Generally, state departments regulate ground ambulance agencies and their personnel, including the EMS medical director. This is not the case in Colorado, the only state in which ground ambulance agencies are licensed at the county level. While California licenses ground ambulances at a regional level to account for the size of the state, and New Mexico uses an independent elected entity to license ground ambulance agencies at the state level, the remaining 47 states license ground ambulance agencies through their state EMS offices/agencies. (See how licensing is conducted across the 50 states in Appendix I)
In Colorado, the oversight of the EMS system involves three different entities. First, CDPHE is responsible for certifying/licensing EMS providers, licensing air ambulance agencies,[67] setting minimum standards for county ground ambulance agency licensure, and selective oversight of EMS medical directors. Second, the Colorado Medical Board, as the physician licensing board, has authority over the EMS medical director’s license. Third, Colorado’s boards of county commissioners are designated by statute to license all EMS ground ambulance agencies that are based in their counties.[68] This statutory framework means that a ground ambulance agency, or an air ambulance agency with a critical care ground transport service, must apply for licensure in each county in which it would like to provide service.[69]
With respect to the ground ambulance agency licensing component, counties typically adopt resolutions that set forth their licensing processes. Counties must incorporate minimum mandatory standards into their licensure process of ground ambulance agencies, including: 1) the minimum equipment to be carried on an ambulance, 2) staff requirements for ambulances, 3) medical oversight and quality improvement of ambulance services, 4) the process used to investigate complaints against an ambulance service, and 5) data collection and reporting to CDPHE by an ambulance service.[70] Aside from these required minimum standards, however, each of Colorado’s 64 counties can impose additional standards on the services they license. Counties also possess sole discretion concerning the extent to which they oversee licensed ground ambulance agencies. Although some counties actively oversee their ground ambulance agency licensing process, some do not, and only become involved in oversight after a significant, concerning event has occurred. Thus, the standards across the counties vary, as does the level of monitoring.
CDPHE has no jurisdiction over suboptimal systemic care delivery either through routine inspections or complaint investigations of ground ambulance agencies. In a decentralized system, accountability is highly variable. If a system failure occurs, CDPHE may hold the individual EMS provider accountable, but it lacks the authority to investigate or sanction the ground ambulance agency’s role in the failure. Only the county has the authority and discretion to hold a ground ambulance agency accountable for deficiencies.
This division of authority can result in unfair regulatory actions. While CDPHE receives complaints about individual EMS providers and occasionally the ambulance agencies themselves, CDPHE can only investigate a complaint to the extent it concerns the EMS providers on the ambulance. Complaints concerning the ambulance agency or the county’s EMS system as a whole must be investigated and addressed at the local/county level. In fact, CDPHE has previously taken disciplinary action against individual EMS providers when the root cause of the complaint was mainly attributable to ground ambulance agency failures, over which CDPHE has no jurisdiction.
Owing to Colorado’s fragmented oversight of its EMS system, the panel also found it difficult to discern “who controls the medicine” when investigating the administration of ketamine in the prehospital setting. The question cannot be answered with a singular response. The panel suggested the EMS agency medical director should control the medicine; but that suggestion begged the question of “who controls the EMS medical director?” As the panel learned, CDPHE sets minimum standards for physicians to be EMS medical directors, but EMS medical directors ultimately answer to the ground ambulance agencies for which they provide medical direction and to the Colorado Medical Board when their alleged acts or omissions potentially threaten the good standing of their professional licenses. The panel agreed that Colorado’s splintered and variable regulatory oversight over EMS medical directors falls short of ensuring the effective and consistent oversight of EMS medical directors.
The panel learned that 47 states regulate their EMS systems through a unified system approach. In a unified system, a state agency regulates EMS ground ambulance agencies and 911 non-transport agencies and EMS personnel. The EMS Agenda 2050 stresses the importance of a unified system; it lists “Integration and Seamless” as a required component of a people-centered system in which:
- healthcare systems, including EMS, are fully integrated. Additionally, local EMS services collaborate frequently with community partners, including public safety agencies, public health, social services and public works. Communication and coordination across the care continuum are seamless, leaving people with a feeling that one system, comprising many integrated parts, is caring for them and their families.[71]
In Colorado, neither EMS ground ambulance agencies nor non-transport agencies (such as fire departments) that provide EMS services are overseen at the state level. The panel acknowledges that EMS providers are a component, and not the totality, of the EMS system; thus, they should not be the only segment of the EMS system that is consistently held to account by its regulatory authority. In the panel’s view, the protection of Colorado’s EMS consumers demands that all components of the EMS system be held accountable to predictable standards under a unified system. Centralization and standardization of EMS system licensure will improve quality of care, provide checks and balances, clarify system oversight, and improve delivery of socially equitable emergency medical services to Colorado consumers.
PANEL RECOMMENDATION
The General Assembly should consolidate the regulation of all components of Colorado’s EMS system under CDPHE, including ground ambulance agencies, into a unified system, under a state licensing program that assures consumer protections are in place.