related stress management and support programs;

(c) The department will determine the value of personnel time included in soft match, to be applied statewide)).

[Statutory Authority: RCW 70.168.040. 02-04-045, 246-976-935, filed 1/29/02, effective 3/1/02. Statutory Authority: Chapter 70.168 RCW. 98-05-035, 246-976-935, filed 2/10/98, effective 3/13/98.]

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