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SDPB. Well, good morning, everybody. I do want to thank you for all coming and being a part of this grand discussion that we're going to have. Right now, I'm going to call Senator Otten. I'll be chairing it just for a few moments. And the reason they gave me the chair at this moment is I've got absolutely zero interest in being the chair. So that's how you get nominated around here. So with that, we will call the Emergency Medical Services Funding Task Force will now come to order. And Madam Secretary, would you please call the roll?

Senators Reed?

Here.

Peterson?

Here.

Here.

Here.

Here.

Here.

Here.

Here.

Here. Mr. Chair, you have a quorum?

We have a quorum, and at this time we will start with the Pledge of Allegiance. Representative Weems, would you lead us in that?

All right.

All right. We will move then to the election itself. I think because the primary was all fresh in our minds that we will do this by secret ballot. And those that are online, the way that we'll handle that is you will message in who you support when we get to that individual.

Okay.

If we only have one nomination for it, then we'll just move for unanimous consent and we'll just move on. So with that, I would ask then first order of business is the election of the chair. Are there any nominations for chair?

Mr.

Chair, I nominate Senator Reed.

Okay, Representative Emery has nominated Senator Reed for chair. Are there any other? Oh, I'm sorry. Second. Representative Williams has seconded it. I get excited when I get to give mallet. All right. So are there any other nominations for chair? All right. Then we can move to anybody online.

Okay.

No messages. We'll give it a couple here. We do need Jeopardy music.

All right.

With that then, I would ask for unanimous consent then for Senator Reed as chairman of The task force. All those in favor, say aye.

Aye.

Those opposed? All right. Congratulations or my condolences, whichever you prefer. And with that, I'm going to disappear.

Thank you, Senator Otten, for chairing. And we'll get started here and to elect the vice chair. And so I'll open nominations for vice chair. Any nominations for vice chair?

I'd like to nominate Representative Emery.

We have a nomination of Representative Emery by Representative Fosness, seconded by Representative Weems. Are there any other nominations for vice chair? Pausing for online. Seeing none, we only have one nomination for vice chair. And so all those in favor of that nomination will say aye.

Aye.

Any opposed?

No.

Did someone have an oppose? Was somebody opposed online?

Yes, Senator Sue Peterson.

Okay, thank you. Okay, and with that, Senator Emery is elected as vice chair.

Representative.

So you want to go ahead and move over here. Thank you everybody for attending. As you know, Senate Bill 89 is what started or what got us this interim task force. It's actually, I think the term we're using is task force. And so a couple things here I think to get started. As you know, we had an interim task force or an interim committee last interim. And we got some good things done, but we felt there was more that needed to be done. And myself, along with Representative Emery, filed Senate Bill 89. And so first thing I'd like to come back to is just talk a little bit about last year, some of the things that we did get done and kind of some of the things that were left open. And then I think what I'd like to do is go around to members that were with us last year to see if they had anything else that they'd like to I'd like to add to it. I think otherwise everybody has the agenda in front of us. So very high level, some of the things that we talked about was, of course, the demand that there is for EMS services. And then the issues that we do have ambulance deserts and that these ambulance areas, a lot of the ambulance services are struggling financially and to have members that are available, to have EMS folks that are available to do the jobs. One of the things we did talk about, of course, was the workforce shortage, as I just mentioned, and that the volunteers were aging out and that younger folks were not coming into the business of EMS, being trained to do it. We got into this little bit of a, well, volunteerism is down. And our comments was, no, volunteerism is not down. There's just so many more things people volunteer for. Plus they're managing their whole, their lives, their whole family lives. And so we do have an issue with the personnel that are needed to staff these ambulances. We also reviewed telemedicine in motion and really just to learn about it and how it has helped in our rural areas. And then we also moved on to some issues that we saw that were a little more short-term. I'll back up to one thing. I talked about the finances of this. We knew that the reimbursement rates, the Medicaid rates are just not covering. And so that was an issue with why ambulance services aren't able— are really struggling financially. We also realized that, you know, what they're able to pay or what we have for the management on the financial side is also difficult. for a lot of these services. And so we needed to— we needed to figure that issue out also. And we'll talk about that a little bit more here in the future. The other thing that we talked about was there was confusion about nurses, whether or not they could be part of the team. And the— so we did pass a bill last year. Many of you were part of that, that helped with that situation. And then also how the drivers were trained.

Okay.

And that they were going through another series of the EVOC training when they've already— some of them had already received it if they were a policeman or any other kind of emergency personnel, fire departments, fire operators, et cetera. So that's something else. One thing that was kind of left open that I think we need to continue talking about is treatment in place. We thought that we kind of had some momentum on that. I think that's something we're going to have to talk about. And we can get into that a little bit more in detail. And the other draft— those are the 2 drafts we had. So I think that was the basics. I mean, that's really high level of what we talked about and what we got done last year. And of course, if anybody wants to go back and look, you can go to the final report. That's from last year interim, all the interim task force. Now, what we're up to this year, what we need to do during this task force, Is, and it's the first section of Senate Bill 89. The first thing is examine mechanisms to fund counties and municipalities for the provision of emergency medical services as an essential service. We have to figure that out because if it's going to be essential, we have to have a funding path. Examine policies for ambulance service payments, including reimbursement standards for out-of-network emergency medical services. Seek input from relevant stakeholders on the provision of emergency medical services as an essential service. Provide to the executive board no later than November 1st report containing findings and recommendations for legislative proposals related to the funding of emergency medical services in the state. And then also, as we had during the last session, we talked quite a bit about the rural healthcare transformation funds. So review planned expenditures of the rural health. Transformation Program and evaluate opportunities to incorporate the funds into emergency medical services funding strategies. And so we can meet up to 5 times and for this time. So we'll also— I don't know if we had it in the agenda, but before we leave, we'll make sure we'll talk about when our next meetings are. So with that, I guess I'll turn it over first to committee members from last year if they'd like to Add anything, Senator Jensen. Do you have anything to add?

No, I think that pretty well wrapped it up. I mean, there was a lot of you know lower level discussion. I think that'll come up this year as far as regionalization and that kind of stuff. So that'll move us forward.

Great, Representative Hunt. Anything to add? Representative Emery.

Um, yeah, I think the the. High level looking at everything is that EMS is conducted differently throughout the entire state of South Dakota. One method isn't going to solve the problem for all of South Dakota. So with this, I hope that we can find a solution that will be equitable for everybody, whether you're a county or a municipality or a private service or governmental service, you know, everybody functions differently. The hospitals that you transport to are spread thin. So there's just a lot of compounding things that go into the emergency medical services system within South Dakota that hopefully this task force can hear and we can come to some sort of solution that can make EMS more deliverable throughout the state.

Thank you. I think that's our same members from last year. Let's see, online. Nope, I think nobody— we don't have anybody new online. Okay, now we'll go around. Any general comments from the new committee members on kind of what they'd like to achieve or any ideas or any big concerns that you see? And I guess I'll start to my left.

Senator Otten.

I think this is a reason I had asked to get put on here. I've always resisted a lot of this, but we have reached the point of implosion in the state of South Dakota, and I didn't think that it was incumbent upon me just to say no. I mean, if I'm saying no all the time, I better be willing to roll up my sleeves and find out why I'm actually no. The bill in which you had just referenced, 89, I had voted against that. And that— the reason for that was Lincoln County was working on a program, and I didn't want to overjump or be inserting something over the county level. But as I've learned more about this, we have a unique opportunity with the rural healthcare transformation and the funding coming out of there that we can actually do something that 100 years from now, the people of South Dakota go, God, they really had it together that day. And so that's why I'm here. I do believe that we can find a solution to this. And I do thank Senator Reed. We've had conversations before, so I'm excited about getting this thing started and coming to a conclusion that the state of South Dakota and its citizens can go, well done.

Thank you, Senator. Representative Weems, anything to start out?

Well, I would just dovetail off Senator Otten. You know, rural health care is so important in our entire state. And so You know, the services provided by EMS start, start a lot of those, those processes. And so I think it's just instrumental to make sure that we have strong EMS services throughout the entire state. And so thrilled to be on here, thrilled to be a part.

Thank you, Representative. Representative Fosness, anything to add?

Very little.

Well said. And I believe I'm— I asked to be a part of this just with 26 years in rural healthcare with nursing homes and hospitals. We're the receiving end of EMS. I also think there's an assumption that especially as we're in peak travel season through South Dakota, that there's areas we drive through where it may be hours before you receive help. I think it's an assumption that there's help there, but we need to do the good work. And as all of us drive home and back and forth to this committee, let's think about that as we drive across this rural landscape. What impact can we make as a summer committee in driving, maybe it's legislation, maybe it's policy, or a blend thereof, to make a difference for the long term, as Senator Otten said?

Thank you. Representative Drew Peterson.

Yeah, thank you, Mr. Chair, and, and thank the e-board for selecting me as well. I, I also asked to be on this committee, and I've talked to a lot of the stakeholders in the room over the last few years, and, and many county commissioners in my district and across state as well. There's a funding issue that we need to address. I hope this is the, the year we can get it done. And I know we have a great group of people from across the state, different demographics, from, from rural to urban and everywhere in between. So I'm looking forward to working with you all.

Thank you, Representative. Senator Sue Peterson, do you have anything to add?

Good morning.

Thank you.

Yes, well, I'm happy to be on the, on the committee. And while I represent an urban district, I grew up in rural Montana. Which is something that most people don't know about me. So I am very well aware, and my parents are still residents of rural Montana. So we understand intimately the, um, the issues that are, are facing rural folks, whether it's in Montana or South Dakota. I think a lot of those issues are the same. I don't consider myself an expert, and I, um, I'm here on this committee as the chair of the Tax Committee because that was a provision in The bill, so that is why I'm on the committee. But hopefully not my only role. I do hope that we can do something that doesn't involve an increase in taxes, but I think there's some other funding sources that we can consider. So happy to be here, and happy to hopefully provide some perspective and also learn a lot.

Thank you, Senator Representative Hughes.

Yes, thank you, Mr.

Chair.

I'm happy to serve on this task force. My experience on medical issues is largely from medical cases that I've handled over the years. And also, in a former life, years ago, I had a number of physician-owned healthcare practices that I assisted, including subspecialty care. In cardiovascular disease. So I know that time is brain and time is heart when it comes to critical care patients, you know, stroke victims, heart attack victims. And I cringe when I think of the delays in treatment that result from our ground ambulance system statewide, because delays equal worsening outcomes and end up either causing death or much more severe, worse outcomes in medical care. I served as the city attorney for a small, very small community north of Sioux Falls for 25 years, and EMS was a recurrent issue. And I know that our 3 major healthcare systems have, in varying degrees, fixed-wing and helicopter air ambulance service. And I've always questioned the role of those healthcare systems in helping to bridge some of the gaps on our ground ambulance, our ground EMS systems. And so I come at this with a fresh perspective, I hope, and I'm happy to serve. I've said yes to every request to serve on task forces or interim committees thus far. And when I was asked, I presume because of my role on the Tax Committee and the departure of the chair and me being vice chair, that that is the basis for my being asked to serve. So I'm looking forward to learning a lot and hopefully contribute at least something of value. So thank you.

Thank you, Representative. Senator Larson.

Thank you. I wanted to be a part of this task force for a lot of the reasons that are already mentioned. You know, even though I represent an urban district, I think that the urban EMS and rural are inextricably linked, as they are in other industries. But just the thing that I can also add is that many of you who know my background is I grew up in South Dakota and lived many years overseas working in the international development field in Asia. And so, I saw emergency medical systems that either don't exist or we're very broken. And I feel like moving back to the United States and back to South Dakota, we take these systems that we have for granted so much, and we really need to maintain and build them to speak to the times that we're in. And if we didn't have those emergency services, and in some areas we don't, or they're very few and far between, it's just something that we take for granted and we need to see pay that special attention to make sure that this gift that we have of infrastructure continues to grow and serve South Dakotans, because it is not a given. It is not a universal given that we would have these systems. So super interested, and like Senator Peterson said, I'll be on the learning end as well and hopefully can contribute something as well. Thank you.

Thank you, Senator. So up next, we're going to have an overview of emergency medical services in South Dakota. And an update on the Rural Health Transformation Project from the Department of Health. And we have Emily Keel and Marty Link here to present. Now, if you can see here, we've got an hour and a half, and that's very deliberate because this is really— come on up, I'm sorry. I think this is an area that we really need to understand and get that base for us, that foundation as we're talking about this. So we'll just go ahead and turn it over to you two and How would you? Would you? Do you want to get through your presentation, or should we be asking questions along the way also?

Mr. Chair, I hope to see this as a conversation. Okay. So we're open to however you'd like to do that.

Okay. And let's let's be informal about you know if if you ask one question, you don't have to ask you know for a follow up. Let's just turn it into a conversation. And if I'm not recognizing you, go ahead and just. You know, go ahead and start your question.

So, all right.

Well, good morning, Mr. Chair, Vice Chair. My name is Emily Keel. I'm the Division Director of Healthcare Access at the South Dakota Department of Health here in Pierre. And as you said earlier, with me today is our Deputy Division Director of Healthcare Access, Marty Link. And he also manages our Office of Emergency Medical Services and our Rural Health Office. And thank you for having us here today. Marty's going to take the reins on the bulk of this presentation, talking to you a little bit more about regional services designation and what we've been doing in the last 18 months or so. And then, you know, we'll have that dialogue and Q&A as we go forward. Like Mr. Chair said, and then I will kind of take the reins too on the rural health transformation presentation, which will come next. And so that's kind of our thoughts on the next pieces of your agenda. So Marty, anything else to add in that introduction there?

No, it sounds great. It's a privilege to be back here. We really— obviously this is near and dear to our heart, and we appreciate the committee bringing this important subject back together. And we appreciate all the support that we have behind us moving forward as a group collectively. All right. So today, as Emily said, Morty Link. Today we intend to overview what's on the slide here, really talking first and foremost about the state of the state of EMS. We want to focus on the facts, right? We want to focus on strategic redesign, especially when we look at rural healthcare transformation moving forward. We also want to be fiscally responsible and accountable, as we have once-in-a-generation funding opportunity before us. When you look at it, EMS in South Dakota is going to appreciate $8 million in this first budget period with rural healthcare transformation, $64 million in total over the next 5 years is what's projected. We want to talk about reimagining EMS. Our focus is really on system redesign. We want to use the one-time funding with Rural Health Transformation to really set up EMS to be successful long-term moving forward. And I think that's appreciated from the entire group. That doesn't mean that we're simply going to open the checkbook and provide the wants that EMS might have. We know those are important things.

Right.

We know there's things that are essential for EMS to be able to move forward. But we really need to look at what's absolutely necessary In order to be able to create and use that funding for that one-time setup so that we can have long-term sustainability. Although we're focused on EMS agencies, some of the conversations that we're going to have are going to be tough. Some of those conversations are going to be challenging because we're looking at the long-term sustainability of EMS moving forward. We understand that some communities may need to explore different service delivery models than they are today. Different partnerships and different regional solutions to be able to maintain EMS. That doesn't necessarily mean that's a bad thing. We were up in Spink County yesterday, and we're going to talk more about that. They changed the service delivery model and made it very robust. I'm very proud, and there's a gentleman behind me by the name of Paul. His son is leading those efforts, and I told him this morning, incredibly proud of your son and the work that he's doing. Because he's looking into the future, he's being strategic, and he's saying we're gonna take the walls down on this box. We need to redesign. And it's incredibly important that— I'd love this committee to be able to go up there and take some time because it is truly special and heartwarming to see a young kid take the reins and really make transformational change. I want to be clear throughout this presentation that we want local communities to be able to continue to make decisions regarding their ambulance services, but it's going to take a coordinated effort. We want to provide the tools, the resources, and the regional solutions to be able to help maintain EMS moving forward. We're going to talk a little bit about the challenges with EMS. Looking at those challenges more represents systemic-wide, system-wide challenges. And then finally, as has been alluded to, we're going to look— talk about rural healthcare transformation. So we look at the state of EMS as it is today. Many EMS agencies have successfully and continue to successfully serve their communities through local leadership and volunteerism. However, many of the challenges facing EMS today require broader system planning, greater financial accountability, and strong regional coordination to ensure long-term sustainability into the future. The initial framework in South Dakota for those that want a little history lesson, was created in the '70s. It allowed communities to establish EMS agencies locally, organically, but it didn't involve statewide planning. The concept wasn't flawed. It created a framework locally for ambulance services to be able to stand up, and it codified EMS as a professional organization, part of the professional healthcare arena. Although some regulations have been time-tested, the EMS system in South Dakota must reimagine— be reimagined, focus on strategic design instead of organically developing here or there. Some of the components to that redesign is we need to look at alternative care delivery models, which is mentioned today, treatment in place. We need to look at triaging of 911 calls. Not every 911 call needs an ambulance. in utilizing those resources. We need to conceptualize that not every EMS response is going to require transport to emergency department. How do we deviate? How do we move some of those patients or not even have to transport those patients altogether as we look at the future of healthcare in pre-hospital setting? And we need to utilize technologies that weren't afforded to us back in the '70s. I think many of you understand that we've done a really good job of that, and we want to be able to move that forward. EMS professions, they're highly trained clinicians, there's no question about that. However, many agencies must also look at the complexity of business practices, financial accountability and stewardship, looking at workforce regulatory responsibilities that sometimes and oftentimes extend beyond the traditional EMS training. If we go to EMT school, we go to paramedic school, we're taught on how to care for patients, right? It doesn't always talk about how do we be financial stewards of an ambulance service? How do we work hand in hand with the city or county that's providing a subsidy to be able to do the report-outs? It doesn't necessarily touch on human resources and all the, the wonderful things an HR department will provide, such as being able to hire and disciplinary and recruitment and retention. Compliance is something that's weaved into everything that we do in prehospital care. But again, that foundational EMS training doesn't always touch on that at the gravity that we want it to. Billing oversight's a big one. Are we billing appropriately? Are we appreciating the amount of work that we're doing taking care of a patient? Are we getting the most value back during reimbursement? And we know that's going to be a topic of discussion, has been for a long time. Strategic planning is a big one. Even our largest organizations struggle at the time and the resources to do the strategic planning. And what we've noticed lately, grant administration is a big one too. We want the dollars, we want to be able to use them wisely, but it takes a lot to be able to apply for the funding, do all the report-outs, the invoicing, and everything else like that. So we want to be able to provide some of that help to our ambulance services. Data reporting is certainly a big one that we look at. So these challenges that I voiced today is not to discredit any of the EMS professionals. More so, we want to highlight some of those systemic challenges that we see that we're trying to address. By addressing these foundational principles, we want to set up EMS agencies for success. Okay, where we're strong, we can provide those resources, you know, and so forth. So we want to be able to partner together effectively. So why EMS matters in And it is essential. There's no question of the importance of EMS. We all know EMS is an essential service. Everybody can agree to that. There's an exception— or there's expectation that if someone calls 911, they're going to get an ambulance. When the ambulance arrives, they're not going to stop and say, we need to validate if you can pay for this service. They're going to treat the patient. They're not going to validate if they have insurance or the proper insurance to be able to cover all the expenses. They're going to treat the patient.

Thank you.

If there's a call for service, regardless of where you are, regardless of where you live, regardless of what you look like, you're going to get an ambulance. That ambulance is going to take the best care of you, and they're going to deliver you to a healthcare arena, the emergency department, and they're going to do the same thing. And we worry about everything else on the back end. A strong healthcare system depends on a strong EMS system. When we look at a strong EMS system, we look at a system that's staffed with EMS professionals, which many of our ambulance services are. It's equipped to respond to any type of emergency. We don't have the luxury of saying today we're going to respond to a cardiac arrest, tomorrow we're going to deliver a baby, the next day we're going to go to trauma. We got to be ready for anything at every time, any, any time of the day. We need to function as a business entity. This is something that more and more is I think what's important for us to understand is that EMS agencies are a business, and we need to function as a business. And if we're not doing that, we need to challenge ourselves, much like people challenge me within my position. Hey, we need to look at things in a different perspective. We want to challenge ambulance services to make sure, are you truly functioning in that business capacity? And if you don't have the resources such as HR, financial— someone to do the financial reporting, how do we bridge that gap?

Thank you.

How do we give the resources to you so you can do the great work that you're doing outside of that traditional EMS education? We want to be accountable. We've got to be accountable. If we're receiving subsidies from local community, we need to make sure that we're accountable to that local community. Are we providing those financial reports? Are we providing revenues and expenditures to be accountable? That's important, right? Again, part of a business process. And then we need to understand the cost of readiness and And make sure that are we truly billing appropriately for that cost of readiness. And I think everybody understands what that means. A lot of times an ambulance is sitting in the garage. There's still a cost to that service. So we want to reimagine EMS. We want to look at, you know, really where the Department of Health is focusing now is intently looking at the future of EMS, making sure we have sustainability for the next generation. Myself, Division Director Emery, and many of the folks that are in the back that have given a long— spent many, many years serving our communities, we need to understand that eventually we're going to hang up that radio. Eventually we're not going to respond on any other calls. Are we setting up that next generation to be successful? And if we're not, how do we shift gears to make sure that we are? Many services say we're doing really good right now. That's great. I want you to look at where you're going to be in 5 years. And those are the tough conversations, because when you start to be— get to that level, then you start to appreciate that, oh, we're going to have 2 or 3 members that are going to retire. That means their service isn't going to be as good as it is right now. Tough conversations. We want to address today's challenges and understand that today's challenges require greater emphasis on system planning, coordination, and that financial accountability. This allows our EMS agencies to do what they do best, take care of our patients. The future of EMS in South Dakota depends on building that coordinated, accountable, and patient-focused EMS system of the future. I want to show you a map here. You look on the screen, you're gonna see a map. This is created by GIS mapping. I've got a gentleman within BIT that's helping us with this. When you look at the map, it It depicts each of our 121 ground ambulance services, noting a 35-mile drive distance from that physical base. Okay, so why is that important? Why do we do that? Well, 35 miles isn't necessarily EMS. It's actually related to CMS, the requirements placed on critical access hospitals. We just put it up here to really emulate the saturation of where ambulance services is and how many boundaries they overlap.

Map.

It does not deplete to the service area of each of the ambulance services, so we want you to think that, but just think of it more so of that 35-mile drive time of physical roads that we have in the state, how long it would take to get from that ambulance service out to different areas of the state. You can see the eastern side of the state is much more saturated than the western side. South Dakota EMS has 3,439 licensed EMS providers According to the Board of Medical and Osteopathic Examiners, a little over 1,900, about half of those 1,900 are affiliated with the ambulance services. So that means we have licensed personnel that carry a license, and then we have those that are actually working and contributing to an ambulance service. Okay, important distinction there. In calendar year 2025, we had our licensed ambulance services ran 122,290 6 calls, which represents a 32% increase from 2020. 2020 to 2025, 32% increase. You can see the, the amount of ambulance calls we're having is exponentially growing. It doesn't necessarily mean that they're life-and-death emergency calls. We're getting more and more that are low acuity, and that's why we need to look at treatment-in-place components That's why we need to look at alternative care delivery models so we don't have an overutilization— I can't say the word— so we don't tax the resources that we have before us going on low acuity calls is what I'm trying to spit out there.

Marty, we've got a question from Senator Peterson. Senator Peterson, go ahead.

Thank you, Mr. Chair. Yes, I appreciate the map and I think it's very telling. I'm wondering if we could possibly do a map of even a smaller radius, because I think if you look at a 35-mile, you're looking at transportation to and from a patient. So you're still probably over an hour in terms of getting someone to help if you have to transport them to a hospital. But that's still a pretty long response time. How did you pick 35 miles?

Go ahead.

Yeah, Senator Peterson, great, great question. So we really took this, we looked at this as what critical access hospitals have in that requirement of 35 miles. So there really wasn't a rhyme and reason. When we look at it from an EMS perspective, we're looking at that base foundational structure of where hospitals are across the state, and we wanted to see where ambulance services are. Again, if we look at strategic strategic redesign of the system. So we know the foundation of where the hospitals are, and then we're looking at these ambulance services. Now, that 35-mile drive time analysis, the beauty of GIS software is we can put in 15 miles, we can put in 10 miles, and that map changes within seconds. And so this is the tip of the iceberg. We're going to get much more granular in this. And when we talk about GIS mapping, it's It's great to have a pretty map there, but we want it to tell us something. With GIS mapping, we can integrate census data and a variety of other data sources to say, okay, what's the population outside of these boundaries? 35, 10, 15, whatever it may be. What's the population within? We can even go to street level. So the sophistication of that is pretty profound. So yeah, rhyme or reason, it really focused in on the hospitals.

Anything else? Senator Peterson?

No, no, I think that covers it. I just think we would have a lot more white spaces on the map with a, you know, a lower radius. And I think it's just important to acknowledge that, that, you know, it doesn't look like there are a lot of areas uncovered in this map, but I think it's maybe more significant of a problem than this map.

Probably delineates.

We'll go ahead and take note of that and maybe as we're having discussions request the data that we'd like to have.

Great point. We anticipated that. So we'll be able to get down to brass tacks there. Thank you.

While we're paused, anybody else?

Questions?

Okay. Go ahead. Thank you.

You bet. Thank you. So EMS system was largely built in a different era. We talk about being built in many of the statutes coming from the '70s. That occurred when there were more volunteers. That occurred when there were more healthcare— local access to healthcare. And it occurred when there was a much lower service delivery model.

Okay.

With regionalization of healthcare, patients are moving greater distances to be able to get that urgent care or the specialized care. So we look at some of the strategic priorities. Individual EMS challenges are increasingly becoming system-wide challenges. Some of the things that we aim to address following the system-related issues is we're doing a lot of work, like I said before, about GIS mapping, but we're also incorporating some data dashboards in that. We're working with that GIS expert to be able to plot hospital locations. As I talked before, we can pull any data that we want to be able to pull out of that specific tool. We can look at population stats by region, by county, by community, and even street level if we need to, to look at specific demographics. There's a concept within, within the office that we want to emulate 15 minutes to life as a focal area. What 15 minutes to life means is that wherever you are in the state, you call 911, there's going to be a trained responder to you within 15 minutes. Okay, y'all drove here this morning, or you drove here yesterday. You know there's a lot, there's a lot of time between one community to the next. And this is truly a stretch goal, but what we're hoping to do with this mapping and the visualization thereof is to be able to say, hey, here's a map of South Dakota, here's where all our 121 ambulance services are, then be able to see, as Senator Peterson talked about, Where are the white spots? And then when we start to overlay where where our fire departments are that have trained responders, where law enforcement is, many of them have AEDs through a grant provided many years ago, have that specialized training. Now you start to see those white spots start to diminish. Again, I'll reference the great work that's done in Spink County. They're taking this upon themselves. They've already discovered that 15 minutes to life in different areas that they have within their county and said, we need to do something about it. Even before all this stuff, right? It goes back to our regional service designation. But that's the spirit of local camaraderie where they're looking and saying, we want somebody there because we know what it's like to respond. We know what it's like, the pain and the heartache and the emotional distress of having a family member be with a loved one when they're in their greatest hour. Sometimes it's just a hand to hold. Sometimes it's that we're going to get down and dirty, we're going to get busy, it's going to be uncomfortable, but we're taking charge because this is a medical emergency. The disparity between those two really comes down to the etiology and how important it is we start providing that care aggressively. So pretty important when you look at all the work that EMS does, and they have to make those split-second decisions at that moment. But many of them are pretty good trained, and they could say, well, Marty, you just cut your finger, stop being a baby. All right, it's gonna be okay. But that's what the training provides. So that 15 minutes of life is certainly a priority that we're gonna be moving forward on. We've already secured an analytic tool through ImageTrend, that's our patient care reporting software. We're gonna be able to take the reporting that we have right now and really make that much user-friendly to be able to see descriptive statistics. So we can see a chart instead of looking at an Excel document, which can sometimes be painful. So that's gonna be at no cost to EMS agencies. Over the next few quarters of this year, we're looking at developing that. We're looking at an internal and an external data dashboard. Now this is going to have high-level information for where EMS agencies are, the types of runs that go on, and so forth. That's going to be valuable not only to the Department of Health, but it's going to be valuable to our key stakeholders out in community. So as they start to make informed decision-making, now it's about real looking at the data and making those informed decisions with the data. Another thing we're excited about— this has been a long-term goal within EMS and the HIEA HIE being Health Information Exchange.

Right.

Hospitals, you put in all your chart— hospitals put in their chart reviews. There's a central location within state that can look at all that data. So if you're a provider and you want to see where did Marty get care, they can look into the Health Information Exchange and say, well, I went to a dentist, I went to a doctor, I've been to a chiropractor, whoever's utilizing the system. And they can see more holistically the care of that patient. So we want to take that to the next level. We want to say, well, we want to have EMS trip reports integrated into that too, because when you look at holistic care for a patient, if you have someone that's utilized EMS 10 times over the course of 2 months, that's problematic. Why did they use it 10 times? Why is EMS going to the same patient, same type of call, helping lift them up off the floor? How do we serve that patient better to make mitigate future falls. That's what's— when you see rural healthcare transformation, you really see that those types of things move forward. So we're excited to be able to bring that forward, and it's just a matter of time before we make those connections. So one of the aims with that— right now we take a patient to the hospital, suspected stroke patient. I'm taking care of this patient. I think it's a stroke. I'm pretty confident it's a stroke. We get them to the hospital. In a big system, we oftentimes ready our truck and we're off to the races getting ready for the next ambulance call. But gosh, Emily, was it really a stroke that I took care of, or did the patient have something else? And so it's a profound question that many of us have. So the HIE is going to allow for bi-directional flow of data. So I can know that, yep, the patient I took care of definitely had a stroke, case closed. If they didn't, I want to be able to know about that so I can go to my medical director and say, I really, I thought I was treating for one thing. Can you help me understand so I can provide better patient care into the future? So we're, again, another thing as we advance EMS. We look at billing practices.

We also have, I think we have another question from Representative Peterson, or Senator Peterson, sorry.

Thank you, Mr. Chair. Just a question on the integration of EMS run reports with the state's health information exchange. Are there privacy concerns with that? I'm not sure everybody wants all of their medical information integrated so that anybody and everybody can see everything. So what are we doing to safeguard that?

Yeah, great question. So you're right in line with our thoughts. You're right in line with the healthcare systems. They're not going to open the book to be able to— for me as an EMS provider to see the whole chapter, the whole book of your life, your healthcare career. That would be irresponsible because that is just between your physician and your specialty providers and you. What this would allow for, Senator Peterson, is just a very basic assessment of what the ending disposition of your case was. So again, it might be something as as simple as saying, yep, this individual had a stroke, or this individual had a complex medical issue that presented as a stroke. So it's not going to open the book of the whole healthcare record because that simply would be irresponsible. Does that help address that?

Well, I was referring to something that you said earlier where they could access the patient incidents if that's how you, you know, call it, um, for the last 6 months or whatever.

And I think you referenced whether they went to the chiropractor or they went here or there or wherever.

And I just don't know that that really is in line with privacy practices.

Yeah. So let me, let me clarify my, my, um, let me clarify what I said there, Senator. So in that regard, The flow of information from going to a physician, the more information we can provide to that physician, the better, so that he or she can make informed decision-making of the care. So my comments of, you know, a patient's history over the last 6 months would be, did they go on— were they picked up by ambulance 10 different occasions and brought to different hospitals or a similar hospital? That information should be privy to your healthcare provider, okay, because that information is flowing up. When we talk about information flowing downstream to that ambulance service, that's where we're just being— that information is specific to, yeah, this patient had a stroke or they had a diabetic issue. So it's not a laundry list of information. Does that help clarify? It's really the direction in which the information is flowing. I understand.

Sure, but you made reference to a chiropractor in that explanation earlier. And so, tell me where that fits in because that's a broader look at all of the patient's medical history.

Yeah, my bad. Maybe I shouldn't have said chiropractor. But I mean, in the grand scheme of things, we— from the perspective of, again, that primary provider taking care of the patient, one thing the health information exchange does is it allows for that complete record of the patient. Again, we're looking at it from a physician-to-a-physician standpoint. When we look at information going from the HIE on what an initial ambulance response ultimately entailed, that final disposition of the patient, that's more specific to that individual etiology of that particular case. So it's not all-encompassing of a patient record. I don't know if I'm explaining this well. Maybe we can take this offline to explain it better.

I guess maybe to clarify, you're working on this health information exchange, so you're not just talking about EMS calls and such. There's other information that will be part of that exchange, or is this just for EMS that you're talking about?

Yeah, that's a great clarification. So with this, yes, we're We're just talking about EMS and bridging what we don't have right now. Right now, our EMS trip reports are not going into the state's HIE. The state HIE is standalone. It functions. It's been functioning robustly for many, many years.

But that's not— is that for EMS or is that for all healthcare information?

This is just for EMS. Okay. The initiative we're talking about is just for EMS.

Okay. Representative Peterson, and then I'll come back to Senator Otten.

Thank you, Mr. Chair. Um, kind of maybe a question to clarify this whole situation, and a valid concern is, to my understanding, EMS providers must comply with HIPAA requirements for patient privacy, correct?

That is correct. Yep, there's a robust HIPAA compliance.

Senator Otten.

And like minds, that's where going back to appropriations and having Secretary McStead come in. We're not thinking about bypassing HEPA requirements. Those are, if you will, they are granite. They've been written in granite. We can't bypass that. What we are talking about is just getting critical information to a doctor at the point of incidence, to that doctor That we can— it might be the individual is out near Buffalo where all of a sudden our thought processes switch from, well, we don't have time for an ambulance, we need air service, we need air service now. And so that's what I think that as we were going through that in appropriations where the kind of the thought process was.

Thank you. Anything else? Representative Weems.

Thank you, Mr. Chairman. My question is, where can EMS services take the patient after they've picked up the patient?

Traditionally, you'll see— traditionally, you'll see EMS, they'll transport patients to the ER. I mean, it's almost robotic. When we look at alternative care delivery models, when we look at the future of prehospital care, we want to make sure that those patients— number one, if they don't need an ambulance, we don't want to have them utilize that resource. There's some proven practices the Rapid City folks in the back can talk about— Mobile Integrated Health Community Paramedicine— where they have a structure in place where a 911 call coming in for service, they can triage that down and say this patient doesn't need an ambulance and we don't need to send an ambulance and a fire truck through town, lights and sirens, to manage somebody that has a broken toenail, for lack of better words. In those instances, Representative, what would happen is that organization would send out a mobile medic person in a Suburban that go and assess the patient. Patient's still important, patient still needs healthcare, but we don't need to go to the emergency department.

So you're saying that the emergency department is not the right place to go if you have a broken toe?

So they would help deviate and say, hey, there's an urgent care clinic down the road, or you don't have a primary care provider, but we need to get you a primary care provider. And they can start opening up those conversations so that patient gets the right care at the right time in the right place outside of that initial EMS response. Does that help?

Yeah, thank you.

Okay.

Anything else?

Yep, go ahead.

Is part of the goal to make the healthcare information more transferable to get everybody on the same charting system? Because I know that Avera has switched over to Epic. Is that a conversation for EMS to get them all on the same charting systems?

Great question. So what we have in the state, the Department of Health supplies what we call ImageTrend. It's a patient care reporting platform, and we supply this free of charge to any ambulance service that wants to use it. This, this is not a commercial off-the-shelf Microsoft Word you get in and start, you start typing a letter. It's very sophisticated. It's based on national standards, national EMS information system data standards. So we provide that free of charge. Now what some ambulance services say is we, we like the base functionality of this, but with our service, since we're advanced life support, since we our medical director wants us to capture 10 more elements, they say we want to deviate, we want to go with our own system. So they'll actually purchase a system called third party. And then, but what we do is we have import, we were able to import that data because there's a standard structure of what the state wants to collect uniformly across the state. So even though there may be a number of agencies that have this third-party software, They still provide that data to us. To your question, Representative Hunt, we know that we know the healthcare systems; they each have their own system. I think more of them are going to Epic across the state. Quote me on that; you'd have to ask them. But I think more of them are transitioning to that. We talk about this whole HIE integration. I probably opened a can of worms. I'm not as articulate as I should be with this. We have two components here. We have the healthcare. System with the HIEs gathering all that information, okay, provider to provider and so forth. All we're simply wanting to do is take that first chapter in that emergency response to say there's some really valuable information here. Again, going back to a stroke patient, if I'm a physician and I want to learn, okay, when did this stroke happen, what was the exact time of the stroke, that's going to be valuable. Now, in an emergency situation, you got to make those decisions right away. But when you look historically, you can go back and you can look at all the ambulance responses. And again, it provides more informed decision-making for that provider that's taking care of the patient. And there'll be much more reports out that we can do some more reporting out on that and maybe have some subject matter expertise on the HIE.

I think it's important though for the grand scheme of how we're trying to better the system and then how important that we've learned, especially over the last interim, that it is a front door, you know, to, to the healthcare system. So I think it's been a good conversation. Anything else? Great. Go ahead and continue on, Marty.

All right, thank you. Again, when we look at the billing practices, we, we want to make sure that our ambulance services are billing effectively. We hired a consultant, Healthcare Strategists. They're an organization that We came in a few years ago, did a statewide assessment of where EMS is in the state. One thing that came to light is we know that there's ambulance services struggling financially. As I talked earlier, we look at EMS really looking at that from a business perspective. So if there's gaps or if we're not billing appropriately or we're leaving money on the table, we need to go back and we need to look at that. Again, the cost of readiness is substantial for an EMS organization. And if we leave money on the table because it's my neighbor, I know this person, I've known them all my life, I don't want to bill, I know they're having financial difficulties, I appreciate that. That touches my heartstrings. But at the end of the day, it's a business. And if we allow that to happen once and twice and all of a sudden we're not being good stewards of the dollars, Then then we need to revisit that. Okay, so we've got an organization. They're coming in. They're going to be doing. They've been doing started some assessments on how our ambulance services billing. Are they billing effectively? Working directly with those services again. We're looking at having a better understanding. We have agencies coming to us saying we need more money. We want them to be informed as far as what is that? What is the amount of money coming in? What's the of money coming out so they can speak to the people they're getting subsidies from. They can speak to committees like this and so forth. You know, we have— when we go in front of appropriations, I guarantee we have to kind of be accountable, right? And we're not picking on anybody. It's just if we want to have informed decision-making, we've got to be able to do that. Again, if I was in an EMS agency, I might say I don't have the specialty in all the financial reporting, but I could find someone that does.

Thank you.

And that's going to help, help me.

I think this is really important, as from what we learned last interim, the idea that when we're looking at making an essential service, we know there might be some funding that's needed to help with that. Let's make sure that the ambulance services can operate as efficiently as possible before we go to that level of needing more funds. And so I think that's a really good comment. I'm glad that you guys are looking at that.

Yeah, the transparency. And again, we want to provide those tools so that we can be transparent and we can, just like we're doing with evidence-based metrics, we want to make sure that we can provide that same level of accountability to our services. Many of them do it well, but again, some of them may not have those resources. The other—

One more. I'm sorry, one more question. Representative Hughes.

Yes, thank you, Mr.

Chair.

My understanding is there's somewhere between 122 and 139 licensed ground ambulance services in South Dakota. And the categories are public, which would be county, city, fire-based, hospital-based, private nonprofit, and tribal. And I'm just wondering if there is a map or a graphic that would would demonstrate which ones are located in what areas of the state. I'd be very, very interested, especially in the hospital-based ones and the public ones, but actually all, all 4 categories.

Yeah, Representative Hughes, that's a great, great comment.

We can—

we're making notes and we can develop those maps and present them to the committee through LRC.

Wonderful, thank you.

Yep, happy to do that. So, we'll talk— we'll get through this so Emily has enough time to go through her presentation too, sorry. So, we look at regional service designation. It's important for us to differentiate, number one, we've got RSD, regional service designation. We got RHT, rural healthcare transformation. In fiscal year '22, we were given $20 million to infuse into EMS. We thought, gosh, we're never going to see this again, so we better do it right. Fast forward, we've got $64 million over the next 5 years. So we're like, it's important for us to reflect back. Did we do it right in fiscal year '22? Did we achieve what we intended to achieve of this regional service designation, having services work together to really strengthen where they are. It's a good litmus test as we look back. Now, I can submit to you it did achieve the vision. We did achieve what services needed, what services wanted, and we're, we're thankful for that. But it's important— we'd be remiss if we didn't go back to say, how did we really do when we structured it within the Department of Health? How did we really do when we allowed the grant opportunities to go out to individual ambulance services, hospitals, and those had a vested interest in EMS. And we'll be good stewards of the finances. So out of $20 million, we separated that into 3 different initiatives. One of them you've already heard about— telemedicine in motion, 2-way video audio connectivity in the back of an ambulance service. Phenomenal. I could talk all day on that. LiPAC replacement, which we did just a few years ago, which we provided 308 Lip pack monitor defibrillators, so measure your heart. If you needed to be defibrillated, will defibrillate. All kinds of, kinds of stuff on the cardiac realm and many other etiologies. And the last one, the regional service designation. So this one was $7.5 million with a small allocation of about $189,000 to be able to do a statewide assessment. Statewide assessment started. That was really the healthcare strategist came into the state, and they said— we said uncover every rock, tell us what we're doing well, what we're not doing well, how do we need to set ourselves up for long-term sustainability. Again, it's a record here, right? We skipped a bump and we're back in the same thing. And it's not just South Dakota, we're seeing this across the nation. So I am incredibly proud of the commitment of this workgroup to say Enough's enough. How do we, how do we take this a step forward? And again, some of those are tough conversations because it stretches us and we have to ask the tough, tough questions. So our regional service designation, it led into a small number of really robust statewide initiatives. I'm going to talk just briefly about those, 3 of them exactly. First one was SADAHO. If you've been around a while, you know that If you have a patient, they really need to get to the hospital. If I'm having a heart attack here, I'm going to go to St. Mary's. If I need intervention, I'm going to be on a plane. I'm going to Sioux Falls. I'll be in Sioux Falls 2 hours, 2 and a half hours, no question. If I break my finger and it's complex and I need a surgeon and I can't drive myself, I might be sitting here for 3 or 4 hours or even longer, or I just hitch a ride because it's low acuity. We don't need the resource of an aircraft to be able to take that patient. So when we talk about the work of what SADAHU is doing, I'm talking specifically to the low acuity patients, to the degree. High acuity, I'm in Sioux Falls, 2.5 hours. Low acuity patients, I might be sitting in a bed in a hospital for 2 to 3 days.

Okay.

That's problematic when we have a loved one that needs to get to tertiary care again for not necessarily an emergent situation, but they need to get there. Critical access hospital needs a bed opened up so they can be ready for the next patient. Receiving facility has a bed open and an interventionist ready there for the patient, but there's a delay in getting that patient there. Those have been around. We've had this conversation. Yeah, in the legislative arena. Tim, Tim Rave is well acquainted with that. So they said, we're going to do something about this. We're going to create a mechanism where we can have a platform online so that, again, those participating, i.e., hospitals and EMS agencies, could look at this portal and say EMR and Peer is transporting a patient to Sioux Falls. They could look before that trip and say, okay, there's a patient that's in Sioux Falls that needs to come back to Swing Bed here in town. Not emergent. That's— it requires a BLS transport. We're going there anyway. Why don't we reach out to Avera and see if we can take that patient and be able to get them back to Pierre? That's really looking into the future. And it's really looking at how do we not only serve our patient that needs to get to Sioux Falls, but also that individual that needs to get back. They're tired of being in Sioux Falls. They want to get back home, right? But if they have to sit there at home or sit there in Sioux Falls for hours or maybe a day before they get a transport, that's problematic. We got to fix it. Okay, so I'm proud of the work that SADAHO has done. They're bringing some hospitals online. Sanford's the first hospital to come online. They're working with Avera, conversations with Monument, and then EMSA just All agencies will be offered that opportunity to take part in it. Why is this important? So, Representative Emery, if you're a business owner and you know a patient has to go to Sioux Falls and you're going to capitalize on that revenue, and you know there's a patient that you can pick up in Sioux Falls and bring back home, as a business owner you're going to say, I want to do that, because otherwise I'm losing money on that, that return.

Trip.

I'm deadheading it. So again, that's where we need to look from that business sense. Okay, a little bit uncomfortable outside the norm, but this is what that opportunity allows for. So it's really looking at how do we make sure that we get patients moved from point A to point B in the timeliest of manners. And sometimes the acceptable timeliness might be you sit in a hospital bed for 2 or 3 days, but certainly not— or 2 or 3 hours. But not 2 or 3 days. Okay. Any questions before we move on?

I think we're good.

Okay. And these are just high-level overviews of it. The next one I want to talk about is Sage Consulting. So Sharon and her group with Sage Consulting have done an outstanding job. And when we talk about it from a business perspective, we talk about looking at finances and what are the, what are the finances of an individual ambulance service. She's been able to go into specific communities and say, how are you doing financially? They might say, we think we're doing pretty good. Well, show us your books. Well, this is what we have. But Sharon, if you know Sharon, she'll say, well, we can do a little bit better than that. So what they've been able to do, again brushing the surface of this, they've been able to work with individual ambulance services, pull out all that data. What's their run data? What kind of ambulance responses are they going on? What is the revenue that they're taking in? What are the expenses of that? And again, as we talked about being good stewards to our city and county officials, that was noted just a little bit ago. If we're going to come to those individuals, we're going to come to appropriations. We've got to be able to have the facts. And Sharon is doing just that. She's allowing information to be presented. To say this is where your ambulance service is operating as you're operating today with future projections of population growth and the way we're seeing a 32% increase across the state in ambulance responses. With those projections, this is where we feel you're going to be in 5 years. That makes informed decision-making. That makes appropriators look and say, okay, now I see the full picture. It's not we need money. It's the full picture, and those facts are important. And again, just touching the service, Sharon would be a great one to reach out to and get much more information. And the last one, South Dakota Foundation for Medical Care. So we talked a little bit about yesterday. We were in Redfield last night looking at the great work that they're doing. One thing the South Dakota Foundation did is they said, we want to take 2 districts, 2 EMS districts, And we want to really focus attention. We want to bring community leaders together, not just EMS folks and the EMS director and the medical director. We want to bring anybody who has an interest in EMS in a local capacity, and we want to bring them to the table. Maybe you meet at the gas station, get a cup of coffee. That's how I learned the most information about an organization, honestly. But they just simply have conversations. And they do it in such a way where people feel comfortable with that. And they say, you know, this is where we are. I think we're struggling in these areas. Can you help us? Can you help us out with that? It might be just bridging the gap with some financial expertise. It might be bridging the gap with, with the city and county officials, whatever, whatever it may be. They've done such an outstanding job. And one of the things things that we want to emulate statewide is an example of Redfield, the Redfield ambulance, big county ambulance, where they've said, they said, we have an ambulance here that we want to just decommission. Okay, we want to take it, we want to sell it off, be done with it. We've got a new one, we're doing really good operationally. And they worked with some local fire departments and local first response agencies, and they said, boy, you know, We would love to receive that ambulance if you want to give it to us, or, you know, for a small nominal fee, we'll take it. And what they're able to do is look at the map of Spink County and say, we have an area here that it takes our ambulance, by the time we crew and get there, might take 30 minutes. But here we have a first response agency who doesn't have an ambulance. They're just responding in their personal vehicles. They're getting to the scene, they're rendering care, they're bridging that gap and they're being that information source. The ambulance service knows, okay, you are coming to a major trauma, okay? We're not talking just a little stuff. It's major trauma. We're getting— we're moving on this one. They were able to take that ambulance they were going to decommission and basically repurpose that, fully stock it. So now in Spink County, we have those gaps consolidating. So the 15 minutes to life to them They're starting to realize that that can happen. And I tell you, if you walk into that seat, I walked in there and I thought to myself, told a couple folks with me, I kind of want to work here because it's something you can tell they took a lot of pride in. You could, I don't know if you could eat off the floor, but definitely the 5-second rule, right? But they had sleeping quarters, private sleeping quarters. So if you live out of town and you want to pull, pull a weekend, you can do that. Full kitchen. But when you look at the community pride, community vitality, Mark often says they're going to the local businesses and saying, we need a fridge, we need a stove, we need all this stuff. This is why. I think they say they booked out their weddings within the ambulance station just because of how it's set up, like 20, 30, 32. That's pretty cool because you're having communities and engaged. So I would really encourage you, if you're, if you're going through there, please visit them. Again, that's, that's very high level there. So Spokane County is something very, very special. Okay, regional service designation. We open up these grant opportunities to ambulance services, hospitals, organizations with a vested interest in EMS. A lot of them focused in on— when the ambulance service applied, they focused in on equipment. It met the need. Okay, because there were some needs. We look at power stair chairs, we look at power cots. That was a, that was a definite need. So, we, we allowed for that to be granted. If we didn't put some parameters on it, that money would have been gone within a month, and we would have had a lot of shiny new equipment. We would have been in the same boat that we were, we were in 5 years ago. So, we wanted to make sure that we limited the type of equipment that could be, could be brought.

Okay.

With that being said, when we look forward, rural health transformation is just too big to say, here's a checkbook. It's too big. Emily wants a brand new ambulance. Okay, here's $350,000. That'd be irresponsible because we have to have those tough conversations of when we look at EMS redesign, are we in a place right now that can support long-term sustainability EMS. If we were, folks, we wouldn't be here right now. So we know there's some systematic changes that need to occur. That doesn't mean that we're, we're just gonna turn the page and say no equipment whatsoever, but we need to be strategic as far as what type of equipment, does it meet the needs, or is it just a shiny new toy?

Okay, go ahead. A couple questions. Can we go back to this slide prior? So there's $7.5 million distributed to these 3 projects, is that fair to say?

No, I'm sorry. There was $7.5 million that was distributed. Oh, help me. There was 39 awards in year 1. So we had 2 round 1s. 39 in round 1, we had 64 in round 2. These were the Each of these had $500,000 or a little bit under.

Sure. Okay.

And that's fine. Just curious with, you know, the Sodaho model, I wonder if there's also data to be extrapolated on maybe some of the tougher areas within that are struggling with facility-to-facility transfer. I mean, I would think that data would be readily available as this gets reported from Sodaho. Is that fair to say? Because if so, like you could pick out some hotspots, right?

And areas.

Okay.

And then Sage Consulting report. Is that a report we could see?

Yeah, I think. Yeah, I think they might be presenting. But okay, awesome. I think we can definitely work with Sharon to be able to get some deliverables to you.

Yeah, because I think that'd be again shows the areas of concern.

We hear it.

It's rhetoric, but I think it's true too that there's rural ambulances struggling. But really data can tell a story too, right? So if there's financial information, billing issues, etc., that can be revealed, it gives us an opportunity to focus dollars. And then the foundation one, I'm a little bit confused with it. I get the conversation, the importance of it, of those conversations. I think that's where grassroots change can really happen. But it'd be, it'd be great to hear more on what the foundation's doing as well.

Yeah, a couple things. Representative, I don't want to speak for Tim Reed with, with the SEDAWA, first of all, so I don't want to put my foot in my mouth there. But we, we can provide some summary of, of what they've been able to accomplish thus far with, with the interfacility transfer. It'd be a summary of the good things that came out of it and summary of some of the challenges that came out of it. They've been doing robust work, but when you're working with healthcare systems and when you're working with EMS agencies, there's bound to be some, some barriers along the way. And they've found those, but they're working for us. So we can definitely get together with Mr. Rave and come up with some reporting there. Going back to the foundation, I feel like I'm trying to be pretty quick here, and I know I'm moving past a lot of stuff that we could literally spend days on. When we look at some of the foundation's work, when we talk about them working with local organizations, local stakeholders. I want to elevate that a little bit to where they're talking about EMS Hometown Heroes, what EMS folks are doing within their different communities where they're hosting webinars on their, on their website. You'll see a series of webinars, Hometown Heroes, I can't remember what the title of it is, but where they talk about the successes of individual EMTs and individual ambulance services. But more so really bringing those organizations together so that they're having conversations. When you look at Spink County, the thing I love about this is they took a few systems that were working independently of each other, and now, as evidence of our conversation with them last night, they had a whiteboard and they had— I swear they had like 7 different communities, and they said, Marty, that's who we pulled into a regional meeting. Meeting just today, and it was 7 communities within Spink County where when they talk about capitalizing on making sure everybody's trained, they're bringing people together. They can't be there in person, they've got them on video, and they're, they're all speaking the same, on the same sheet of music. So they're making sure they're trained appropriately. If they have medical direction that they want to bring in, they can talk, you know, have medical Director talk about what's going well, what's not going well. As I talked about human resource capacity, they were able to touch on some of those things. Maybe not to the degree that eventually they will get to, but they're doing profound work. Representative, I would love for them to come up and provide testimony because the work they've done— I can't say I have a favorite child, but these 3, I'm pretty proud of them.

Mm-hmm.

They're being an extension. They understand the importance of EMS and they're really taking it to the next level. So I'd love maybe the committee to hear a presentation from them right from the horse's mouth, if that would work.

I think what we're seeing here is kind of the overall message is there's a lot of good things that came out of this initial money, or this initial funding, and there's a lot more that we can continue on because a lot of this was discussed last interim too, and it's going to It's good to see it happen. The SAGE consulting, it's going to be important that, you know, in how we decide for, as I talked about before, efficiency and stuff, that this group is available or something like that is available to me on almost a continuous basis. We've got to build this into the model because if you're saying, okay, wait, we had a 3-year plan, now we better reevaluate because we've got 3 more years. So we've got to see where are we going, what's changed, and those kind of things. with it. So I think, I think that's what I'm kind of taking from this. Representative Hughes, you had a question? Representative Hughes?

It has been answered. Thank you. I guess my hand's still up.

Oh, okay. No problem.

But it was just up one time.

Make sure. Senator Jensen, thank you very much. Appreciate it.

Okay, continue on.

So why don't you just make sure timing-wise, how much time do you have?

25 minutes.

Okay, 20.

Try to stay on track for our noon, but again, I think this is very critical information to make sure that we, that we get it in.

So I have a question and maybe a comment too. And this is something I think taxpayers are going to want to hear. With all this rural healthcare money and all this work being done, and I hate to step on toes, but it seems like with little or no legislative oversight. And now this committee has put together to legislatively try and put some fixes together for EMS, trying to figure out how all that dovetails. And when this money's gone, are we going to— are Are we going to be having to continue that kind of funding? I think it's been a frustration with the rural healthcare funding from day one that it's almost purely administrative and no legislative oversight. So I'm trying to figure out, is rural healthcare driving what we're going to do for EMS, or is this committee going to drive what we want to do for EMS and work with the— does that make sense? I think the taxpayers are going to want to know that.

Yeah, I can try to answer that.

Mr.

Chair, may I answer? Okay, for the record, Emily Keel, Division Director, Healthcare Access. Thank you for that question. I think it's a combination of all of those things, and we don't want to be so dismissed that we're not integrating, you know, everybody into the conversation and making sure that we're listening to all of you in this task force. Again, we thank you for allowing us to be be here and share the information. One thing with Rural Health Transformation funding, and I'll talk about this here shortly, is we are being held accountable to submit quarterly reports to the legislative audit. And so we take that very seriously as well, and making sure that the stewardship behind how the money is being spent. And again, I'll talk about that here shortly too. So I might get to answer your question more thoroughly.

Thank you.

All the requests for proposals that we've been doing, we are very much following all of the procurement laws of the state of South Dakota. And so I think at any time that you guys have more questions or any committee would want us to talk about rural healthcare transformation, I think our department stands by and we're ready to do that as time does go on. But as we speak about EMS, And this task force and the Rural Healthcare Transformation funding and EMS having a specific initiative in that federal funding, it's very important that we're rolling that out in a transparent way and educating not only this task force but the taxpayers and our communities with what we're doing and why we're doing it. Is there anything else to add to that, Marty?

I think you hit the nail on the head there.

Thank you, Emily. And I, I do think, because we've got 4 more years of this funding, some of the things we're talking about here could still guide how we go forward here. Plus, as we're listening to what is, what is being done, I'm sure we're not— I think the track you're taking is working, but there may be some tweaks as we go through this, as we're listening to everybody, is how I feel about it. But I do believe we need to have some input on it so we're making sure that the constituents plus the folks here that we report to are also part of the process. Go ahead, Senator Otten.

Much of what is being talked about here within the rural healthcare transformation, we've had these reports in appropriations. We've gone through Of right of this, those monies are not to prop up anything at the local level. It is is an infrastructure in itself. So we are getting our feedback on it, and and just me being me, I've had conversations with Mr. Rave. I've had them with the secretary, and then of course when I was transferring to this committee. Some of those conversations is ongoing, so I can tell you that if if since we've got so many providers here, if they're looking at trying to prop something up as what we've got in statutory law of making counties responsible for it, we do not have the money for that kind of stuff. So the only way this is going to work is when we shift to regionalization period.

Well, that's a good segue. It absolutely is. Yes, thanks for the segue, Senator Otten. So go ahead.

All right, sounds good. So when we look at regionalization, we got to say why regionalization? What are the benefits? So this is going to allow for more improved coordinated planning between EMS agencies, hospitals, law enforcement, certainly our 911 PSAP centers, and our fire services. Again, are we all singing on the same sheet of music? And and working together collectively. It will allow for sharing of resources, training, and specialized equipment. If we have a high-fidelity simulator that costs $100,000, do we need one in each 121 services? Absolutely not. But if we can be strategic with that, which we have been in past years, it makes perfect sense.

Mm-hmm.

We want to look at workforce pools. So if you're struggling getting folks to be able to come in your community and take a weekend call, maybe they'll folks at Spink County say, well, we've got a couple that are really engaged, we can send them over, they'd be happy to help you out to give a service a break.

And Marty, I'm just— and we also, I think we've got, I think I sent it to Matthew, somebody that's talked about, that's looking towards this workforce kind of pooling strategy. I think I sent that to you. But there's— and I— you do? Okay. I was hoping that you could come up and talk about it during the public testimony, or are you on the agenda for later on this afternoon? But during the public testimony, if you'd come up and talk about it that we spoke on the phone about. Thank you. Sorry, but I just know that there's some good things happening out there too that the providers are pushing. So go ahead, keep going, Marty.

Okay, sounds good. In addition to those workforce polls, we're looking at how do we utilize the data better for better decision-making. Decision-making, not only just internally, but like I said before, having that public-facing dashboard so people, people can make better decisions at a local level. Ultimately, we want to perform— we want to provide a more coordinated response while ensuring every 911 call for service receives the highest quality trained providers, the best equipped ambulance, and the timeliest of responses. We need And we're going to get there. You know, I always pick on Turner County. They probably hate me for this, but I love the folks down there. So you look at Turner County, they've got 5 services in that one county. And I'm not saying they need to regionalize, but I'm saying, boy, what an opportunity for them to get together and say, if we have one training— if we can have one training night for all of us, would that benefit us? If we can have someone that can come in HR and look at all our policies, Would that benefit us? If looking into the future, we forecast that one of the services may not be sustainable, how do we talk together to make sure that we can have a robust system there? Again, some of those conversations aren't fun to have, but writing's on the wall, and we want to be able to help support that. So what can regional EMS accomplish? Instead of focusing on the individual agencies, individual equipment needs, individual projects.

We want—

the department's focusing in on some big bucket items. We want to establish EMS hubs and regions to be able to coordinate coverage and reduce response times. Again, don't think of this as, you know, here's the plan, you've got to follow it. There's going to be, here's a skeleton, how do we work together and have a good conversation on how to make this make this work across the state. We want to expand EMS workforce training, recruitment, and retention.

That—

boy, that's a big one, not only in EMS, not only in our initiative, but many of the other initiatives with rural health transformation. Near real-time data, telemedicine, and integrating hospital systems are going to be paramount, where we're all talking on the same sheet of music. And then continued support of technical assistance and provide that EMS EMS oversight across the state. As noted on the slide before, system-wide improvements to workforce operations, finance, healthcare integration, and governance will only improve the success for us moving forward with long-term sustainability. Our aim is not to simply spend down Rural Health Transformation dollars. As we said before, that'd be an easy one to do. Our goal is to leave a stronger, more sustainable EMS system than we have today. Everything that we're doing is focused on ensuring EMS remains available for future generations, for South Dakotans and those traveling through this beautiful state. What is successful? What does success look like, you might ask? So when we look at this, success is accountability. We've got to have sound business practices. We need to have financial stewardship, and we need to be patient centered focus for the strong— for a strong EMS system moving forward. Success requires thoughtful system design, strategic investment, and long-term commitment to ensure emergency medical services remain available to all South Dakotans. Said this before in times, EMS is really at the crossroads. We can continue to react to the workforce shortages, to the financial stability and the growing service demands where we can build a sustainable system that's prepared for the future. That's the goal. By 2030, success means we have a stronger EMS workforce, improved access to care, better regional coordination, informed decision-making, and financial stability for local services. It means that every community, regardless of size or location, can rely on timely, high-quality emergency medical services when they need it the most. The decisions that we make today determine whether EMS remains a strained safety net or becomes a resilient, integrated component in South Dakota's healthcare delivery system. I just want to end by saying EMS is truly an essential service And this once-in-a-generation $64 million investment that we have before us over the next 5 years will truly be transformative. But that simply in itself, that once-in-a-generation funding, for EMS truly to be sustainable, we need the EMS industry to focus on preparing and setting up the next generation of prehospital professionals so we can be successful into the future. With that, I'll turn it over to you.

Thanks, Marty. Just a general comment. As I've looked at this for the past interim and this session, I think it's important that there's 2 sides to this. One being, you know, the efficiency, right? If we get the efficiency as best as possible, and then to make sure that it's funded to what needs to be that people can survive. But I think they go hand in hand. And that's why I think this was really important to see what's going on, you know, to make sure that it's transparent and efficient. And then we can come along and say, okay, now how do we make sure that it is financially sustainable? So I think that financial sustainability is also going to be on us as we continue to talk about this. So thank you, Marty. Emily, if you want to go ahead, unless there's any— go ahead.

I have one question for Marty. As far as the sustainability here in South Dakota, I mean, are we looking to incorporate some of these in with the EMS 2050 guidelines that the DOT had put out in the early 2020s?

Are you referring to the EMS Agenda for the Future 2050?

Yeah.

Yeah, so, you know, that was, that was developed— that's, it's a bit dated, right? So we've got to be able to look back on some of the goodness that's still there. We've got to look at some of the data components that we currently have and make sure that as we move forward, we can look at some of the concepts that was developed under that NHTSA opportunity, that NHTSA grant back then. But we need to look at where we are today. If we can dovetail some of those, great, absolutely. But it's going to— we're going to be taking information from a variety of different sources to ultimately make this successful.

Great.

Okay, go ahead, Emily. Thank you.

Okay, well, thank you all very much for those questions, the conversations. Thank you to Deputy Director Marty Link here. I thought he did a fantastic job. It's a lot to go through in a short amount of time, which I know you guys can appreciate that as well. So next on the agenda, I do I want to talk to you about rural health transformation. Some of what I'm going to share here today you probably have heard and you're aware of. Some of it maybe you're not aware of, and I would encourage the same questions and conversation here in the last hour that we've been having. I will preface that by saying I might not know all of the answers to your questions. This is huge, unprecedented, And unlike anything we've ever done, and I'm fortunate enough every day, every week now since this has been implemented to get to work with a team of about 25 people. So I am not necessarily the expert. However, it it does fall into the responsibilities and the roles that both Marty and I have at the state to help lead and project direct and manage this on behalf of the state of South Dakota. So good morning to you all again. I'm going to visit with you about what it is, how it came to be, what we're doing, and share that big picture level, and we'll kind of hone in on some of the EMS components that tie into what Marty was talking about here too. Secretary Maegstad, our cabinet secretary for the Department of Health, has been quoted saying that we are building the plane as we are flying it, and that has never been truer in my 20-year career in state government as well. But it couldn't be done without both the teams from Department of Health and the Department of Social Services. So this is an interagency departmental effort, and I would just like to say on behalf of Secretary Maegstad today, she, she would certainly be here, but she She is also helping to host our federal partners for rural health transformation. They were here on site yesterday and then today they're up in Mobridge and Selby doing a couple site visits and then they'll be back in town later this afternoon. So she's doing the great work there along with Secretary Althoff at the Department of Social Services. So going into the next slide. Slide here, a little bit of background and legislative authority. This was established through the federal legislation supporting the health system redesign. The program goal here is to strengthen rural healthcare access, workforce, and sustainability—all key words and phrases you've been hearing throughout the morning. Very big themes, very big trends. Our funding authority at the State Department of Health came through. You folks here in the room and listening through the South Dakota Legislature, House Bill 1044 was signed on January 29th, just this past year by Governor Roden. It was the first bill signed by him, and so we feel very honored and excited about the work that has been done to date and since then. The federal allocation and the funding authority. So just. Just a little bit of stepping back there. The total funding over the next 5 fiscal years from the feds is $50 billion across the entire country. Our South Dakota award for FY 2026 is approximately $189.4 million. It's a multi-year investment. And as Marty said earlier too, it is once-in-a-generation funding. Now, South Dakota could see up to $1 billion Yep, billion. Over the next 5 years. And the state, it's important to know that the state's not keeping this money. Our responsibility is to develop that framework. And that, you know, that stewardship is critical to everything that we're doing. One, transparency in how this funding is going out through requests for proposals and application processes, the accountability that we have and that we're putting out into the communities and then following those procurement laws. As I mentioned earlier, when Senator Jensen asked the question, you know, our accountability and operations at the State Department is, you know, we're, we're submitting annual reports as well as quarterly reports to our federal partners. That's a requirement. The site visits, as I mentioned, one's happening right now. And then we will have, I believe, at least one every year that we receive the grant funding. And then we also have to submit the quarterly reports to the legislative audit as per the funding authority that we received this last legislative session. All right. Eligible uses and strategy areas that were dropped down from the federal direction. And I just kind of bulleted these out here. I'm going to go into some more details on what the state has opted to move into. A lot of what you see here on the screen will be reflective in the 10 initiatives that we are implementing and have been implementing in the last 6 months or so. Here is a map of our rural counties in South Dakota, just kind of showcasing how rural and how frontier we are. 64 of the 66 counties are classified as rural. In our state, tribal nations, high poverty regions facing persistent disparities and barriers to long distances of care with limited specialty access. You heard about some of these challenges. You guys are no stranger to those challenges. I myself live in West Sully County, so I'm 30 miles west of Oneida, who has an EMS and fire. And 30 miles north of Pierre, and so those long distances to care are very important to me and my family. I have 8 miles of gravel, so I always pray to the Lord that we do not run into any emergencies during the middle of winter because I don't I don't know what that would look like. But I'm confident in the work that Marty, my team, and all of us are doing to to stay firm on that 15 minutes to life because that's That's very important to all of us and all of our families and our neighbors. But we do have some gaps, and rural health transformation is going to help build the bridge to some of those gaps listed here: maternity care deserts, the mental health workforce shortages. I'm going to talk a little bit about enhancing the community health worker initiative, and then, you know, the elevated chronic disease rates in several regions of our state. And so Definitely building the gap or the bridges to these gaps with this funding. I did want to pause. Marty, is there anything to add to this slide? I know you're very familiar with it too.

No, I think—

Okay.

I think you covered it.

Okay, sounds good. Keep moving here. So I talked about how I'd come back to our focus areas. The big buckets are right there listed on the screen as far as the strategy that we're taking and the approach that we're taking for South Dakota. So connecting data and technology, advancing the rural workforce, keeping healthcare access local and strong, and then transforming systems for sustainability. I guess some key points that I would make here just for background, you know, we used a community-driven and collaborative approach to shape these 10 initiatives within these 4 focus areas. Okay. You know, it began with listening sessions last fall. We've across the team talked to rural hospitals. We've talked to the critical access clinics. We've talked to our tribal partners, the EMS agencies, providers, as well as community members. This is not something that's being done in a dark hole whatsoever. We are very much taking that community-driven approach because we are not. Keeping the money at the state level. So moving into a few of these focus areas and the initiatives that will be embedded within them, one of the biggest buckets is technology and data. And so when you look down at the details of this, it's digital health modernization, it's enhancing patient care quality, it's modernizing the digital technology in our equipment, it's ensuring data security. So supporting those upgrades to meet current and future data privacy and cybersecurity needs is going to be huge. That can be a very vulnerable area, and that is one thing that we're looking for when systems communities are submitting applications for this initiative and for this funding that's available. We look to improve interoperability here. So talking about the health information Information exchange, which is South Dakota Health Link. This is where we were looking to support the integration with the health information exchange to enhance the interoperability between all healthcare entities in South Dakota, including EMS, which Marty spoke to a little bit. And we can get more details on that if you guys want as that project moves forward. And then achieving long-term sustainability. Of course, that's going to be a key component to. Everything that we're talking about when it comes to rural healthcare transformation. So a lot of stakeholder engagement and technical assistance calls have been at the root of the Tech and Data right now. This initiative is actually open for funding right now. Applications are being submitted. They're due June 30th. We just had, I think, over 250 people on 2 technical assistance calls here in the month of June. And so people are paying attention. They're learning right there with us about what some of these next-level capabilities are when it comes to tech and data. The rural workforce. So another big bucket. This includes recruitment incentives for clinicians and support staff. This is where we're looking to enforce and implement retention strategies. This is where we're expanding and strengthening our rural healthcare workforce. We've got a rural health training hub that's going to coordinate education and support. This is where we look at the community health worker expansion and enhancements to really focus in on professional development and network— networking across the state of South Dakota on what's working and what's not. And I will sidebar. I'm not the greatest storyteller that Marty is, but we were in Brookings yesterday, Senator Reed, and it was time well spent. It wasn't enough time, but we were at the Brookings Health System, and we got a chance to meet and greet. And we've known Alyssa Olson for a long time. She's an EMT by trade and has now evolved her career into this community health worker.

Yes.

I don't think that they would see the bottom line that they see today without Alyssa. She is transformative, in the true definition, and fostering a work ethic that, in this generation, I think is unseen. And so, if you get a chance, Senator Reid, if you would even want to invite some of your colleagues here to visit the healthcare system, I think they would welcome that. She is transforming lives and families in and around the Brookings community. I think they serve up to a radius of 30 miles. And she has created a model that— what am I trying to say here— where she's not a social worker, she's not a doctor, but she's helping families and individuals bridge the gap to, where can I get—

Resources.

Like a fire alarm or a carbon dioxide alarm for the home. And she's picking up the phone and she's calling, um, Louis— is it Louis? The Louis drugstore in Brookings? Or— okay, is that what it is?

Louis and Lowe's.

Louis, Lowe's. Lowe's. I was like, I know they don't have a NARS yet. But, um, she's picking up the phone and she's calling Lowe's to see if they would be willing to help supply that tiny of an element to add to somebody's home, to keep them safe, to keep them healthy, to reduce ER visits. Now, how she does that— there's a whole character work ethic that builds from the background of who she is as a person, because they have to trust her first in order to understand how she's able to help them. And that is all—

That's a great point.

wrapped up into what a community health worker does, and we're looking to build on that model. So Alyssa Olson, yeah, if you're listening, we've tapped her a couple times at the Department of Health 'cause she's got some tearjerker stories, language barrier type stories, poverty-stricken stories, and they're real and they're raw and they're happening across the state. And so building that workforce I think is essential to what we do.

I think it's also important to note that they're keeping folks from the ER.

Yes.

Because of the health outcomes.

Yes, thank you. All right, so looking at this next slide, what does keeping healthcare access local and strong mean? Well, it's not just words because true to form, there is a gentleman by the name of Matthew Ballard at The Department of Social Services who is leading this and lifting up the Rural Strong grants as part of this healthcare transformation initiative. And he had 85 applications come through that their teams are deciphering through and going to be making some funding decisions here in the next probably month or so before they contract anything out. But these are grants to really strengthen hospitals, clinics, and local access points. This is holistic efforts to care. This is looking at maternal and infant health initiatives. If you've listened to Secretary Magstadt, you know moms and babies are a huge priority for her. And yeah, so that's all integrated into these Rural Strong grants as well as chronic disease management and the community-based care support. So kudos to him and his team. We expect, you know, I talked about the tech and data one too, we probably expect upwards to 100 to 120 applications that will come through for that initiative as well. So it's— when I say we're building the plane as we're flying it, this plane is unlike any plane I've ever seen before. It's big and it's taking a team of us to work on all of it. All right. Transforming systems for sustainability. The feds have stressed these words, transforming Transformation and sustainability, or transformational and sustainable. And so we are taking those definitions of those words very seriously because every application, every proposal that is submitted to us must include a sustainability plan. So it's been said here too today, I'm paraphrasing, but the fact that it can't just be one-time funding, it can't just you know, be 5 years and, you know, you got the money and now you're done. No, we are expecting a plan in writing of how these systems, these providers, these EMS services are going to sustain the funding that they're applying for, that they're asking for in their communities, and share that back with us and carry that through throughout the grant funding. The next slide here is an infographic showcasing our implementation timeline. It's probably changed a little bit because, again, you know, we're modifying this and building it as we go, but kind of sections off the quarters here and what we're doing. And we've stayed true to our word. Once we got that funding authority, we went to work. And I believe the first RFP—

2018.

was issued end of February. And I'll talk a little bit about the recap of kind of where we've been here with the numbers. When we applied for this funding last fall, we had a team of 80 involved in that proposal submission. You know, we've broken it down now to get our implementation team at a membership of probably 25 to 30 on a daily, weekly basis, but over 80 team members across Department of Health, Department of Social Services, the Governor's Office. We had a contractor hired to help with project management and getting that submitted, making sure all our T's were crossed and I's were dotted last fall. So pretty proud of the, the team that's come together to build this. Again, since February, my numbers have increased since that. We've released 20 requests for proposals. 16 have closed and we currently have 4 open right now. And if I could just pause for a minute, Senator, that's, that's a huge amount of work. I know you are all very familiar with the procurement laws as well and understanding the scale and scope of what it takes to write, draft, review, finalize an RFP and then get it to To posting and sharing and the comms plan that comes behind that to ensure that you're gonna have proposals. And then getting their proposals, you could have 1, you could have 5, you could have 50, you could have 85. And then you have to build the team to review that and ensure that you've got the criteria to grade them. And we've issued 20. And so it's just— It's crazy to think about how far we've come in a very, very short amount of time. And again, that's kudos to the team. We do have 3 RFPs pending that will likely be issued— Marty, correct me if I'm wrong— probably yet this quarter or sometime yet this summer. And those are focused on the data atlas again. So building upon the data and tech initiative and the interoperability and having External kind of data out there so that anybody could really, you know, determine what they're looking for and go to that data atlas. Melissa Magstad has also defined that as being like the Amazon of data in healthcare in South Dakota. So, and that's putting it very swiftly, and there's a lot more that comes to that. to that too that we could talk more about. But then workforce recruitment and retention, we'll be issuing more information on that in an RFP yet this summer, and then EMS will have another RFP that's out there talking more specifically about regionalization efforts and everything too. We've got, I believe it's now 3 contracts that have been awarded, so the money has gone out. Those were all project management based, but we do have a couple that are going to be signed yet this week that are really driving the initiatives and the strategies and the focus areas that I talked about too. So the money is getting out there. I talked about the Rural Strong grants. As far as our comms plan and what we're doing as far as transparency and accountability and keeping, you know, stakeholders informed, we've had 4 press releases to date. We've— 5. Initiated targeted emails at our stakeholders. I think we've issued probably 25 of those according to the report that we have. And that's specific to making sure that the people who need to know about what we're doing— and I would say that's anywhere and everywhere across the state, these local communities— as long as they're ready and willing to draft a proposal in the areas where they see their gaps, We want them to know about what's going on here. And we've hosted webinars and technical assistance calls, and we've been in meetings and have delivered presentations, up to about 20 of those in those buckets since probably March. Yeah, mid-February.

So thank you for all this. I think there's a lot of good written stuff here, and I know because I was kind of trying to push you along that we did skip one slide that Marty had. And I'm gonna— it's slide 9. And I think that's an important one. And I think I kind of pushed you ahead so you skipped it. But I think it's really important for this group to understand those 3 things. So maybe if you just give us a highlight of the 3 major expenses of the Rural Healthcare Transformation Program for EMS.

Okay, so slide 9. So, while we're pulling that up, yeah, as we talked about earlier, the $64 million total for EMS over the next 5 years, $8 million for this particular quarter, or for this first budget year. So, this is going to be broken— how we distribute the dollars is going to be broken into 3 primary RFPs. $8 million, as Emily talked about coming in, $8 million is going to go out. It may not all be in The first budget year, we might have to carry some over, which is appropriate and CMS approved. But we've got 3 primary RFPs. The first one is open, it is already closed, and we're in the process of scoring those. I can't talk a lot about them. I can share high level what that is. We're looking at one primary consultant to be able to come in, assist the department, and be able to get this message out.

Okay.

To work with all the stakeholders along with us, to really take a concept that may be this big and to make sure that we can work with our individual partners across the state, all the different regions and so forth. So, that first one is going to be a huge assistance to us. As Emily talked about, all this workload that's been done so far, we're going to be in fast forward once we start awarding these, because that means now we're going to truly get to work on the next step of this process. And we knew early on, if we were going to do this effectively, if we were going to spend the money effectively and be responsible with it, we're going to need some people to come in and be able to help us. So that RFP is going to go to one organization, more than likely, and they're going to be able to assist us in taking this to the next step. We're excited for that one to launch, because then we can start to really have much more webinars specific to the details that will be able to move forward and we'll be able to bring people into that fold.

So the first one that we're talking about here really is to get the regionalization idea at least out there to folks.

Yeah.

And so that's the first thing. And then go on to the second one, what's going on there.

And I would just add in that first one, Mr. Chair, That's really stakeholder engagement and project management for all things to come for EMS when it comes to rural health transformation. So stakeholder engagement, talking about regionalization and the concepts that have been drafted for a plan, not the plan, and then project management.

Yep, and then the second RFP that's currently open right now is gonna focus on EMS workforce infrastructure and system modernization. Now, this is going to be a big one. There's a lot to unpack within this one. There's 4 different initiatives under this umbrella. But it talks about things such as workforce. How do we have— how do we bring workforce recruitment and retention? It goes into specific detail as far as dispatch centers and dispatch capability. When an emergency response gets dispatched out, is everybody on the same Is everybody hearing this? It's interesting when you look at some pockets of the state, a tone goes out on a radio and says we need an ambulance for a cardiac arrest. We might have 4 or 5 different responders going to the ambulance garage. Nobody knows who's going to go on that ambulance call until they get to the ambulance garage. Okay, so these are some of our dated systems that we're, that we're going to improve. There's a lot of capacity out there that talks about like I am responder. So on your phone, you could say, okay, we're getting the call and everybody— or on a radio, I should say— you can communicate. Everybody's in the know. Everybody knows who's going down to the truck. Everybody knows who's going to respond. And then we have that second tier, which is really a phone where you can coordinate and saying, okay, I know 2 people are going to be responding to this ambulance call. And then there's There's still that opportunity that we have for improving overall communication where literally is whoever shows up at the ambulance garage. Once you have that number within 10, 15 minutes, they know who's going to be on the call. So we look at improving communications. There's a barrier there because that extends not only to the responders. So if Emily and I are called, we get down to the garage and like, we need other people. Who else is coming? We don't know. But also that extends to the dispatchers who are on the phone with a loved one saying, when's the ambulance going to get here? So we're going to improve that from a dispatch perspective. Okay, so that one's currently open. That's gonna, you know, that might provide some specialized equipment and technology, but really here what we like about that is we have the overall project management and then we have this one that's really looking at once those regions are defined, what do we need infrastructure-wise to be able to build that up into sustainable solutions, kind of like the Spinn County examples we've talked about? And then the third and final RFP, as Emily alluded to, is going to come later this summer. That's where the individual regions are going to be able to say, okay, we've had time, we see the overarching vision of regionalization and hub design, we've improved our infrastructure on the RFP number 2, i.e., we've helped with dispatch systems. We've got some EMT and paramedic classes that are in play. We're getting HR services to us so that we can help promote EMS and really shore up some of the gaps that we have. Then that final RFP is where individual regions are going to be able to come and say, okay, here's, here's where we see some gaps that we need. To accomplish this overarching vision. It might be a piece of equipment. It might be something very specific like a simulator that they want for training aids, but something specific to that particular region that's going to propel them into long-term sustainability. So $8 million, we've got to obligate by October here. That's— it's not going to be an issue. We're going to be able to do that fairly quickly, but the benefit of obligating those dollars, with approval of CMS, is we're going to be able to carry that funding over. So, we talk a lot about being fiscally responsible. We could say— we could have said, let's get the money out as soon as we can, and that would have been very easy. But we knew that we had budget period 1, and then we had a carryover option for budget period 2. So, that's what we're going to be taking on. So, we're going to obligate the funds by October 30th.

Thank you.

If it takes us a little bit into that second budget period or all the way through that second budget period to be able to spend it down, so long as we're being fiscally responsible and we're getting everybody together in one accord and making things happen, it would be successful. Okay, so a lot of money we're just taking out. We're going as quickly as we can, but we're being conservative with the approach to make sure that we do it right, learning from the success we had with RIL, Regional Service Designation. Thank you.

Thank you. I just— I think this is— if anybody's got any questions, please jump in, but I think this kind of brings everything together. I'm kind of glad we did this slide at the end, but I think this is going to be important as we go on in the afternoon to start talking about, you know, what are the needs as we hear from different organizations and then the public input. So that's why I wanted to make sure we came back to it. Any questions on this last slide or anything? No. Anything else? Senator Otten. Just a quick statement.

Anybody that's been in appropriations has heard this statement: one-time monies are one-time monies. I don't care what your expectations are. It's one-time monies.

It's always good to have appropriators with reminders. Anything else? If anybody's going to testify this afternoon that isn't on the agenda, we have the public— you know, to have public comment. There's an electronic way of signing in now. So you either can— if you have the agenda up in front of you on your computer, you can click on it, or there's a QR code back there at the podium that you can also sign up. I'd sign up even if you weren't going to present— or I'm sorry, if you maybe think you're going to present, or sometimes you— when you hear something, all of a sudden you say, no, now I want to get up and talk about that issue. Just go ahead and sign up now so the staff has it. It will make it work easier for them. So if you have even an inkling you might talk later on this afternoon, please sign up. So with that, we will take a 30-minute break for lunch. I would like to thank you. Sorry to get jumped ahead of things. Thank you to our Department of Health folks here, Emily and Marty, and we will come back at 12:30. Thank you. We'll go ahead with some planned presentations we had on perspectives on emergency medical services in South Dakota. And so, Alan, you're up first. If you go ahead and introduce yourself for the record.

My name is Alan Perry. I'm the president of the South Dakota EMS Association. My apologies up front, I'm a little out of my wheelhouse here. I spend most of my days in the back of an ambulance and managing a crew at home, so If I messed up procedurally, I apologize.

But that's what we want. We want someone with that experience.

I'm going to be giving you the on-the-ground experience, that type of perspective. I've been in EMS full-time for about 13 years. I spent my first 2 years actually working under Representative Emery out in Rosebud, serving the people of the Rosebud Tribe. Learned many, many lessons out there. I've taken those along. Right now, I'm the director of the Lennox Ambulance in Lennox, South Dakota. We're a city-based ambulance service that covers about 175 square miles, currently only funded by about 1.5 square miles of population. So we'll talk about that a little bit later and our attempts to get some funding to help support our service. I do have a presentation, are there slides?

Sorry. No, y'all, it's all good.

Okay.

Awesome. And then the move I just did, perfect. Thank you, thank you.

And I'll get the screen. Oh, we'll need to share it real quick, actually. Forget about that.

Awesome. Thank you, sir. If any of you have questions as I go along, please feel free to jump in and ask those questions.

Yeah, just— oh, and I think we have everybody back online too, but same thing, if you If you guys would just raise your hand, I'll make sure that we stop and answer your questions. So go ahead, Alan.

For— are you—

There we go.

What does EMS do in South Dakota? We provide 24/7 emergency response, 365 days of the year. That's days, nights, weekends, holidays. That's the middle of Thanksgiving dinner. That's Christmas morning with your children. If that call comes in, we're responding to those emergencies. We have basic and advanced life support services across the state. I believe there's 122 services. Across the state, and they range from either BLS to ALS and BLS, depending on the time of day, to a full ALS service. Providing cardiac and stroke care, inter-facility transfers, and we heard a little bit earlier how important inter-facility transfers are to patient movement, either to higher levels of care or lower levels of care to open up those rooms. Mass casualty responses, and also a lot of services provide community health education. Whether it's CPR classes, whether it's the community health worker portions, but providing that education to those communities. If EMS truly disappears, there is no replacement for EMS. You cannot create this once again. So we have to do whatever we can to sustain it. Current state of EMS. South Dakota is primarily rural and frontier service. I have a little typo on here. It's 64 of the 66 counties. 66 are considered rural, not frontier, by the Rural Healthcare Transformation Grant information. But that's all but 2 counties in the state are either rural or frontier. It means there's lots of areas out there that are going to be waiting a long time for that service to come. Long-distance transfers. When I worked in Rosebud, we would take patients to Sioux Falls. That's a 4-hour transfer. Obviously, it's inter-facility, but that's a long time to be on the road with a patient. Aging workforce and volunteers, actually. The average age of EMS providers in the state is 51 years old. We have people in their 70s and into their 80s that are still providing care daily on ambulance services. It's a big burden to some of those people, but they're afraid if they step down, who's gonna step into their place? We have a difficulty recruiting EMS staff. Everybody knows EMS was set up as volunteer. A lot of people are having to have 2-income families to support their children. The kids have lots of activities at home or at school. They just don't have the extra time to be volunteering. They don't have the time to take the classes. It's just kind of a predicament that we're all in at this point.

Can I— want to jump in there because I think some good questions around— because I know we're going to be talking about this a lot. But so we talk about folks having, you know, like 2 jobs to survive. So we just, we're not seeing the volunteerism for this. They say, oh, maybe volunteering in their community might be with their kids' baseball team. So I don't want to knock that people aren't volunteering anymore, but what will it take to get more folks going into the career path of EMS? What do you think that'll take?

There's lots of ideas on that.

Volunteer or paid, however.

I will talk in my experience of where I'm at. We are a service 20 miles south of Sioux Falls. We run right now 500 calls a year. We're looking at expanding territory, helping out some of our neighbors. We are looking to go to a 24/7 service, paid service, so that we can get those professionals, we can get those EMTs, those paramedics, those AEMTs there to fill those positions and to render care when it's needed. So for us, it is actually wages. It is being that second job for a lot of people so they can support their families with it and be able to render that care.

Thank you.

Also, call volume is increasing. In 2024, there was about 115,000 calls in the state of South Dakota, and we heard this morning in 2025, there's 122,000 calls in the state of South Dakota. That's a call about every 4 minutes someplace in South Dakota. So think how many EMS calls have gone out since we started these meetings this morning, and there's somebody there answering that call, getting into that truck, and going and taking care of them and transporting them to an ambulance. And like the very last point on there is the growing reliance on paid staffing, and that's not just us. You hear that time and time again across the state. EMS was started as a volunteer service. Many of the services are still volunteer. Like I said earlier, families needed 2 incomes to survive. The volunteerism is decreasing, not necessarily in total, but we're seeing a decrease in the volunteerism in the EMS side of things. They're volunteering with their kids at schools, their softball teams, their churches, their communities. Volunteering in EMS is a very stressful situation. It's a very stressful job, and they're just changing where they're putting their volunteer time. The training for EMT has increased. An EMT back in 1975 was 81 hours. Today it's 150 to 80 hours, 150 to 180 hours, and that's only to set foot in the truck with your very basic level of care. And then ongoing education, every 2 years you have to have more education to recertify. So just the education component of it is going up exponentially. Competition with paying jobs and the burnout due to the high stress. Rural EMS is a beast of its own. I always say that rural EMS is, it's a blessing and a curse at the same time. It's a blessing because you walk into a house, I can say, hey Mary, how are you doing today? I know who she is. I can say what a lot of her medical conditions are because I've been there before. But also on those really bad calls, you've You pull up to an accident on the side of the interstate and you walk up and you're like, I know this person. So it can be really stressful in that aspect because you know them and they're dear to you. We've talked about reimbursement. Reimbursement in EMS just does not cover the cost. Medicaid or Medicare reimbursement, cost-to-reimbursement gap is 54 to 63%. They did the cost data collection survey from 2020 to 2025, and that was the information that came out of that. There is just not there the reimbursement to fulfill.

We've got a question from Senator Larson. Go ahead.

Yeah, just thank you very much. Before we move on, do you have any data on the percentage of EMS workers which are volunteer versus those that are paid? And then second question would be, Do you have any figures on the average salary for paid EMS workers?

I do not have any percentages of paid to volunteer. I'm guessing the state EMS office could provide some of that information through the recertification process that's going on right now. And as for salaries, I think they range. Typically, they're lower end. I can tell you what I'm paying at my service. I am paying my paramedics a starting wage of $21 an hour. So my EMTs are going to start at $12 an hour. Thank you.

I have a question. I'm wondering, on the training, does any of that get reimbursed, or what is the average cost for the training to become an EMT? And is that like daily classes, online classes? Tell me a little bit about that.

Okay, for an EMT, typically we just finished one in our service. Typically an EMT class runs 3 to 4 months. A lot of times Tuesday and Thursday evenings for 4 hours. It's just how we run it in our service. And then a Saturday once a month for skills. A class typically costs like $800, but we have gotten a grant through the, Healthcare Transformation? No, the first one.

Regional Services.

Regional Services, thank you. Regional Services grant to offer those classes for free. So actually, what we do is we require a down payment of like $300 for them to take that class. Once they test, they get that money back, but that gives them some skin in the game, so it's not just a free class, and they're there to learn, they're there to get that experience.

Anything else? I guess we're kind of on the previous slide. Go ahead.

Just while we're at it, Representative Peterson. Thank you, Mr. Chair. Just if we could get a little bit of that data— excuse me— and as members we can keep that private, but it'd be nice for us to know where we are and then obviously where we may go. If it's more volunteer, we'll know that those costs are going to go up in the future in those service areas.

Marty's going to take care of that. Thank you. Anything else? Okay. Sorry. Good stuff, though.

All good. Medicaid reimbursements. Medicaid reimbursements are even less than Medicare reimbursements. 60% or so of our calls are Medicare or Medicaid. So if we're only getting a partial reimbursement for those, it makes it very tough for us to not lose money on this. Commercial insurance payments inconsistent. They have their mandatory write-offs and everything. They have what they're going to pay and what they're not going to pay. And then what's left over to the patients, we bill the patients if it's commercial insurance, but they don't always pay that. So then we go to collections with them and that type of thing. But sometimes it's a long time before we get payments for those calls. The other fact is we're in a society where typically productivity is reimbursable. So if you go to a job, You're paid because you're productive, you're doing a job. All of public safety is— it's readiness. You have to pay on readiness. You have to be ready 24/7, 365 days a year to go. That's fire, that's PD, that's EMS, that's all of them. Cost of readiness—

Sorry to back you up, Alan. Go to the previous slide.

Yes.

So when you're talking about that cost-to-reimbursement gap, right? 54 to 63%. Does that take into account readiness?

Yes, it does. Okay, because that cost data collection survey actually figured into it the cost of volunteerism. So they put a dollar figure on what it costs for the benefit of a volunteer.

So I guess when I see readiness, that's also the equipment, and, you know, not just the person sitting there, you So does it include equipment then?

Yes.

Okay.

Yep. Great. It includes all costs of running a service. And we were just talking about readiness. Costs of readiness are many, and these are needed for 1,000 calls or 50 calls. Personnel, your ambulances, all the equipment that's inside. We heard Marty talk earlier about— they gave out the LifePak 15s. That's like $25,000 apiece if you have to purchase them outright. Medical equipment is insanely expensive. We're having to remount one of our ambulances this year. It's $175,000. To buy a brand new ambulance, you're looking at $300,000 to $350,000. And that's empty. That's not— that's fully outfitted. Equipment, medications that we have to keep on hand, that all expire. So they can only be there for so long. Supplies are the same way. Everything comes with an expiration date. You have to have it on the shelf. You may not use it It may expire and you may have to throw it away. Fuel, insurance, training, facilities, all of that stuff plays into that readiness cost. All of that is, you know, we have to have it no matter if we roll or not. Why is EMS different? Police is tax-supported essential service. Your fire is a tax-supported essential service. EMS is expected to function as an Essential service, but we're out there doing bake sales, we're doing soup feeds to make sure we can get enough money to keep our services running. You know, why is EMS the only public service that's not expected to pay— or that is expected to pay for itself? Making us essential and coming up with some kind of funding is going to be a huge benefit to keeping EMS rolling long-term.

Thank you.

Funding solutions. Stuff we just come up with. Potential options. Dedicated state EMS funding. Where that comes from, that's the hard part. How that's allocated, that's another hard situation. Increased Medicaid reimbursements. If we can get our Medicaid reimbursements up, that helps. Workforce retention and recruitment funding. Operational support funding. Funding that's a partnership between the state State and local governments. One that we had last year was Senate Bill 211. It was the Patient Protection Act. It would have increased the reimbursement rates from private insurance for EMS. That was huge. If that's something we could look at again in upcoming legislative sessions, that would really help us out a lot, bringing up that private insurance reimbursement. And what is your return on investment? Investment in EMS truly saves lives. We heard this morning, you know, time is life. The sooner we can get there, the more lives we can save and we can affect positively. It preserves rural healthcare access. We're that vehicle to get people from their homes to that hospital, to that ER room. If they weren't— if they couldn't get there, they'd be worse off by the time they would get themselves to that hospital, if they did. Supports movement between hospitals, improves disaster preparedness, protects economic development, and your communities truly cannot survive— or not survive, but not thrive without EMS. They're what, at the very essence, makes them one of the most places you want to go live. If you have EMS services, you know if you need it, they're there.

Thank you.

I'm going to talk just a little bit about us and our service personnel. We have been looking at funding options since 2022. We looked at starting an ambulance district, forming an ambulance tax district. Um, Codified Law 31-11A talks about how to form a tax district. There's 2 ways to do it. One's through resolution by your governing bodies, one's through petition. Those two processes puts it on the ballot. The first time we went through a resolution of governing bodies, we got all three of our cities that we cover, one of our counties, and we got to the last county commission and we could not push it through. They would not put it onto the ballot for us. So things kind of got halted. In December of 2025, our city council released a letter that said if we could not find a funding option. By January 1st, 2027, we will no longer leave the city limits of Lenox. We will only serve what's in Lenox. Like I said earlier, we cover about 175 square miles. That's 3 towns, 9 townships, parts of 2 counties, 9 miles of the interstate. And they— we will not be able to leave the city if we don't get some unfunding. That obviously spurred debate. Stirred a lot of conversation. We've been moving forward, and Senator Otten's wife is one of our county commissioners. We owe her a huge debt of gratitude for pushing that conversation forward, for wanting to learn more, wanting to understand how the process works. And because of her pushing, we actually got to a meeting last night where we had both of our counties in attendance, we had all of our cities in attendance, we had our townships in attendance. Attendance, and we actually had some other areas outside that are considering joining us in attendance and have agreed to work together to come up with some kind of funding option to push this forward. They don't want to lose EMS in our area. So it's important that the discussion is out there, that it's opening up, and anything that can help from outside the local, from the state level, is going to help that drastically. And I know that's not just the case in Lenox, that's the case across the state. There's other places that are looking at the same issues. They're not gonna be able to continue servicing all that territory if they don't get some help. Our request, I guess, respectfully, we request designation as an essential service. I know that comes with funding. I know that's where the hard part is. We would love to have some oversight of all aspects of EMS in one office. Right now we have 2 offices. Our licensure goes to the South Dakota Board of Medical and Osteopathic Examiners, and our ambulance licensing goes to the Department of Health EMS office. If we could be under one roof in that aspect, it would be really, really nice. Then there's things that aren't going to drop through the cracks. A long-term—

sorry, you got a question from Senator Ott.

Do you— any agency that you would prefer to have that under that You would think we're good?

I think there's benefits to both. Prior to 2 years ago, we were— our EMTs were under the Department of EMS, and all of our ALS personnel, our I's, our A's, and our paramedics were under the SDBMOE. Now we're all under one, but we're still split.

What kind of consternation does that do?

We sometimes lack— I'm trying to think how to politically correct this— say this— lack the— we run into a lot of issues with licensing our personnel. There is a process that It's quite lengthy. There's fingerprints involved, and we understand the reason behind it, but we don't always get a lot of reception on the other end and help with those processes. And that's with the board. We didn't have those same issues with the Department of Health. However, they also didn't have the ALS components under their roof at that time.

Does it fail normally because of felonies?

A lot of it has to do with us being a compact state. Allowing us to practice in other states under our license, and so because of that, they're looking for any kind of history, background felonies, all that kind of stuff, so they can ensure that licensure.

Anything else while we're on a pause here? Okay, thank you for. It's important for for us to have. No worries. So appreciate it.

Keep keep on going. Long-term commitment to protect EMS. Obviously, all of you who are in this room, you are committed to making something happen for EMS, and we are very appreciative of that. Stable and reliable EMS funding solutions and improvement reimbursement rates. Like I said, if we could increase Medicaid reimbursements and also that Senate Bill 211 from last year, if we could reintroduce something like that, that would greatly help this coming year. EMS is not optional. It's not a luxury. It's not nice to have. EMS saves lives every single day, and every South Dakotan deserves to have that.

This has been great.

Questions? Everybody good? Go ahead, Representative Peterson.

Thank you. Thanks for your presentation today. So you have 9 miles. In kind of a 12 by 12 territory, I'm sure it's not like that, but, you know, or 13 by 13, whatever, something close to that. About how many of your calls are interstate calls and how many are not?

Right now we run around 500 calls a year. I'm going to say probably about 55 to 60 of those are interstate calls per year.

Go ahead, Senator Jensen.

Yeah, it's going to be kind of a roundabout full circle because we, you know, one of the big discussions is still property taxes. Property taxes pay for public safety and those things in the counties. So, you know, we've heard last summer that some of the backfills from some of the counties were up to $100,000 or more to backfill the services for the year So of course that comes from property taxes. So Lenox here in my district, of course, is that backfilled by the city or by the county, or do you know how that works?

We are currently supported 100% by the city of Lenox. We receive no funding from either of the counties that we serve. Okay, thank you.

Representative Emery, and then I'll come to you. Okay.

Thank you, Alan, for being here. Can you— do you have any statistics or knowledge of what does it cost to fund one ambulance with 2 providers?

For a year?

For a year.

I don't have that off the top of my head.

Okay. Well, maybe the next presenter could answer that.

Brian can help you with that. Yes.

Senator, are you on the same line of questioning?

Just a point of clarification, like McCook County is backfilling every year. It's 6,000 people in our county, nearly 400,000.

Good data. Representative Fosness.

Uh, go back a few slides to the cost reimbursement gap, that 54 to 63%. Just to Is that a generality statewide or is that an example of the city ambulance you're a part of?

That was pulled from that cost data collection survey nationwide.

Nationwide for Medicare, Medicaid. I'd like to extrapolate that with more specifics to true South Dakota examples, maybe an urban example and a rural example so I can better understand what that looks like. For example, average Medicare rate is this on the net pay, average daily cost for the ambulance service, you know, for that runner. However, I'm just confused with this gap. So some better detail to it. I believe it. I just want to better believe it, if that makes sense.

And I can't give you that off the top of my head here.

I can get that back for you. Great. Senator Otten.

Go back to Senator Jensen's question. I classify Lennox having to do what they had to do from old world reality to new world reality. And by that I mean going back to volunteerism. You go back, you know, I go back far enough where like on Thursdays when everybody got their paycheck and whatnot, where did you go? Well, you went to Lennox. There was that camaraderie with other communities. And so I think that they did that mainly as, I know Joe down the street, I know Sam, I know Bill, and we'll just do this because they're neighbors, they go to the church, they, you know, and, and that is being separated at this, this point in time where we don't have that anymore. That's, um, especially, you know, when you go through the deal with T-splitting away from a Lenox on school and a variety of other things. So that's— I think that is the catalyst to that one.

Anything from online? Any of our task force members that are online? Okay, doesn't sound like it. Anything, any last— this has been very good. Thank you for being here. Very helpful. Go ahead, Representative.

Sorry, one more clarification. It's not just about Medicare. I'm interested also in the commercial rates as well breakdown that could be averaged amongst the commercial payers and then also Medicaid too and what Medicaid is doing. I think that would help us all.

I think what we're talking about, we kind of need an overall model, don't we, to understand this so we can see it? And is that something that Department of Health has, Marty?

I think that's one thing we're working on with our consultant. We can talk to them about It gets a little bit deeper into what we originally had him do, but we can certainly add and get back to the committee.

Great. That would be great.

Marty, the Ambulance Association does have all that information that was put together by DWDW.

Thank you. Anything else? Okay. Thank you very much.

Thank you for your time.

Let's see, up next we have Brian Hambeck, president of the South Dakota Ambulance Association. If you'd go ahead and introduce yourself also for the record.

Oh, turn that on. Good afternoon, everybody. I see some familiar faces. And some new faces, which is wonderful. My name is Brian Hambeck. I'm the executive director and paramedic of Spearfish Ambulance Service and president of the South Dakota Ambulance Association. We've been talking last year, well, for the last several years, on EMS sustainability, and my position has always been and always will be, it comes down to funding. Yes. Senator Reed really helped us out last year, and I'm going to discuss that Patient Protection Act, Senate Bill 211, that was proposed last year. I'd like to say a big congratulations to— I heard 3 people on this committee that said they want to be here. That shows a commitment to EMS and what you want to do, and I thank you for that. We all know this. So, when it comes to finances, and I'll say what I did the last year, it's a puzzle for funding EMS. We're a unique breed. We were started back in the early '70s as a grassroots organization within communities, really didn't get adopted into Medicare's funding or billing until the late '70s. And they listed us not as healthcare providers. We are listed as an ambulance service as a supplier, which means they're paying for the truck, which is different, isn't it? They have come out since then in the late '70s, early '80s and broken that down into different categories. So there is so much that they will pay for a BLS truck, basic life support. For non-emergent and emergent. There's so much they will pay for an ALS truck. That means you have to have at least one ALS provider on there doing ALS skills or assessments. And that's ALS 1, which is non-emergent and emergent. And then ALS 2, that is the grand kind of big bill that we submit for things like cardiac arrests or major traumas.

Okay.

where we are doing some heroic stuff with that patient, intubating, defibrillation, needle thoracotomy to get pneumothorax reduced, cricothyrotomy, things like that. That's only stuff that paramedics can do out here. So they pay for that. That's an ALS Level 2. And then there's specialty care transport, which really our scope of practice in South Dakota doesn't have anything in there that would fall into the specialty care transport arena. Okay. Some areas are expanding on that and utilizing that, but most areas are not. So we are paid as a supplier. When Medicare did a cost data analysis, this has been now 4 years ago, it showed that, yeah, right now Medicare is paying 55% of what it costs me to roll tires on a call. 55%. How many businesses would stay open If their net was 55% of their cost, none, absolutely none. So we scrimp and save and try to reduce costs on our side of it as far as our expenditures in order to make it under that. In Spearfish, 62% of my call volume are Medicare-aged patients. 62%. I have to live. My budget has to live within that Medicare. Allowable fee schedule. So unfortunately, my employees are— I mean, they're paid. We do offer some benefits. But they're not paid like they should be.

Brian, can I interrupt before you get— I want to back up. When you said the cost to roll. Yep. Okay. Does that include readiness or is that that trip?

That's all part of what Alan had talked about, that cost data analysis that Medicare did.

Okay. I think it's just important to always make sure that we understand it's part of readiness.

It is. It is. So with fuel prices up, you know, our reimbursement not going up, it's hard to keep tires rolling. There are 2 healthcare agencies or healthcare facilities in a sense that are the most abused. One is an emergency room. Anyone that presents to an ER has to be seen and has to be treated. And the other one is EMS. We don't have a choice. They call 911, I have to roll tires, I have to send a crew. That's money out the door whether they have the capability to pay for it or not. We all have those abusers in our local communities. We had one gal a couple years ago that In 2.5 years, she called an ambulance 233 times. She accepted transport on maybe 25% of those. Those are the only 25% that we could bill to Medicare and Medicaid and get paid for. The other 75%, we took it. The last time we took her in, she ended up a couple months later passing away in Sioux Falls. And stuck us. We're holding $15,000 worth of past bills on her. There's no way to get that back. So that's money out the door that I won't ever see income on. So last year, big kudos and a big thank you to Senator Reed on Senate Bill 211. I didn't realize how much back office negotiating was happening in there. But I think he handled it very well. Senate Bill 211 is a patient protection act, and I asked— or your secretary actually gave you copies of this, correct?

Yes.

Fantastic. Which would not allow us— this is all part of the No Surprise Act that was passed federally about 5 years ago. That said we we cannot go after a patient for any amount of monies that insurance did not pay for. The No Surprise Act was then basically they carved ground ambulance out of it, with the exception of the very last paragraph in that act. It still lists ground ambulance. So states have had to come up with this Patient Protection Act, which tells. Simply that we will not bill a patient over and above what insurance will pay for. This is all for commercial insurance. When we're talking about that puzzle of financing, we got one piece that's Medicare. We got one piece that's Medicaid. One piece that's VA. One piece that may be IHS, tribal. Private insurance. And the last piece is self-pays. We may get paid on those. We may not. Okay. You know, we just have to take that as part of this. So what we're dealing with Senate Bill 211 last year is that private pay insurance, which states we will not bill a patient over and above what insurance will pay except for deductibles and coinsurance. All right? Those are already in their insurance plans. Okay? We'll take what they pay and the bill is done. Is taken care of. However, it does stipulate in there that the insurance companies need to step up. They need to either pay— last year it was in the bill that if it is a city, county, public entity that advertises their rate, they have to pay that advertised rate. After the Senate passed that in Health and Human Services, we had quite a discussion with Wellmark, and she said that was the biggest Thorne and her side on that, because now cities and counties could go back if that passed through. They could go back and say, "All right, a BLS run is now six thousand dollars. You've got to pay it." Well, that's not right, and I get that. I understand that. So I also had them or had your secretary give you this. This has taken that line out of it. Which says that private insurance will pay what the provider bills, the lesser of what the provider bills or 350% of Medicare allowable. Now, in this summary of the Patient Protection Act, there are 21 states who have passed this. It was asked in— on the Senate floor last year, why is the state having to do this? Well, because federal won't.

Right.

So states are protecting their own ambulance services by passing this legislation and making sure their EMS entities can stay viable and sustainable. There are 21 states that have passed this legislation in one form or another. The range is anywhere from— I think the lowest is 275% or 250%. The average is about 350%.

Okay.

325 to 350. West Virginia and Illinois are actually at 400% of Medicare allowable. So, 21 states, and I know it's in 5 other legislatures, other states' legislatures around the country to be passed. So, please take time and look at that because it lists what the provisions are in there. But I would really like to see this reintroduced this year as a funding source. Thinking outside the box, how do we fund EMS? Tax districts are fine, but the state wants to cut out property taxes. And those are the only ones that would end up paying for EMS, is property owners. Kind of unfair to property owners in a sense, isn't it? I'm looking for input here. Other ideas are we have proposed a penny sales tax or a penny tax on gasoline per gallon. We are on those roadways. We have to roll tires. We are part of DOT and National Highway Traffic Safety Administration, NHTSA. So that would go towards your local EMS wherever that gas is purchased at. And everybody's responsible then. Anyone who owns a car, including tourists, would be paying in to help support EMS in this state. Another thought is a dollar tax on license plate renewal. I keep paying a dollar tax for disposal, and I have no idea what that's going to because I've kept the same plates on my truck for 5 years now. You know, so a dollar for com— or a dollar for regular license plates and $3 for commercial. That's an option. I had one of my crew members yesterday saying, why can't we put a tax on these marijuana dispensaries? Because I'm going to tell you folks, we're picking up a bunch of these people. Um, we had a call earlier this week. Um, they said an 18 to 21-year-old Unresponsive. Crew rushed out there. Turned out to be a 13-year-old who was high and had taken too much marijuana. This is affecting us and we're seeing it every day. I'm sure cities like Rapid and Sioux Falls see it more often than we do, but it's there. So, um—

Brian, can I ask you a question just about what you're talking about? What's your— do you know your percentage of tourists? That you're responding to, whether it be along the roadways or in hotels and such?

I don't. We haven't broken that down. We cover Spearfish, we cover 600 square miles, including part of the Black Hills National Forest. So some of those rescues, we have one area up Spearfish Canyon that it's— we have a written tally and the ER does too. They've got a little board on the back of the office, Doctor's office. How many trips are we going to make up to Devil's Bathtub this summer? Because everybody goes up there. We get a lot of them that slip and fall on those slimy rocks, break an ankle or hit their head, and they require rescue. That for us is a 3-hour run to get up there, rescue them, get them down out of that canyon and transported. So yeah, and most of them are tourists that We end up picking up. Thank you. Sorry, sorry, I don't have more specific stuff for you, Senator. If anyone needs those numbers as far as reimbursement from insurance, I have them. If you have questions on that, please feel free.

Could you provide that information to Matthew? That you have on your phone?

Yeah, um, just after this I'll get your email. I can send this directly to you out of there.

You bet. Thank you. Any questions then for Brian? Go ahead, Representative Peterson. Thank you.

I don't know how long that is, but if you could give a little bit of an overview for the people in the room, you know, just so we can comprehend the reimbursement a little bit.

All right, so, um, Most of the state is— Medicare breaks down reimbursement according to those BLS, emergent, ALS, ALS 2. So each have different rates as you escalate up. Medicare also adds— they have add-ons. So anything urban is a set rate. Anything rural, they add on 6% to what their base rate is on this. And by the way, Medicare and Medicaid only pay a base rate and mileage. That's it. All right. For most of South Dakota, including Spearfish, we're super rural. And it's all based on zip code and population density. Okay. They add on 26% for super rural. So Medicare urban allowable, let's just Pick ALS emergent. Allowable for Medicare is $473. Medicare in their cost data analysis showed it took— it cost $1,300 to roll tires. That was the average. But they're paying $473. Super rural is $586. $1,066 on that. Commercial payers are being billed $1,250. That's better. That's closer to what it's costing us, but they aren't paying that. Okay. Medicaid for that is $266.

Mr. Chair, just for clarity—

I'm going to actually— Senator Otten, and then come back to you.

Okay.

Go back to your mileage. Is there a cap on the mileage? And then if there isn't, are we using the IRS model for reimbursement? Is there something already set?

There's something already set through Medicare. Now Medicare will set that mileage rate for 0 to 25 miles, it's so much, like $9.61 a mile. For anything up to like 50 or 51 miles, then it's $10.96 a mile is what they reimburse. Okay. Private insurance right now is paying $14. Okay.

So Representative Fosness.

Yeah, just trying to keep up with the— were you in ALS number 2 then Medicare pays $5.86?

No, ALS 1. ALS 1 emergent is, yeah, the $586.

1 emergent, $586.

Yeah, now if it's ALS 2, now we're talking Medicare will pay me $848. That still doesn't recoup my costs for a BLS run, you know. I'm looking for ideas, folks, how we can approach this, and I know you guys are too. And I thank you.

Hold on, we got more questions.

Just to talk with you. I mean, those numbers are a little more in line with what I was coming in in my head, 20 to 36% reimbursement.

Yeah.

Right. That's what I was coming in with in my head. So those numbers closer to 50%, I thought those were actually a little rosier than reality in rural districts like you work and where I live.

Right, right. That add-on is a nice benefit that Medicare provides. But they are still underfunding by 45% at least.

So a follow-up on the private payer, the commercial insurance. What are you getting reimbursed generally on? You said you billed at a certain amount, but you're not getting that. What are you usually getting? And just for our background knowledge, are individual Healthcare insurance providers, are they reimbursing at different amounts or are they fairly similar?

Nope, they're at different amounts. Blue Cross has not raised their rates with us in 6 years. I did get a letter from them this last April that said we are upping your fee schedule rates, and it came in at a grand total of 2% increase. We went through COVID with the same amount of money on these patients. My costs tripled. My— in some supply areas, hell, wages doubled on that, you know, and no reimbursement increases. So Medicare's mileage rate was actually paying better than Wellmark, Blue Cross Blue Shield, almost within pennies.

Okay.

So other—

online, online, are there any questions? Not seeing or hearing of any. Go ahead, Senator Otten.

I'm pretty sure you can't answer this, but then the privates aren't meeting it because they don't have to?

Exactly.

All right, that's where I thought— yeah.

We are a small fish. Actually, you want to know, private insurance nationwide, any guesses on their payout to EMS? What percentage? Any thoughts?

0.196%.

0.196%. Less than 0.2%. They don't care about EMS.

One more time on that, so I make sure I heard you correctly. Start at the beginning.

The payout from private insurance, and that's UnitedHealthcare, Avera, Sanford, Blue Cross Blue Shield, all of them, is less than 0.2% to EMS.

Of their— Less than 0.2%. Of their revenue? I mean, of their— of their total—

Of all their pay.

Out of all their pay.

Their payouts.

Everything they pay out. Okay. That's what I wanted to get to.

Yep. So, you know, we discussed this last year. Colorado did this patient care— patient protection thing, and insurance came back saying it's going to cost us increased premiums. Well, the increased premiums that they finally drilled down to the numbers, for a family of 4, it would cost an extra $62 a year. in premiums to meet this requirement, to pay that 350% of Medicare allowable. I don't know a family around that wouldn't say, you know what, if I've got good ambulance service coverage and reliable, I'll pay the $62 a year extra. But my health insurance premium went up $58 last year. In 2025, it went $300 a month extra. So they're getting their money. They're just not paying us.

Go ahead. Hello. Hi. So I guess I'll pose my question that I asked Ellen disease the same way. How do you know how much it costs to staff one ambulance per year?

Yeah, actually we had a group in that did some did some work in the state of South Dakota. They started in 2010 with a workforce summit. John Becknell— Marty, what group is that? Safety Solutions. Safety Solutions. And so they did some leadership classes throughout the state. And we did a governor's task force throughout this as well. And John had brought up paying— at this time, we're talking about 8 years ago— paying Paying $10 an hour for 2 EMTs, okay, 24 hours a day, no overtime, no benefits, to staff 1 ambulance, it was $478,000 a year just for 1 ambulance coverage of that. Now you add ALS, it's going to be considerably more than that. He also brought up that, you know, it takes about 600 calls a year to afford a full-time crew. So what else? That answer your question?

Okay. Anything else?

Go ahead, Representative Peterson.

Thank you. A different question that I don't think we talked about yet. Billing the patient. You can bill Do you bill them up, or how does that work? Because if a private insurer or commercial pays their bill, you can't send them additional to make up the difference. Is that correct?

In this, yeah. In this Patient Protection Act.

How about if there's a copay or out-of-pocket in my insurance plan that I'd have $1,000 or $500 or whatever? Do you bill that to me, or Do I, as a patient, pay that to the insurance company to get to you?

No, you'd pay us directly on that.

Are you—

Huh?

Follow-up.

You can bill the deductibles and the copays.

You do.

From my recollection, those deductibles and copays have shrunk over the years. Is that what you're seeing, or does that really depend on the insurance provider?

It depends on the provider. Health plans have gotten so expensive. Out-of-pocket, $7,000 a year.

Right. And I'll rephrase that. So yeah, premiums are going up, but for instance, ambulance costs to the user have actually gone down direct from my pocket to your billing system, but the insurance company isn't necessarily making up the difference of what it used to be.

No. No, my budget every year I plan on— there's contractual write-offs. That's the Medicare and Medicaid deductions that I have to take, I have to write off. And that includes Blue Cross and whoever else we're in network with. That's contractual adjustment. And then there's uncollectibles. My contractual adjustments is about 23% of my budget for patient income. Write-offs such as collections is about, oh, 12%. Those are patients that just can't pay or won't pay.

Okay, are you done?

Okay, I have one more question. So as far as billing, is every 130 services in the state actually billing for their service, or how many of them are just providing it without any We had, we had about 3 services that I remember earlier on in our association that were not paying their staff at all.

It was strictly volunteer. And they weren't billing the patient except for maybe $200. Well, they've come around and they realize that they're leaving a lot of money on the table and they've got expenses they got to meet, you know, and they need income to do that. And so they've come around and they're now So they are actually billing more appropriately. A lot of us go through a billing company. The one we use is PCC, and they're pretty good about setting these rates or helping us set these rates to where we're not leaving money on the table. We're actually capturing what we need to be capturing in this.

So along that line, do you know roughly How many services are using a billing company versus not?

Most.

Most are?

Yeah. The complexity of billing Medicare and Medicaid is nothing like getting money to or getting a bill to UnitedHealthcare or some other offshoot insurance company. And that goes back through a clearinghouse that then sends a check on. So yeah. Thank you.

Okay, appreciate your time. Stick around, that's how you can help. Okay, in case you have a question. Let's see, I think—

thank you for your time.

Thank you for being here. Sarah Rankin, I think you're up next, and if you'd please introduce yourself.

Good afternoon, members of the committee.

My name is Sara Rankin and I'm the executive director of the South Dakota Municipal League.

I want to start off by thanking you for the invitation to be part of this conversation. The league very much appreciates it.

EMS is near and dear to all of our cities' municipalities' hearts. Obviously, it is a huge indicator of quality of life for our residents. And so we are, we're really appreciative to be part of the conversation.

Across South Dakota, cities are investing significant resources to help ensure that our EMS services remain available. In 2024, the Department of Legislative Audit report illustrates that the level of investment communities are making is significant.

Rapid City's latest financial report shows more than 6% $2.5 million in ambulance expenses appropriated by the city, while Watertown appropriated more than $3.6 million to ambulance services. Vermilion reported ambulance expenditures exceeding $816,000. These are not small side items in a city budget. They make a real impact. And so, you know, when you speak with our cities, they're happy to do so. They understand that EMS is an essential service in their community. These investments are not limited to just those larger communities. Ipswich reported nearly $195,000 in ambulance expenditures, with Faith reporting more than $176,000.

These are small communities, folks, and that's a big budget item for them.

In Wall, the city's financial report shows an outstanding ambulance loan balance of more than $73,000, which highlights the capital investments many communities make To keep their services operating, these were numbers from 2024. I explained to both the chair and vice chair of the committee that the 2025 numbers are not available yet. They were due to the Department of Legislative Audit in May. So hoping by your next meeting that those are available, and I'll make sure that I get those to Matthew so that he can distribute them to you. These examples demonstrate that municipalities are active partners in supporting EMS. Cities contribute local dollars, facilities. Equipment, staff support, and leadership to help sustain these essential services.

Representative Emery mentioned this once already today, but EMS— one of the strengths of South Dakota's EMS system is its flexibility.

Municipal partnerships look different from one community to the next. Some cities operate ambulance services, which the previous speaker spoke about, Lenox. Some others support volunteer organizations, nonprofit providers, or hospital-based systems. Many communities participate in regional partnerships that bring together their cities, counties, healthcare providers, and EMS agencies to serve a larger geographic area. While the structure may vary, the commitment is the same. As this conversation continues, municipalities want to remain part of the solution. Although the financial resources are finite, we're willing to use the resources we do have to meet with stakeholders, to help with retention, And just recently, the Municipal League has started quarterly calls with Mr.

Lincoln, Ms. Keel, on how the Municipal League can help spread the word on and trying to recruit and retain some EMS, some folks to provide those services.

The key to recognizing successful EMS systems are built through local partnerships, and the Municipal League would like to remain part of that conversation and be a vital partner. Again, if there's anything that you're particularly looking for, we are collecting some information from our members. That does take a little time, and with the short turnaround, we weren't able to get those numbers. But if there's anything in particular you're looking for, please just let us know and we'll do our best to provide you that information. And I'll stick around for questions.

Thank you. Questions for Ms. Rankin? Any questions online? I think this isn't really a question, but as we're looking at this whole funding puzzle, I think we're going to have cities participating along with counties, and how to try to figure all of that out too will be interesting. You know, the discussion from Lenox that, you know, the city was ready to say, well, you're not going to go out of our city limits, and all of that plays in. So it's going to be a difficult puzzle. So thank you. Dan, do we have you online?

Yes, sir, I'm here. Okay, great.

There you are. Would you please introduce yourself and then go ahead and provide your testimony? Yeah, thank you, Mr.

Chair, members of the legislature. Dan Klemisch. I serve as Yankton County Commissioner and just like to thank you for this opportunity. Thank you, Mr. Chair. Thank you, Mr. Secretary, for the opportunity to testify. I think we're all here because we realize there's a crisis with South Dakota EMS, and we realize there's a lot of challenges, and too few people understand that when you dial 911, we're at the point where somebody might not be able to show up. So a little bit about the other perspective from the counties is Yankton County, We operate the largest county-run ambulance in the state of South Dakota. We operate 4 ambulance crews and employ 50 full-time and 14 part-time personnel to include 10 paramedics, 17 EMTs, 2 EMRs, and 3 billing staff members. And we respond to about 2,500 Calls each year, and unfortunately the demand keeps rising year after year so that almost every every year is a new record, which is what we don't want to have. But that's what's happening. Despite the dedication and professionalism, the system that they work for, you know, we feel is failing them. It's not the EMS personnel's fault. They continue to do a great job and. Answer calls day after day. As we all know, the are long. They sacrifice a lot of time with families and routinely respond to pretty traumatic situations, and they're doing asking of them. But I think you know talking to the the group and our people, there's a growing perception that. They're really being— our EMT and our medical personnel are being abandoned. They feel law enforcement services and firefighters all have funding mechanisms, but EMS, emergency medical services, seem like they're kind of an afterthought a lot of time. And in our situation, our county has been forced to shoulder this burden all by itself. I'll give you some numbers that We have 43% of our ambulance patients are covered by Medicare. And when we do do calls, our recovery rate is about 45% of what we bill. So I guess you could look at that as a 55% loss. 8% of our patients are Medicare patients. That reimbursement rate is even lower. And 16% of our patients are self-pay, which collections are pretty minimal on that. And even our commercial insurance frequently fails to cover our actual costs of the ambulance. So, you know, quite frankly, we're doing more and more calls each year and we lose money on every call we do. That's not, that's not a sustainable business model. On top of that, about 30% of our calls, or about a third of our calls, generate little to no income because they involve lift assists, refusals when the ambulance shows up, people will just refuse to go, or just non-transport situations. And that number seems to continue to rise. People will see somebody or an accident happen and call, and there'll just be a refusal. Well, there's still costs involved in that and driving the ambulance all across the county to get to a location, and then the patient refuses the call. Again, the taxpayers lose money in Yankton County's case. The property taxpayers lose money every time we respond to a call, and it's not a criticism of the patients. I think it's a criticism of how it's funded. You know, we have huge insurance companies that want to reduce costs, and the government wants to contain costs rather than ensuring that there's sustainability. The reimbursement system, and I think we all agree with that, has become really disconnected from the actual costs of providing services. What you're able to bill Really isn't isn't based on what the actual costs are. In Yankton County, in our county, the taxpayers property taxpayers are projected to subsidize our ambulance operation between four hundred and five hundred thousand dollars annually, and that continues to to rise. You know, we we struggle to recruit. And retain qualified personnel. We have significant turnover in our ambulance. We spent more than 8 months trying to hire an ambulance director, and eventually when we found one, we could only hire him part-time. So it's been a real struggle. Burnout of employees is— that's a big thing too. Our ambulance facility that we have in Yankton County is 120 years old. I'll say that again. It's an old train depot that's 120 years old. It is by no means modern. We've been forced to convert mop closets into office spaces and training rooms into sleeping quarters. And we cannot afford to build the facility that we need. We do get some grants to help pay for equipment every once in a while, but there's no long-term ability to replace equipment that, that is used up after a few years. So that's a big concern. At the same time, the rest of the county budget is constrained by Our growth caps and limits. Labor costs continue to rise, healthcare costs, equipment, insurance, fuel, vehicle replacements. I think this is interesting too. County, our tax revenues are allowed to go up 3% or CPI, whatever, less. The last 5 years, ambulance have gone up an average of 10.66%. Every year for the last year. So as these costs are far exceeding our ability, um, to pay for that, yet local government, in our case our county, are expected to absorb these costs. Uh, Yankton County, our last year, our ambulance, we budgeted $1.5 million. That's roughly 10% Our entire budget for our entire county is going to EMS. We've tried to work with our local municipalities, the city of Yankton, and they have had no interest in supporting us. So our system in Yankton County is funded solely by the county. We do not get any support from any municipality within our county, even Yankton. city of Yankton, which is a Class 1 municipality, nor do we get any support from our very large hospital, Avera. Both have not shown any interest in supporting it. So it is— our system is 100% on the backs of the property taxpayers. And it's, it's interesting because between 80 to 90% of the calls are located within the city of Yankton. They have chosen not to contribute. To the ambulance, so yeah, I guess I also want to just take a moment and address kind of a situation that what I've heard from the EMS leaders and and other county officials in the state is kind of difficult for us to understand why why counties and ambulance services are being. Pushed to the breaking point. We're exhausting our local property tax resources trying to replace this equipment. And then we see our state of South Dakota continues to report budget surpluses. And the last figures I read is in 2025, there was a $63 million state surplus, and there's $492 million in reserves. And I guess I gotta ask the question, is how did we get to the point where our state can have such large reserve funds and then our EMS is on the verge of collapse? I don't know. I think that maybe should be discussed. It feels too often in the case of the counties that Costs get shifted from peer to the local governments, and in peer when that happens, they celebrate it as that well we reduce taxes. But those didn't go away; it gets shifted from sales tax onto the backs of the cities and the counties and the ambulance district through property taxes again. So the choices that we have to make. In our county, in Yankton County, is what do we fund? Do we fund our roads? Do we fund our bridges? Do we fund law enforcement? Do we fund our ambulance? These decisions are getting pretty tough to make. So I guess I feel that the state needs to take a more active partnership in EMS statewide. The approach that we have, and at least in our opinion, isn't sustainable. So, so I would respectfully ask this group and the legislature to consider a few of these following points: provide counties and municipalities with clear authority to establish ambulance levies similar to the funding mechanisms for fire, roads, Bridges. We can we can do tax levies to support roads and bridges, fire, and even library funding. Why can't we do a tax levy dedicated to funding EMS or ambulance services? In Yankton County's case, it would make a lot of sense for us to do that. There's a lot of support for our citizens. Why couldn't we? Why couldn't we do a levy like that? Currently, state law won't allow that. Second, I would ask that you guys look at simplifying the ambulance district process and allow greater flexibility. Also, in our case, if an ambulance system is already operating, such as under Yankton County, it's cumbersome for us to then transition that To an ambulance district. For example, what happens to the county employees who have 15 to 20 years of service with the county? Now they're with the district. How does that work with their retirement? How does that work with their insurance? How would that work with Yankton County owning all the equipment and then an ambulance gets set up and it takes a district gets set up and it takes an entire year for them to generate the property taxes for them to start operating? There's a lot of questions and gray area in there that. I think it could be clarified to make the transition easier. Third, I think you guys, it would be great if you developed some sort of regional EMS support model that would encourage shared staffing and training, coordinate purchasing and other operations. Fourth, we need to work with our federal partners to address the reimbursement rates for Medicare, Medicaid, The last I heard, I believe they've been updated— they haven't been updated since 2008. That needs to happen. Another, I think, no-brain solution that I did bring up last time was allow counties and ambulance districts to use the Obligation Recovery Center to collect debts. We have a significant amount of ambulance bills that are not paid. Counties can only put a lien on somebody's real property. If somebody uses an ambulance and they don't own property, there's really nothing that a county can do to collect these bills. And this seems like a really simple thing. I think we all agree if you owe money to anybody, you should pay that. And the state has an obligation recovery center to help the state collect its bills. Why can't the counties and the municipalities use that same thing? I mean, that would be significantly helping ambulances across the state. Another option is maybe some sort of docking fee. Again, I said we deliver almost all our patients to our local hospital, Avera Hospital. Avera Hospital, it's a nonprofit. It doesn't pay property tax. It has also chosen not to support our ambulance system, maybe some sort of fee when a patient is brought there. Finally, you could also consider some dedicated EMS funding through other options: alcohol taxes, contractor excise tax, video lottery, or even now with Senate Bill 96, counties are authorized to impose a half-cent sales tax. A half-cent sales tax to fund EMS services. That could be an option as well. Again, to summarize, when, when someone in our state has a heart attack, when a kid can't breathe, when a farmer is injured in the field, we all expect an ambulance to show up and arrive. And that's our expectation. But quite frankly, expectations aren't what funds the ambulance services. And I, I am concerned about the long-term sustainability, at least for Yankton County's situation and throughout the state. And appreciate your time. Um, thank you, and I'd be happy to stand by for any questions.

Thank you, Dan. Any questions? Anything from online? Oh, go ahead.

Hi, Dan. Thanks for your testimony today. Drew Peterson. For your billing and collections, how are you guys managing that right now?

Well, we do in-house billing. I'm sorry, Mr. Chair. We do in-house billing. We have 3 personnel who do that in-house. We've, we've tried to use different services to do that, and it just hasn't been effective. So, but it is a real challenge. We— quite a few of these bills get rejected, and it is a very burdensome process. And we're the largest county-run, and I can only imagine how difficult it is for the smaller ambulances to do billing. But it is a real challenge.

Any further questions? Seeing none, thanks again, Dan. If you want to hang out, if we have any questions for you, you sure can. Will do. Thank you. Thank you. Okay, we're moving on to public testimony. Committee members have any comments?

Sure. Yes, thank you, Mr. Chair. Maybe Brian or Alan could answer this. Maybe somebody has A ballpark number. When we look statewide at the shortfall of funding for all ambulance services in EMS statewide, are we talking $10 million, $100 million? You know, what kind of target could we possibly be looking at to try and solve? Does anybody have that number? Because it seems to me we should have a target to be looking at.

And I, and I think our One of our issues is— I think this is great because we also have some places where cities and counties are propping this funding up. And then we also have the issues with the reimbursement rates and the commercial insurance rates. Puzzle is the best word that's so far been used to try to figure all this out.

It's tough.

It's tough, yeah. Okay, with that, Anything else? We'll go ahead and open it up for public testimony. And hopefully everybody that wants to talk has signed up. If you're not, please, there is a QR code in the back that you can go ahead and sign in with your phone. So is anybody— I know we've got some people signed up, but should we talk about labor? Yes, please. And I'll make sure everybody gets— I don't know if I got it sent to Matthew or not, but your proposal that you're working through, if you just kind of go ahead and introduce yourself first and your role and then—

My name is Bridget Hathaway.

I'm from Jones County, which is Murdo. In our county, there's also Draper and Okotan.

I'm with the Emery Fire Department that services our county.

And I just have been listening all day, so I just wanted to kind of give you a little bit of aspect on us.

We do have 900 and—

where did I put my notes here? 912 square miles that we cover, and we are a volunteer service.

We have 17 people on our service. What's that? Yes, I do. You want them now?

Okay.

I think it would be good to have them now. Thank you.

I just have a few.

And it will also be uploaded to the full open document list too for everybody. That's okay. That's fine.

As I was saying, we cover 912 square miles plus we have interstate running through us. We're volunteer service. So I got to thinking back at conference in October, EMS conference is always at the end of October, how can we think outside the box to help our smaller services? We're Jones County.

There's Monarch County to the south of us, Lyman County to the east of us, Jackson County to the west of us, what can we do? In our district, we're District 5, there's 11 counties in that district all the way from the south to the north and some to the east. So what can we do?

What can we do within our district to help make that better? And so I came up with this EMS support pool proposal.

Basically, Helping with the burnout with these small communities that are volunteer services, how can we help support each other?

So if we had an EMS pool and if you're looking at almost like a traveling nursing type of thing where say I put out there and say, hey, Jones County needs some help for these 2 days.

Anybody in this EMS pool available, they could come in, we could give them the tools that they need to be within our community and run some calls.

We all have celebrations happening, especially in the summertime, simple things like that. So it's just laid out. There's a purpose, a background, a program review, objectives.

Okay. Eligibility requirements, activation process. There's some legal and liability considerations that we need to think of. I just need a little bit more guidance with this, and if there's something that we can do within our legislation to help make that better or to make this work, and I know that we've talked about We talked about some regionalizations and pools and stuff.

Maybe this is something on that aspect that would look like that.

Thank you. One of the— through Rebecca Reimer shared this, Representative Reimer. And I just thought it was kind of unique, you know, just— and we've talked about this a little bit more. There's a, you know, there's the ideas here of regionalization. And just, I I like the concept that internally within that you're trying to present something, and I do think it is something that other areas, mostly the more remote areas, really could look at. So that's why I just kind of wanted her to present this, that there's concepts out there that can be used. Any questions?

I have a question.

Go ahead.

Plan, have you ever like looked into the Clipboard Health? I know it's nursing homes. They really reach out to a lot of nurses across the state and they have an app that you can log on to and give them all your credentials and then it's easy access. If I would want to go work in Sioux Falls for 2 or 3 days that I have off, or if I want to work in Spearfish, I just go to that app and can easily access it. I just didn't know if you're aware. No, and I know that there was another I think it was called SERVE.

I can't remember exactly. That kind of got started back when COVID happened, that people could put their credentials in and stuff like that too. So I'm guessing it's similar to that. Just something to look at and think about, and maybe we can integrate it into I think it's important to know certain things or certain legislations just because we all have different medical directors. We all have the funding. We were just talking about that, different funding options and stuff.

How does this all work? In our District 5, we have what, 4 paid services? I mean, does that look right for them versus us who are on the smaller side and might just need somebody for a couple days? Yeah.

once in a while, you know, versus some of the bigger services might need somebody to come in and fill in for 13 weeks or something, you know. So these are all things that we all are thinking about too on the lower level of things. So—

Mr. Chair, if you're— I think I heard you asking for feedback from this. Okay, I'll Just transparently give you some feedback.

Good.

The people behind the program will make it successful. And the increased amount of collaboration and communication with the whole broader group, it will be essential for that to be successful too, because it's a bigger geography, different personalities, right? But the ability to streamline some of the efficiencies such as education for EMS personnel, Maybe managing social media pages could be done by one instead of by— did you say 4 or 5 different services? You could— if you can streamline and collaborate, one person can do that for all. But it's, you know, I applaud this. This is the kind of creativity in a program. I haven't read everything on it, but from what I can see, I would say keep working with that, but put communication to the top. That'll make it successful. And then, the right leader running it, too, I think, will mean make or break on this. Just feedback.

Yes.

Thank you for presenting this. I think it's great. That whole idea, exactly what you said. When we're sitting here looking at the higher level, we know that there's good stuff happening, and, you know, that the Ammons districts are really working hard to make sure they can survive, and with ideas like this. So, thank you. Continue with public testimony. Just go ahead and turn on the mic and introduce yourself and the organization if you're with one.

Hi, good afternoon everyone. My name is Stacy Fredenberg. I'm with the South Dakota Foundation for Medical Care. I'm the Director of Operations there, so I'm just going to share a little bit more about the work that we've been doing that was mentioned Previously. So part of our project is it's limited to the north-central section of the state, so it doesn't represent statewide. We've been working with 17 different counties across that area, which is EMS District 4 and EMS District 7. And that goes as far west as Lemon, as far east as Sisseton, and And then down into the Huron Redfield area as well. So when we started this project, our goal was to focus on 4 key activities, and that included community engagement. We did an assessment, and then we created an improvement plan and started implementation on that plan. And we also did awareness and training throughout that process. So we're a true We're kind of toward the end of our project, so we're launching our improvement projects at this point. But we have had engagement from 10 to 12 different communities, and what we've discovered is that these communities are already working together to try to solve some of these problems that they're facing. There's 3 priority areas That are common. Workforce, obviously, funding, and then collaboration is the other priority topic that they identified. And so as we were working through our process of doing our assessments and then our improvement plan, we started helping people gather together around their common issues. So everyone was saying workforce is An issue. So I'll just give you an example. Lemon created an EMS cadet program. They have 19 high school students that go through a class, and then they're able to go on ambulance rides and provide additional support and eventually get their EMT certifications. And that's part of their pipeline build. As we were doing our project, we would Brought them on to do a presentation to the rest of the communities. Webster picked up on that. They said, hey, that sounds like a great idea. They implemented— within 6 months of learning about Lemons, they were able to implement a cadet program in their community as well and launch that. So this is the type of work that we've been doing collectively, pulling in different content experts, trying to open communication lines. We know there's great work happening, but not everybody, not everybody that runs an EMS agency or is working in the community also knows those great things that are happening. So part of our role has been to increase that collaboration and bring together those entities. Like you were talking about, one person can do social media, One person can do training or work through some of those things collectively. These people are wearing 5 different hats. They don't have time to figure out strategic planning.

Right.

And we've been pulling them together and saying, hey, these are your priorities. How can you get there? What's your goal? How many people do you need in your— on your EMS crew to be viable? What is that number? What is it? Because once you know what you're working toward, then it's easier to get there. So we've been coming alongside them, and I think that's part of the issue too, is with the shortages, with the strain, with the demands of their daily obligations, they don't necessarily have the time or the expertise to stop and consider what is our long-term plan, It takes time, effort, and skill to do that piece of it as well. And so that's what SDFMC has been coming in doing, trying to elevate the skills in those arenas, help them understand what does that process look like, what kind of questions do you ask, how do you get the answers that you need so that you can move forward into the next step. And so I just wanted to provide a little bit of background on We do have a full— I can provide the assessment report that we've done and the foundational— our improvement plan is customizable. It has key activities or strategies. We know not everybody is going to choose those same activities, so we tried to make it so they could adopt what worked for each agency. And we've already seen Mobridge and Up in that area, there's 5 different communities that have been working together. We know Redfield's already been working together, so encouraging that process of regionalization. So as we move toward that, they're already having those conversations, and that's something that we want to continue to support moving forward. So that's just a background on our project. If you have any other questions, I'm happy to answer those.

Great. Any questions? It's great what you've got started here. That was really, really good. Anybody online would like to ask a question? Okay. Thank you very much. Thank you. Continue with public testimony. If you'd go ahead and introduce yourself, please.

Good afternoon. My name is Paul Sheets. I'm with the Tripp County Ambulance Service. My EMT number is 1720. My other number from the state is 0056, or the one I have to pay money for. So I've been doing this quite a few years. I was chief of police for 25 years and was a director for about 30 years with our ambulance service. I just wanted to kind of tell you a little bit about what we've been doing in Tripp County to try to promote EMS. In 2014, we started a cadet program, and what that is, is we have high school students that apply to be a cadet, and they're— the school, with the Winner School District and the Colombe School District, They can apply to be a cadet, and during the school years, we have pagers there, and they're able to come down and go on ambulance calls. Usually there's 2 of them at a time. We do weekly classes with them to let them know what they can do, what they can't do, and they are really a big help for us because they can help carry equipment. There's usually only 2 of us on call. So that gives us 4. And they're able to do a lot of things when we practice doing codes. We practice a lot of different things. So they take our documentation. They do a lot of things that frees up the EMTs or the advanced people there with us. So over the years, we've had approximately 120 students who went through with us. And... Out of that, we have— we know for sure at least 25 of those have went into the medical field. We have 4 right now that just went through our class that are going to be— that are EMTs. They are— we have EMTs, we have paramedics, we have nurses, and we have a physician that started in our cadet program. So, that has been one really positive thing that a lot of the students that went through that said, well, we don't know if we can stand the blood, and we don't know if we can stand somebody puking. And so, they went out— I mean, if they can't do it, they've learned that before they decide what field that they want to go into. So, I just want to tell you, what does the cadet program mean to us? So on March 6th of '26, we had one of my cadets were coming back from Pine Ridge at a basketball game. It's 11:30 in the evening. And if you look back on March 6th, we had black ice. They probably shouldn't have been out on it, but they were at a basketball game and they're all coming back to winter and they come upon a car accident.

Okay.

They're not in a bus. The bus is coming behind them. They're with their parents and they're coming along, and there's a 17-year-old male that's out on the road flagging them down as they're the first one, and he's rolled his little pickup, and there's a 21-year-old female inside the car that they won't be able to get out. They had called 911, but it takes a little while for an ambulance to get there, so— They're in the backseat. She got inside the vehicle. She said, I'm a cadet and I'm taking the EMT class. And they were in there, and about 15 minutes later, another part of the winter group was coming. A CNAP, or she was a nurse practitioner, was coming, which is a friend of theirs, and she got in the vehicle and helped. They did CPR. They opened her airway. And approximately half an hour later, the ambulance showed up. This 21-year-old female was flown to Rapid City, was on a ventilator, and eventually was able to come home. So these same group of people right now, as we were sitting here today listening to testimony, they're in Indianapolis right now. That they're at HOSA. That's Health Occupation Students of America. They're there as EMTs, and it's a participation class that they have to— they had to go through South Dakota to get there. They were third place, third in the state, and they're at HOSA right now competing as— I'm sure I'll get an email or a text after a bit to tell me how they're doing. And the other one was there And he's the first one to get a $2,000 scholarship from HOSA from South Dakota. When I talked to some people at Sanford, they said, we don't know if any students from South Dakota have made it to HOSA in Indianapolis. So it's been a great thing for that. But that's one thing that we can get students involved with the workforce and be able to continue with them and make sure that— Yeah. If this is something they want to do, and they're very dedicated. When we have the flight crew come up, and the flight crews have all shown them the plane and been very supportive of everything we're doing with the cadets because they they know because somebody's been bragging on them. These are my cadets that are here, so they've been very supportive. So we've been doing that, and we've also in 2023 we received a SAMSA grant. About $400,000. And over the years with that grant, what we did was we had online EMT class that we partnered up with, and we were able to— right now we're sitting at 373 students that have went through it. And we've had 7 classes, and we're starting our 8th class, and then our SAMHSA grant will run out.

Okay.

But with that SAMHSA grant, we've put a lot more EMTs into South Dakota. So this grant was— the SAMHSA grant was focused mostly West River in the low populated or the frontier group. That's the ones that could go through it. The first year we did it, we did it free, but we found out that some of them weren't taking the test, so we had to have them pay $250.

Okay.

But if they passed it, then most of the counties would reimburse them the $250. We found out if it was free, sometimes they weren't taking the test. We also paid for the National Registry test and also some programs to get them ready to take the test. So we also— because once you're an EMT in South Dakota and every place, you have to have continuing education. So we've been paying for 350 spots since 2023 that we've been paying for to have an online one because we have people out in Wood and other places said, I can't drive to Winter all the time to get my continuing education. There should be some way that I can do it. I have the internet and they've been able to do that. So we're trying to retain those EMTs that we have out there because they can't always If they're calving, if they're doing things, they just can't leave. So we have a monthly one that's online that they can try to continue to keep their certifications going. By no means does this mean that we— we need money. We were able to get grant money from the last time to buy some mannequins, some training equipment, and we're putting in for grant money now. We do need this money. I think everyone here knows that. I heard someone say, well, aren't the counties doing stuff? We are trying to do stuff, not depending on all this, but we do need your support and we need to find a way to keep funding our ambulance services.

Thank you. Any questions? Go ahead, Representative Williams. Thank you.

Of the 350 spots for online Continuing education, how many are coming back to your area to do EMT?

So, the continuing education is anybody in the state of South Dakota can get online. And so, it's not— it's in every— whoever wants to have it. Those 350, that's for each year for the 4 years now. There's been— we've been paying for 350 spots, and that's because you have to They register, and so not every monthly session is there 350 people on there because there's certain things if they only— if they need more OB or something, there seems to be more people in that class. But we have 350 that signed up. We have about 280, I mean, depending on each session a month.

Okay.

But they're already— they're at other people's services.

Great.

Hope that clarifies that.

Thank you. Thank you very much.

Thank you.

Just go ahead and introduce yourself and the organization you're with.

Will do. Robert Rendon. I am the Section Chief of Medical Operations for the Rapid City Fire Department. I also serve as the I'm the vice president for the South Dakota Ambulance Association. Thank you, senators, representatives, and staff who serve on this important task force. I appreciate the opportunity to speak with you today. Addressing EMS funding in South Dakota is not a one-size-fits-all challenge, and I do not believe it can be fully solved by a single summer task force. This issue— the issues are complex, interconnected, and will require sustained attention.

Thank you.

Before I move on with the rest of my— I wanted to kind of touch base and correct a couple of things. One, the Rapid City Fire Department— or the city of Rapid City does not give the Rapid City Fire Department's ambulance service $6.5 million a year. Our annual budget is $6.5 million, all of which is given— brought to us through reimbursement. The city doesn't currently supplement the ambulance service itself. It is attached to the fire department, but it's an enterprise fund that is completely separate. We will be moving forward at some point, the city will be supplementing the ambulance service out of necessity, because we do run currently about a $500,000 to $1 million shortfall depending on the year. And to answer Senator Jensen's question about the shortfall total for the industry around the state, that's going to be a pretty tough number to come up with. I'll use Rapid City as an example. We don't really know what that would mean for Rapid City or Pennington County because we've been providing that service for most of the county and surrounding areas at no cost up to this point. We are kind of following suit with what Lenox did in terms of approaching the municipalities that we do serve as well as the county. Kind of like Mitchell did. Peer, they supplement AMR, which is a large national corporation. So you can see the need for supplement in terms of budgets for ambulance services across the state. So I just kind of wanted to put that out there. In my view, the 3 biggest barriers in the state of South Dakota currently are restrictive or inefficient state policy, inadequate reimbursement rates, and staffing shortages, as many have talked about here currently. The first 2 kind of drive the third one, so I would like to address them in kind of a reverse order. To hire and retain highly qualified EMS professionals, agencies must be able to pay a living wage. Right now, in many parts of South Dakota, entry-level jobs in fast food restaurants pay as much, or if not more, than many EMS positions. That is not sustainable for a profession that requires such a high level of training, responsibility, and public trust. But to pay competitive wages, EMS agencies must first receive adequate reimbursement for the services that they provide. Reimbursement rates are, in practice, heavily influenced by the Centers for Medicare and Medicaid Services. While CMS does not directly set all rates for every payer, private insurers often base their contracted rates on Medicare reimbursement. This creates major challenges for EMS providers, as you have heard what the Medicare reimbursement rates are. One of the most significant problems is that many insurers Blue Cross Blue Shield, for example, they send their payments directly to the patient rather than the ambulance service provider, unless the provider is contracted with them, which is why insurance companies really want ambulance services to contract with them. That means the provider is left trying to recover payment from the insured individual, who may have already spent the check, or hoping the patient forwards it voluntarily. As a result, EMS agencies are often forced into contracts simply to ensure payment is sent directly to them. Those contracts typically require providers to accept Medicare-based reimbursement rates rather than their actual fee schedule or customary charges. Providers enter these agreements not because the terms are adequate, but because the alternative is even worse— spending more time and money chasing payment that may never be recovered. In short, they accept inadequate reimbursement in exchange for certainty of some type of payment. This is also why insurers strongly oppose legislation requiring reimbursement above Medicare rates, such as the bill that was mentioned earlier by Brian. Such laws have been imposed on more than a dozen states, as he mentioned, that mandate payment levels ranging from anywhere from 150 to 400% of Medicare. It is also important to address the rhetoric around the so-called surprise billing or balance billing. Those terms were popularized through insurance industry lobbying, often to shift blame onto EMS providers who were simply attempting to recover the unpaid portion of the bill after the insurers failed to pay— failed to fully reimburse the emergency services provided. For their own customers or the insured. 2 policy changes that could make a substantial difference, and I believe this is tied sort of to the bill that we hope to reintroduce next year in terms of— I think it was Senate Bill 211, correct? Yep. Requiring more appropriate reimbursement rates falls in line with that 300% above or whatever the number ends up being above Medicare reimbursable rates and requiring direct payment to providers without forcing them into contracts with insurance companies. There are already multiple examples, as you were given, where those things have been addressed in state legislation. Turning to state policy, our hands are largely tied when it comes to Medicare because states have little authority to change those rules. Medicaid is different because it is a federal-state partnership. South Dakota does have some ability to shape what services are covered and how reimbursement works. To be fair, South Dakota Medicaid is one of the higher-paying Medicaid programs in the country. Even so, it still pays around that 20% of our actual cost. That gap is pretty significant and is unsustainable. I've heard the term that we are at a crossroads or we're almost to a failing point. We are at a failing point. The industry, I should say. Policy change with broad benefits would be allowing EMS providers to transport patients to appropriate alternative healthcare destinations rather than only to the emergency room. Several states do this already with the help of—

what's the—

Telehealth. Telehealth, sorry. Like the telehealth program Marty in the state office has implemented into South Dakota, a lot of states do use this telehealth program to help physicians decide whether or not this patient can be transported to an appropriate facility outside of emergency room. This would benefit patients by directing them to a lower cost and more appropriate setting when clinically appropriate. It would benefit hospitals by reducing unnecessary emergency department crowding and preserving beds for more critical patients. And it would also benefit the Medicaid system by lowering avoidable costs. Colorado expects their new law that they just signed 2 weeks ago to save them an estimated $5 million a year. I appreciate your time and willingness to take on this issue, all of you. I really do. So does the Rapid City Fire Department. EMS funding in South Dakota will not be fixed overnight, but with thoughtful policy changes around reimbursement, direct payment, treatment in place, and alternative destination transport, we can begin making meaningful progress. Thank you for allowing me to speak today.

Thank you, Robert. I got a question to start this off. And Representative Fosness, you probably know something more about this also in, in how the contract is negotiated. I know that insurance companies negotiate with you or your, you know, your hospital And then, but now, do they actually negotiate then with each individual service?

Correct.

And tell me a little bit about how that goes.

So I'm not directly involved with the negotiation piece. The individual that sits above me, which is the division chief, he is the one that would be, and the chief would be directly involved with those policies. I can give you one small example at a local level because we contract with Monument Health quite a bit. Or we are attempting to contract with Monument Health quite a bit for their inter-facility transports. Basically, it's a contract that they use across the board for most people, most services that they have, and they kind of begin their process at that 100% of Medicare rate. We have been unsuccessful at this point because we have been trying to take a strong stance that that's no longer acceptable for us Because it, again, doesn't even cover the cost of running the wheels. And so it has been a challenge. And that's at a small-scale level.

I'll just weigh in. I think it's a slippery slope. To not sign a contract then could lead you to not be an approved vendor for them, right?

Correct. No, absolutely. Yeah.

It's especially scary in emergency services. So, you know, yes, true, in the rural hospital arena you contract with the commercial payers. I would think, you know, it was alluded to PCC doing a majority of the third-party billing. They do ours. Would handle a number of those arrangements with commercial payers. But I don't know, I think it would be great to hear from some commercial payers in front of this group too to hear how those processes work.

Sorry, Chair. Also, I think it would be great to invite PCC. They do a great deal of billing for a great amount of the services that are here in South Dakota, so it might not be a bad invite for the next session.

Thank you. Any other— oh, Senator Larson.

Yeah, just a quick question. Um, thank you so much for your presentation. You at the end mentioned an example about Colorado who had implemented of the ideas and innovations that you mentioned at the end of your presentation. Can you tell me a little bit more about that? Just curious if we can learn what were the components of that legislation.

So the components, in short, were implementation of telehealth care into their ambulance services, tying in with being able to transport to, like, an urgent care type facility. For us in Rapid City, it would basically equal to an urgent care or our IHS facility since a lot of our customers do go— are qualified for IHS, but we have to take them to the ER specifically. And then it also— there were 2 different bills that they signed. I don't have the specifics in front of me in terms of Like what the what it says.

Sorry, that's fine. I was just curious.

I can't answer that anymore in any greater detail.

No worries. I was just curious topically what was in there, and I think you've answered that question. So thank you.

Yep. Chair, if I may. Go ahead. I believe it was Senator Larson earlier that was asking questions about the healthcare information portal that Marty had mentioned. And I just wanted to speak on the importance of the sharing of information forward and backwards. He had also mentioned that we have a mobile integrated health program in Rapid City that includes mobile medics/community paramedics as well as CHWs. And they do a great deal of work trying to work with Monument Health on addiction medicine patients, respite center patients, and then also our high utilizers. But we, through contracting with Monument, we are able to use patient information in Epic to be able to really help those patients through the social determinants of health model in terms of what they need, where they need to go, helping them get there, and then continuing their success in healing. So the portal that he mentioned, I think, could be—

Yeah.

hugely beneficial if, if used appropriately.

Thank you. This has been great. Thank you. Anything else? Thank you very much.

Good afternoon. I am Keri Weems with the Wausau Volunteer Fire Department. A little history about When COVID hit, I was running the Wall ambulance. They are a tax district. The mill levy has been brought up numerous times today. That mill levy has been maxed out every single year and still have a hard time keeping ends afloat. So just for the record, everybody's talking how we can handle this, but why am I here for the fire department? Before I begin, I'd like to note that while reviewing today's agenda, I noticed a critical group missing from the discussion of emergency services in South Dakota, our rural fire departments. This is due in a large part because of the response delays. The reason I felt compelled to stand before you today is simple. The demands placed on volunteer emergency responders have been challenged dramatically. What was once a relatively low-volume service has evolved into a constant response system for emergencies of every kind. Volunteer fire departments respond to medical emergencies, motor vehicle accidents, grass fires, structure fires, search and rescue operations, hazardous situations, and incidents along major transportation corridors such as Interstate 90. When 911 is called, our volunteers respond every time. Yet despite providing these critical public safety services, rural volunteer fire departments receive little to no direct state funding for the emergency response work they perform. South Dakota proudly identifies itself as an ag state. Many of the individuals who answer emergency pages in our rural communities are the very agriculture producers, business owners, and community leaders who help drive our local economies. They leave their fields, their livestock, their families, and their jobs to answer those calls. The state also actively promotes tourism, encouraging millions of visitors to travel our highways each year and Communities like Wasta help protect those travelers along the Interstate 90 corridor. We respond to vehicle accidents, wildlife collisions, fires, medical emergencies, and other incidents involving residents and visitors alike. For those unfamiliar with Wasta, we are located approximately 10 miles west of Wall along the Cheyenne River and provide emergency response services across a significant portion of the I-90 corridor. Despite billing for every eligible incident, The reality is that emergency response is not free. Fuel, equipment, training, maintenance, insurance, and protective gear all come at a cost. What makes volunteer departments remarkable is that these costs are often supported by people who are not paid employees. Our volunteers use vacation time to attend training, They leave work to assist with emergencies. They spend evenings and weekends maintaining equipment, writing grants, conducting fundraisers, and improving their departments using their own skills and trades. Yet many of these responses involve travelers simply passing through our communities. Rural volunteers are expected to provide the same professional emergency response for millions of visitors traveling our highways each year, while the financial burden remains on local taxpayers. Fundraisers, and volunteers. The people answering these calls are not doing it for profit or recognition. They're doing it because someone needs help. South Dakota actively promotes tourism and welcomes visitors from across the nation, and we are proud to serve those who travel through our state. However, the responsibility and cost of protecting both South Dakota residents and those visitors should not rest solely on the shoulders of rural volunteer departments. A sustainable funding solution is needed to ensure these departments can continue providing the critical services that communities and travelers alike depend on. I'm going to take a breather there because I'm also a landowner on this I-90 corridor. We roughly cover a 12-mile stretch. My husband is the fire chief for Wasta. I'm a volunteer. We own 8 miles of that stretch. The I-90 corridor cuts us right in half. Every landowner who currently resides within Wasta fire department is our volunteers responding to those calls. So you guys were mentioning property taxes earlier. We're already paying. We are the hands. We are the ones donating our time, our efforts. We're donating water because our funding isn't there. We are doing everything we can truthfully to cover assets that aren't ours. Like, we— in the last 15 years, I can recall 3 fires actually on our land, on property. So we're trying to figure out, like, how come the I-90 can cut right through our fire district? And we are— we have great respect for Rapid City. They are our mutual aid for the Wall ambulance, and Wasda Fire is in both locations. So we have great response times with them, letting them know, hey, this is what we have going on. We encourage Rapid over Wall because Rapid can provide us paramedics. Thank you. So it's truthfully all hands on deck. And I think today what I'm asking the task force to do is to review how rural volunteer fire departments are funded and reimbursed as well as the emergency side, because we all play a very crucial part in everyday operations.

Thank you for your testimony. It's definitely an area that we But we need to include, I mean, rural fire. I think a lot of our rural ambulances are rural firefighters as well. But that being said, just because particularly down down in your area and the issue that is happening within Pennington County, what will it look like if Rapid City Fire decides we will no longer they'll no longer leave Rapid City? And you have the same problem in Wall, right? Wall doesn't have an ambulance hardly ever as staff. What's that going to look like for Wasta?

That's a great question, Representative Emery. So when I was serving the ambulance board, any ambulance service did shut down and they had asked WAL to cover that. It's a very, very tense room to walk into when they ask to cover other areas. A lot of times we tell our farmers and ranchers currently, get in the vehicle and drive like heck to Rapid. Like, you can beat the response time of these ambulance services. It's scary, no matter what. Either your delayed response time, your gravel roads. We're a rural state. So it's truthfully like you're at your own best judgment when it comes to that. We all hope and pray that the ambulance service isn't tied up currently. And we're very blessed with Rapid having numerous locations. And obviously, there's a big meeting tonight to discuss the New Underwood to Wall coverage. And Of course, that's what we were talking about earlier. I'm like, oh, I'll be there because we need to find out what we relay to all parties.

Thank you for being here.

So you—

one time you mentioned, is it— are you in a fire district there or an ambulance district or both?

The ambulance is a district. The fire department is not. Okay.

And the fire department Is it funded by WASTA? No. Is it— is it—

we are funded by donations and grants, respectfully, more so the township than anything.

Okay. Well, thank you, Mr. Chair, and thank you for your testimony. And, and I— your district where you live is probably the biggest disparity between local calls versus interstate calls, tourism calls, right? And yet you're not getting any reimbursement from tourism tax dollars, state tax dollars, things like that. And you're, as a landowner taxpayer, you are funding those emergency services for those people that are not local taxpayers. So thank you for really identifying that issue. I live in a rural district way east of you, not nearly as rural as you are, but we— I looked earlier, we have about 45 miles in In my 2 counties that are on the interstate. And similar issue, but I'm sure your ratios are a lot higher. But you did an amazing job of identifying that we need to look beyond local tax dollars to address some of these issues. And as we've been talking today, there's so many different things that we need to address all at once. But that is one. You did a really well done job on showing us that.

Thank you. Do we have any questions from online? Well, thank you for this. It's really important that you were here to help us out in how we're looking at this. So thank you very much.

Thank you, guys.

If you'd go ahead and introduce yourself and if you're with an organization.

Good afternoon. I'm Joyce Kartak. I'm a County Commissioner from Tripp County. Thank you for your service and studying EMS. Tripp County is solely responsible for our service. On a transfer, we get paid about a third of what we bill. Write-offs for the past 3 years total over $500,000 for us. The majority of our rural community is Medicare and Medicaid. We do employ a person just for billing Which does help collections. Whether that's beneficial versus having somebody else do it, I don't know. Part of the community includes tribal lands. They are an hour from a tribal ambulance, so when they call us, we serve them, but we really struggle getting paid. The distances in our county can be 45 minutes one way to our hospital. It is an hour and a half to Pierre, an hour to Chamberlain, 3 hours to Sioux Falls or Rapid City. Our hospital no longer delivers babies. This can be a long time for a mom and a baby in distress. We no longer have full-time surgery services, so these get transferred out. The county budget struggles too, just like every other county. We never know when a culvert has to be replaced, road washes out. We have more snow than we know what to do with. We don't know how much the the jail will cost? What if an inmate needs hospital services and needs transferred or expensive medications? How many mental health bills will, will there be, to say nothing of all the court costs and juvenile expenses? What happens when we can no longer pay for our ambulance? The city doesn't want it. The hospital doesn't want it. Why would they want a service that is losing money? This involves everyone in our state. It's hurting rural communities the most. We never know when we will need to call 911, and we need to keep the service strong. Thank you for your time.

Thank you. Questions? Go ahead, Senator. Mr. Chair, just wanted to hear that number again.

So you, for lack of a better word, subsidize about $400,000 to $500,000 a year to the service?

That was over 3 years. 3 years. Okay, thank Quarterly, it's at least 35,000 to 40,000 that we just write off every quarter.

One more question. Do you know the amount of interstate that goes through Tripp? No interstate. Oh, I thought Tripp County had.

We're clear on the southern, straight south of here. City of Winter.

Sorry.

I do have a question. Just kind of understanding. What your residents— how they address their issues. So we've had a couple young— well, we have 2 young kids now. So when a mother goes into labor, in some areas you probably jump in the car and you go. In your area, is that what people do, or are they calling the ambulance because there's a decent chance the baby's going to be born on the way to the hospital?

Depends on the circumstance. They may make it to the hospital and still be able to deliver and get an air ambulance in there to get them out. But, you know, but—

It's a big challenge. It's— in wanting to grow a family, it's something that everybody has to think about in making that decision.

And I'm a registered nurse too that spent 35 years in the OR in Winter, and I know of babies And maybe moms that wouldn't have made it if we weren't there for a stat C-section. So it's scary. Scary for my kids.

Thank you for being here. Go ahead and turn on the mic. Great. Yeah, and then introduce yourself.

Gary Langrock, EMS chief with Watertown Fire Rescue. I just have a few comments I'd like to share that specific to our area that a lot of what I could talk about has been covered already. So in Watertown, we are the sole ambulance service for Coddington County, just over 700 and I believe 17 square miles. Last year we responded to 3,251 EMS calls.

Of those, about 380 were inter-facility transfers. So majority of what we do is transfers to Sioux Falls. We routinely go to Fargo and Minneapolis, Rochester. We've been to Iowa City. We even last year took a transfer to Rapid City. So we are finding ourselves going farther and farther out all the time. So talking of budget shortfalls for 2025, our budget shortfall was just under $2.4 million.

So from And that gap continues to grow, and at its current rate, it's going to continue to grow without certain changes.

So just so we clarify on the number, the $2.4 million is what is being subsidized?

Correct.

Okay, from the city?

Correct. So when talking about what it costs to have a fire ambulance, so we are fire-based, ambulance.

So to run our fire department 24/7, fire and ambulance, with our budget, we're just under $700 per hour. When you factor in the ambulance-only side of that, to have an ambulance service with—

we have 5 ALS ambulances—

we're about right around $445 an hour just to have personnel Those 5 ambulances staffed 365, 24/7.

As far as the staffing goes, again, we are in Watertown, we're starting to feel the squeeze as far as staffing.

We are extremely lucky that we do have Lake Area Technical College, that their med fire rescue program does provide us with a lot of our employees. This year, we have probably hired more part-time med fire rescue students than we ever have. We generally try and hire those first-year students once they've received their EMT certification. That way they can be our ambulance operators to free up staff for other things. You know, but again, if, as if we're feeling the squeeze, from staffing issues.

I can't imagine what these small volunteer services are feeling also. So it's just a couple of things I just wanted to point out for us specifically in Watertown. And, you know, we're doing some things internally to try and reduce our costs.

You know, as far as purchasing ambulances, we did have 5 individuals go through the CHW program.

So we're trying to get that going.

So we are trying, trying to find ways to cut costs. But again, as far as reimbursements, our numbers are going to be very similar to what they are statewide. I said I would appreciate your time and listening and stand by for any questions.

Thank you. Any questions at this time? Yeah, go ahead, Senator Jensen.

Yeah, I just want to clarify a couple of the numbers you said. $2.4 million, but that includes fire? That includes the entire apparatus?

That's just the ambulance.

Just the ambulance.

Just the ambulance.

And that $445 an hour, is that in-service time or is that— if I took that out to an annual cost to provide that ambulance, how much might that one ambulance be?

Like I said, we do have—

like I said, we have 5 ambulances.

You know, if you were to break that down, Like I said, that includes all 5 ambulances, everything from the building to maintenance to personnel.

So just that portion of it.

So if you wanted to do the math a little clearer, you could just break that down, divide by those numbers.

Further questions? Anything online? Thank you for being here. Anyone else that would like to testify? We do have one person online, and that's Hayden Merkel. Are you still online with us? No? Okay. Okay. Anybody else? Had to hear from you, Maynard. I was kind of wondering.

Maynard Konechny from Kimball, representing the South Dakota EMS Association as a lobbyist. I've been in front of you guys a lot of times. This is one of those issues we've talked about for many, many years. As Paul said, his number is in the thousands. My number's 492. I got 52 years in. So when they talk about the average age of an EMT of 51 years, I'm probably a little above that, but I enjoy doing it. I went into it to help those that couldn't help themselves. And I want to continue as long as I can. I'm still able to take call, work in our local ambulance. As you've heard from a number of people, the funding is a big issue. Mitchell had an issue where they told the Hanson County and Davison County people that they weren't leaving the city limits. They went and did something about it. Lenox is in the process. Rapid City has come up with an issue that they don't want to leave their city limits because nobody is helping to fund. The reimbursement rates you've heard from numerous people is a big issue. We aren't getting reimbursed near what a call takes. To put those wheels on the ground and leave the shed and go treat people. If you want to go with the commissioner from Tripp County, she was talking about they no longer deliver babies. There are times I get an email or a text or phone call from the Chamberlain Hospital. They have no no maternity. Personnel on duty. We'd have to go to Mitchell. So from Winner all the way to Mitchell, there's maybe nobody in there. There's deserts of all kinds going on with rural healthcare in this state. I really want to thank you guys for being a part of this. For those of you that were here last year, kudos. You put in a lot of work last year and we made some headway. I'm hoping that we can continue that. And I've been involved for a long time. I plan to stay there. And if there's anything I can give you some info or help on, please Feel free to contact me. Most of you got my phone numbers, so I hear from a lot of you. But just to recap that you've heard today that there's serious issues with funding, and we're not sure how we're going to get there, but hopefully we can work together and accomplish that. So. I don't know if anybody has any questions, but go ahead, Representative.

Thank you, Mr.

Chair. Oh, thank you, Maynard. Since you're here, and I could ask this any many people that have talked today, the idea of regionalization—what's your first reaction to that?

You know, I think in certain areas, I think it'll work. You know, in some areas. Who do you who do you go to? How how do you set that up? I mean, I know Marty and them have some ideas. Brian's worked on some stuff until we see a plan and see what's going to happen. It's kind of hard, but I mean, we we've got to do something. I guess if I use my service, I I've got. I-90 and Highway 45 going by my— through my district. We cover 638 square miles. I've got the eastern half of Brule County down to the Charles Mix County line, up to Highway 34, so I got part of Buffalo County. I got a little corner of Gerald County, and I got a little corner of the reservation because 2 of my EMTs live on the reservation. They act as first responders. If we have anything up in that area, we automatically call them. They're on our paging system and everything. They respond with— they've got an AED. They've actually got an old Lucas, which needs to be replaced cost-wise, but they respond.

Okay.

I have first responders that live out in the country. They've all got a bag with oxygen and an AED. My northwest corner where those 2 EMTs live is 28 miles from the service. I have one that lives 28 miles to the southwest. He's got an AED and oxygen.

Okay.

They act as first responders. If they're around, they're there on scene before we get there. During the day, the one down south and one that lives halfway between Kimball and the 2 up in the northeast— northwest, they work in Chamberlain, so they're not around. But at night, they respond. And And they do go. It's we do the best we can. We've just picked up four new ones. One of them, I'm still waiting for the board to finish out the paperwork. It's been since January. It's it's it's nerve-wracking. of the paperwork and they won't let people know where they're at and it delays the situation. But like I say, we have, we have a lot of interstate and now with the new truck stop in Kimball, we have a portion of our calls go right to that location there, plus accidents out on the interstate and 45.

So anything else for Maynard? Go ahead, Senator.

Yes, Mayor, thank you. Thank you for all you've done and all you continue to do. Um, do we have a handle on— and maybe I've heard it today, but I, I didn't hear it because of hearing aids, right? But anyway, um, do we have any idea how many Of the EMS personnel are volunteers versus paid? What percentage or a number?

I, I think we've figured right around 82, 82 to 87%, Marty, roughly. Of the services, yeah, are volunteer in the state.

Similar to firefighters then?

Yep. Very similar.

Okay, thank you.

I would say pretty close in there someplace, but Marty can get that for sure.

But I'm asking, is it individual services that are 82% or is 82% of the EMS field volunteers?

Well, most of the services, there's what, 10, 11, 12 paid services. There's getting to be a few more. that are doing things with paid people, but the majority of them are volunteer ambulance services and volunteer personnel yet.

Okay. Thank you.

I guess one thing I didn't mention was the gal from Wasta that talked about the fire department. I mean, we're fortunate. We're housed in the same building. If we have a wreck or a fire, farm accident or anything like that, our fire department automatically rolls with a rescue rig and a fire truck for— and they don't get paid for that. So there again, I mean, it's just part of what we do in the communities.

Great. Thank you, Maynard. Hopefully you'll be sticking around, I'm guessing.

Oh, yeah.

Good. Jerome, did you plan on testifying? I wasn't, but I will now. I shouldn't have called you up. So you're the only one on the list that hasn't spoken.

Jerome Harvey, fire administrator for Pendleton County, South Dakota. Senator Reid, thank you for asking me to come up and Address this august body in the committee here today. Currently, we cover approximately 40,000 square miles. We cover that with 34 fire stations. We have 7 ambulance services. 5 of them are district or funded through a taxing district. One is city. One is federally funded. Addressing some of the issues that have been brought up today, just for some clarification points on my for my own clarification and for the. Committee here. One of the problems I have, of course Marty and I have gone the rounds in this, is not considering 2 of our counties not to be rural. Anybody want to get in a truck with me on the way home, I'll take you north of Wall and drop you off at Pedro tonight. You tell me if that isn't rural. There's something really wrong about that. And that's actually caused quite a bit of problems with one of our primary providers. Rapid City Fire Department providing coverage over 3,300 square miles in a 3-county area, not to be considered rural. Now I know Mr. Link has talked to them about the Rural Transformation Grant. Hopefully something can come out of that. But that is a rural area, people. We cover over 90 square miles— or excuse me, 90 miles of Interstate 90. There's 8,000 miles of state highways in the state of South Dakota. Where am I going with that piece of it? We talked some discussion earlier about the surplus, and we brag about having a surplus. We brag about South Dakota being open for business, and please come, you know, the whole world can come live with us. I tell you folks, it's not working for us. Talking about being a business, Mr. Link brought up about we need to be better about being a business. Yes, the business practices In certain services, yes, everybody needs to work on their business practices, but fire rescue, EMS, and search is not a business. It's critical infrastructure. It's a basic government service. All of those can be considered essential. The idea that you want to create one essential category within the law for one piece of that service is wrong when it takes everybody. Maynard just brought up about The rescue squads run out from the fire department. So we run 15 rescue squads. When I first started out 48 years ago, $10,000 would buy you a jaws of life and you were in business being in a rescue squad. Today, that's north of $60,000 to $100,000. Where does the Wahl Volunteer Fire Department come up with $60,000 to $100,000 to replace a jaws of life? To cover interstate. Over half of all ambulance services calls per year are on the interstate, for example, alone. There was some discussion earlier about air ops, and anybody that's been spending time in the military will talk about the air operations coming up and winning the war for you. I've been an operations chief on Type 1 teams, Type 1 incident commander, been all over the world working on incidents. I will tell you, never plan a successful operation based solely on air operations. It will fail every time. We have excellent air service. Air Methods does a nice job for us, but when you need that air operations to come in and save the day, there's fog, there's weather, there's high winds, all sorts of issues that go along with that. So please don't plan your EMS being a successful, totally successful emergency medical system based solely on air operations. What is the problem with retention and funding? And part of retention as far as people, last summer, the number that was thrown around as far as EMS Our emergency medical personnel in South Dakota, 85% were volunteer. 96.6% of our fire service in South Dakota is all volunteer. So what are some of the issues there? Why don't people come into the service anymore? Yes, I agree with you. There's the— you got to coach. When I was coming up, it was you coached the baseball team, you coached the basketball team, you taught Sunday school on the weekends, and you manned the volunteer fire department and the Volunteer EMS. Those days are long gone. People do not respect, as a society, do not respect fire, rescue, EMS, and search as a profession. One of the comments, and it always twerks me a little bit, is commenting about what's professional versus not being professional. I have 525 rostered volunteer firefighters. Over half of them are some type of an EMR or EMT. Trained. Some of them are volunteer paramedics. All my people, whether they're career or volunteer, are professionals. And we need to look at that. And that comes from this august body here as far as the legislature addressing these services as being professional. It is needed. And yes, Senator, it's going to take some funding from the state. Again, 90-some miles that my dispatch center works that we cover on the interstate I can tell you the amount of times that this— I had a rescue squad that was involved in an accident. It was called out for an accident in vehicles that pay state fuel tax. They're on a state right-of-way.

They are—

the state refused to shut the highway down according to the statute. The Secretary of Public Safety and Secretary of Department of Transportation Can shut down the interstate. They refused to shut down the interstate in the middle of a blizzard. They were struck by another vehicle, and had survived that one. The problem happened when they were hit with a second vehicle. They hit them; they bounced up against the guardrail that kept them from going down into the coulee. We used the jaws of life off the truck to get them out, and transported a couple of them to the hospital. What was the state of South Dakota's response to that volunteer fire department? for causing damage to that guardrail. It was to bill the volunteer fire department for that guardrail. It really comes down to sustainability. We have over 2 million visitors that go to Mount Rushmore alone. The amount of times that my Battle Creek Fire and the Keystone Ambulance responds to problems at Mount Rushmore alone, and there is no sustainable funding coming back from the federal government to supplement anything that they're doing there as far as providing those services. And yes, why are we spending money? I know Senator Reed has heard me say this before. Some people heard me say this last summer. Why are we spending money on fake Mount Rushmores in the Macy's Thanksgiving Day Parade. I don't understand that when I got people that don't have the funding to man the ambulance and man the fire engine and take care of critical infrastructure here in the state. Take this, the funding that you have, you're going to have to plan on it because it comes down to that. Yes, we can talk about retention and volunteerism and license plates and all the other stuff that, that are feel-good things, but it comes down as far as going from here to 2030, like Marty's talking about, and beyond, it comes down to funding. And if you want South Dakota to continue to grow and continue to be this great state, the legislature has got to get involved in funding these critical services. The current fire departments, the current search and rescue teams, the ambulance services, so on and so forth that provide this critical infrastructure are those departments for the state of South Dakota. And that's the thing that I'll leave you with is you just can't throw the baby out with the bathwater on this. This is serious. I look at this all the time, work with volunteers every day. My thing is I think we're beyond the precipice that we're already on the downward side of this as far as the overall volunteerism and requiring or relying on volunteers to provide these critical infrastructure services. The downside of that. The other thing I'll leave with is, Mr. Chairman, on that great sour note, I will invite the committee to— our task force to come to Pennington County. We'd be glad to host you, have you come out and get a firsthand chance to talk to some more people. Anybody wants to come out and look at some of our areas, the stuff that are rural areas that are frontier areas, even though they're not recognized by that map, I'd encourage you to come on out. We'd be glad to host you and have your next meeting or whatever you guys want to do there.

Thank you, Jerome. And we've also got an offer from Watertown too, and we'll discuss that where our next meetings are going— where our next meeting should be. So thank you very much. Questions for Jerome? We all know where to find him. I was able to call him on several issues. So Terrific. Okay. 10 after 3. Our next is next steps, information we need, where we think we're going. We could take a couple-minute break, or we could go through it, you know, and hopefully be done by 4. What would you guys like to do?

Push on.

Push on? If anybody needs to, you know, step away for a minute, go ahead and do it. So, okay. Where to start? I guess just— I guess the puzzle is kind of the main word. We got to somehow figure out kind of the funding puzzle. I think we heard— my feelings is we heard where we're going with some regionalization possibilities, efficiencies and such. You know, I think that has to be a part of this, right? Because if we need the accountability, we need the transparency and everything What's going on. But then there's also the funding. And I think we heard quite a bit about— I mean, there's so many parts of it, just to kind of get the conversation going. You know, for— there's fire districts and ambulance districts involved. You know, we got government agencies, whether it be counties or cities, that are also subsidizing. And then the billing. I just kind of put it down to billing, where we've got, you know, got private pay in there too. Um-hum. Commercial, Medicare, and Medicaid seem to be coming up. And so what's the whole balance here of how we figure out how this should work? And then there seems to me there's going to be a gap. And if we can't— how do we figure out paying for that gap that's there? And I think a very good reference was made. The whole idea of here, the 8, 9 miles of that stretch. Was the landowner. He cut right through their land. I thought was very. So we got. I think we got to think about this different than than than levies also. So those are my general ideas, and I'm not throwing out just a big concept that'll solve the problem. But I just want to get the conversation going. Thank you.

So I just want to thank the lady from Wasta. I live in southern Zebach County. When we talk about deserts. In 2006, I had a grandma that passed away. She had a car accident in the middle of Ziebach County. 2 hours before the ambulance responded, before she got there, she was dead on the way to the hospital. Unfortunately, my family came across another accident 5 miles from my home. Helicopter response. 3 hours before the helicopter got there, my dad had to hold a 5-year-old little girl that died in his arms. That's the reality in rural South Dakota. That is the reality. I do not want to see us go any further backward than we already are. The last ambulance call that I had to make for an employee, over an hour and a half response time. Thankfully it wasn't a major deal, but it was a big enough deal that I didn't want to move the neck in that situation. That being said, I was on the property tax task force and we've got this rural health transformation money coming in. I don't think either of those avenues is the long-term solution for this gaping problem. I'd be interested in discussing a fuel tax because we've talked about tourism, we've talked about how a lot of this is being a response on the interstate. I'd be interested in seeing more from that direction. And the reality is Zebot County can't afford to supplement any more than they already are the ambulance ambulances that they are supplementing. Zebot County doesn't have the tax base for it. Corson County barely has the tax base for it. Hardin County can't do more than they're doing. Lemon is doing everything that they can to supply. Enning shut down. The need was so much that they came back, but they're struggling as is. I'm so thankful to have been on the committee last summer because I got to I get to meet some people from my district that, like, are the— some of the best people in my district. You guys are willing to bend over backwards and save people's lives in horrible situations. I choose to live where I live, and I'm willing to die without access because that's a choice I make because I love where I live. That is not a choice that I'm willing to make as a representative for my neighbors. So I would like to see us quit kicking this can down the road and figure out a way for the state to back fill a need because this is a priority. And I am a fiscal conservative, so I don't like increasing taxes. I don't like talking that way. But one of the fundamental roles of government is roads, and I'm going to say public safety and EMS and fire department aspects. So I would like to see that be the direction that we take with this, this task force instead of letting this bleeding wound Thank you. Yeah, thank you.

I think I get a little bit concerned about the regionalization for a couple of reasons. And in one of the slides, it had the word governance. Okay, so you create regions, so then you got to have staff. You have to have people that are going to set up the standards for that region. And then we've got all these volunteer fire departments. So I'm kind of heavy into volunteer fire departments too. But so we have all these ambulance services that barely get by now. And what I worry about is that then there's governance, because you have to have regional governance. Then of course, then you're probably gonna have to have a state-level governance. How much more government do we add to be able to do this? That's a concern. And what kind of standards are they gonna set that the small departments can't meet? You know, if they come up as a region and they say, well, this is the bottom line sets of standards that you have to have right now, and they increase those standards, some of these volunteer departments that aren't making it now will have even a harder time trying to comply with any more governance. I totally agree with Representative Hunt that it's just like the firefighters, and thank you all for the PPE, voting for that bill last session. The firefighters, they can't even afford to have updated personal protective equipment. That's why I keep bringing up the question is You know, like any business model, I know, I know, say it costs $500,000 to keep my doors open and I only got $300,000 reimbursed last year. I have a $200,000 shortfall. What did I hear? We have 122 ambulance services. Every one of them should be able to do that simple calculation and pull a number together. And I don't care if it's just an educated guess, but I just think One of the first places to start is to know how much money we're talking about, even before we look at any kind of a, you know, and I agree, maybe a fuel tax might be the place to go. And I hate taxes and I don't want to vote for a tax, but these are services that just have to happen. And then we can't, we can't let it continue to die. You know, I think Senator Otten said it earlier. I think From a lot of us with the gray or no hair, it was a pride in public service. We volunteered. I volunteered in law enforcement before I went into law enforcement. I did it for the pride of my community. I did it for— I did it to serve my community. But we see less and less and less of that in the younger people. And Maynard, the longer you stick around, the higher that age is gonna go, okay? That 51.

Yeah.

So, but we appreciate you. But I think we just don't have that sense of community pride anymore in volunteerism that we used to see 30, 40, 50 years ago. So I think in some ways, we have to— we just have to find a way, you know, maybe we end up having to figure out that more of the volunteers, or at least a part of them, are funded so that we have somebody that isn't—

Yeah.

You know, getting off their tractor to go over to the ambulance. So, you know, this is a big deal. It really is. And I appreciate being on this committee.

I want to echo what the senator just said about an aging workforce and volunteer group in EMS. I'd actually like to see the data on that statewide. I think that would probably live in Osteopathic boards, right? I can't see through the beam. Is that a head nod?

Yes.

Okay, because I think that'd be, again, more data points for us to understand. I do worry about regionalization and that just being the straw that breaks the proverbial camel's back on increased retirements and just a reason to get out of this business. That could really also further put our ambulance districts at jeopardy as a state. And so, man, I've learned a lot today. First meeting, appreciate it. And I appreciate the dedication and service of the people that testified today. It's obvious you can, you can feel it, right, that you do this to serve people in our great state. And so thank you. And we'll continue the conversation with real results, I hope, to be at the end of this. Thank you.

Go ahead, Representative Peterson.

Echoing a lot of great comments today, and, and Representative just mentioned it, but, you know, thank you for what you're doing, right? We didn't really talk about that a lot today, but, you know, you're, you're taking care of all of us, and we don't know when we're going to need your help, but we're going to need it sometime. So we're all thankful for that. And the Chair really laid it out well. It's a puzzle, right? And the one thing that I wanted to mention is we're probably going to step on some toes along the way, right? And I hope you can give— we can give each other some grace during that because we're all trying to get to the end goal of making this better and sustainable. But it's really hard to tackle that when you're talking one way, you might be stepping on the people behind you and turn around and you'll do it back, right? So we're going to all work together to try to figure this out. And I didn't come— I've thought about this for for a lot of years. And because the county commissioner brought it to my attention many years ago. And but I didn't come in with any preconceived, this is how we got to do it. There's some ideas out there, but we need— we're going to work together to figure that out. And I'm excited to do that. But I really do think that this can be the year we can figure this out. And I feel that amongst this committee very strongly. And we haven't heard from anybody online, but I'm guessing Hopefully they seem like they're, they're going in the same direction as we are. So I just want to thank the chair and vice chair and everybody on this committee and all the stakeholders. And you— we got each other's numbers, right? So let's continue to work forward on this.

Just an added note on that, Representative, is that's why I put 5 days in the— or 5 meetings in the bill, right? We, we've got to get this done this time. A lot of times when we have our interim committees, it's, well, you don't— we can only afford 3 times, or, you know, can you get it done quicker? That's why I put 5 different meeting times in to make sure we get this done. I think that because of already— we're starting to get focused in already on what we're going to do in this first meeting. That was somewhat from the last meeting too, or the last interim committee we had really helped us. But I really do want to make sure that we're moving forward right away. So any comments? I guess I'm going to stay in the room just for a minute. Representative Weems.

Well, um, Mr. Chairman, committee, I'm, I'm really glad to be on this, um, task force. I think today was really educational. I'm, um, I— we have to solve this, and I don't I think it's by— let me do a little background. I've spent 15 years in medical billing. So I'm a little concerned about the focus on reimbursement. And so I know people are looking at me like, what? But I've seen those EOBs for all the years. And the ambulance is not alone on having significant write-offs.

Thank you.

So, so that I think we need to do a little bit more study on that, and that's a huge fight to get CMS and Medicaid reimbursement higher at the levels that you guys really feel like it needs to be at. Don't think I didn't hear you. I heard you loud and clear. I just was digesting it and thinking. I'm not sure that's a fight we can fix in a year. So we have to look at other ways to fund critical services. You know, this is— and Representative Peterson said it very, very well. You know, you never know when you're going to need EMS services, but when you need it, you need it. And we thank you all for stepping up and doing that. And I love the cadet program. I don't know how many EMS services are doing the cadet program. I don't know if that's increasing longevity of, you know, bringing more people into the staffing. I think That's a creative way to look at that. I'm hopeful. And I'm not ready to write off the regional services yet because I've seen regional in other areas be a productive way to centralize hiring, to centralize some other things that could help all of you.

Thank you.

in a way that maybe you're not thinking of right now. So, training, all of the things that could be regionalized. And TRIP was pretty amazing when they're— they've got a grant to do 350 training spots, and people across the entire state are utilizing that. That alone proves regionalization will work for some aspects.

Thank you.

Of EMS. I think that's enough for me to say right now. I don't have the answers, but I learned a lot and I'm really glad to be a part of hopefully the solution.

Great. Representative Fosness, do you have something you want to add at this time? No? Okay. We'll go online and I'll come back. I think we'll set you up here for last and between us Thank you.

First of all, thank you to all of the participants today, and all the presenters, and especially the folks who came in to give public testimony. I think that some of that was just really insightful, and really passionate to hear about those experiences on the ground, and how these issues are playing out in people's daily lives, and in the delivery of EMS services. I just have a couple of comments and then maybe a suggestion for how to divide this up going forward. One, I just kind of echoing what Senator Jensen said about volunteerism and how that's being reduced in and kind of community trust and how that's gone down over the past, I think, 30, 40 years. Well, I think that's true. I also want to acknowledge that it is really hard You know, when I was growing up, like many of you, my dad worked and my mom stayed home, and that was most of the families in my area that had a situation like that. Nowadays, I think that most people have 2 working parents, if they have 2 parents, and it's just we're all suffering from a time poverty that doesn't really allow us to volunteer very much. You know, my husband is also a reserve police. So we— that's a pretty big sacrifice for a family. And, you know, so I just want to put that out there, that it's quite hard to survive and then get all your volunteer desires met. We are kind of suffering from that time poverty. And then finally, I just want to say that if I could really, at the very high level, look at the kind of buckets of information that we've heard about today, and in terms of vis-à-vis the solutions that we might develop or want to brainstorm on, I see 3 major buckets. One of that is looking at regionalism and what aspects of that might be applicable to our state, or even pieces of that. The second one would be reimbursements and what we can do as a legislature to address some of those topics at the very high level. And then third, I think I'm hearing just Revenue. And where will that come from? Where will it be displaced? New taxes, new fees— no one likes that. While it's, it's a conservative perspective is to not, you know, um, want to raise taxes, it's also the conservative perspective, at least in my opinion, that we can't expect things for free. So we just need to fill that gap, and the revenues would be the, the, that kind of final third piece. So just wanted to throw that out there as a sort of next step for looking at how to break this down into smaller bite-sized pieces.

Thank you, Senator. Representative Hughes.

Well, um, I'm impressed by the sincerity and the knowledge and the skill of the persons that testified, and it goes without saying that Yeah, Representative Hughes, I think you muted, or did he actually fall off?

I can't see him on the—

No, I'm sorry, I, I, uh, I thought I had unclicked my mute button, but I didn't, Mr. Chair. Thank you. Um, well, the, uh, this has been An informative and educational experience today, and I'm very impressed with the quality of the testimony and the subject matter expertise that has been demonstrated from both really throughout the testimony, both the you know the government people as well as the ambulance people. We've you know we've got. We— it's so obvious that we have a problem here. And, you know, we've got the volunteer dominant issues, the low volume, high readiness costs, the challenges of training, certification, burnout, and the need for innovations. And I would like to look at the Spink County program, but I also know that we need a funding source. And I'm always interested in commercial insurance. And Representative Stevens and I are going to look at some insurance reform issues for public entities, especially with respect to school districts. And I think oftentimes we, we just get into this mode of thinking where we just deal with the premium increases. And I want to remind everyone here that there are only 2 industries in the United States of America that by federal law are exempt from antitrust laws. And the first is Major League Baseball. Baseball owners have the benefit of billions of dollars a year in costs because they can collude, they can price fix. And the second is insurance. Since the McCarran-Ferguson Act in 1945, The entire insurance industry has been exempt from the antitrust laws, so they can conduct predatory, predatory pricing. They can selectively enter or collude to leave markets to concentrate economic power. And I just think that sadly, we're in a situation where these are powerful, powerful lobbying interests. But if we're really going to solve the reimbursement side of this, We're going to look, we're going to need to look at some type of insurance reform, for example, which which may include requiring as a matter of state law that in order for policies of insurance to be sold, they have to cover certain things like EMS. To me, those are the the obvious solutions because we can literally work ourselves into a frenzy. Number one, by by not looking at I mean why are we increasing taxes? When we have a way of spreading out the cost amongst commercial insurance. And the other would be to get some help from our congressional leaders on Medicare reimbursement. And so these are some of the thoughts I have. Then the other is that I looked at one of the healthcare systems' Form 990, which typically they're about 2 years behind. And one of the healthcare systems had $332 million in net revenue. And I think to myself, wow, why aren't we calling upon our healthcare systems who ultimately treat a lot of these patients, especially the critical care ones? And why are we not being bold enough to say to them, we need to— we need you to focus some of your philanthropy and some of the justification for your tax-exempt status by helping to subsidize the provision of EMS services in South Dakota. So those are the directions I'm headed. I don't know how many of you all will sign on with me, but to me, those are some probable meritorious solutions to solve this problem we have. We got all these great people that are giving and volunteering and caring for our family, our friends, and our loved ones. And, uh, there, there are some obvious avenues that I would like to see us pursue. So thank you.

Thank you, Representative.

I'll go to Senator Otten now.

Thank you, Mr. Chair. I go back to thinking when I went to the pro tem and asked to get put on the committee, one of the first things he said, well, why do you want to be on that thing? And I said, because I want to solve it. And that came from a series of conversations that I had. But one of the gentlemen, when I first arrived in Pierre, it'd be 7 sessions ago, I've turned into the old dog of the group now. He was my mentor and I had called him. I call him every once in a while to get feedback. He says, well, heck, we were working on this when I was there and even before. So I said, 2 decades we've been working on this and the best that we can do is come up with a system that's actually collapsing on us. So that actually puts us into a very strong position to be able to solve a problem. Do I think we will get it 100%? No. Can we get it 80%? I think that's very possible. We can work on the rest into the future. And I've been here long enough where we've taken on some pretty big things and we've got them done because there was no choice. So I look at all these things that we look at as opportunities, opportunities that we will never have again. You've got the transformation from the feds. I think that regionalization, I am not scared of that in the least. I'm sure that quite a few of you out there are going to be miffed about it, but if I was, I've always looked at Good legislation is, have I torqued off both sides? Are all of you upset in the room? And if I'm getting everybody going, yeah, we're all upset, we've hit the sweet spot. On how do we get there with the money, we're going to have to come up with funds on this. It's going to have to be allocated directly to that so the state of South Dakota sees it. I think the citizens There's some ideas that I've got and down the line here we'll be talking about those. But I think if the citizens see, you know, take it that you got a bill and you actually saw something and it is modest, that they look at it. I mean, we're not talking hundreds, but it is modest where they look at that and go, you know, really for the scope of it, that's not a big deal. Thank you. If we can get it there, we've got a starting point to move ourselves forward. So I think on the taxation end, that's not a big deal for me. I have been— I just had a meeting with BFM, Bureau of Finance and Management, yesterday, and I'm always in contact with them. And of course, we'll have to wait for the election on the governor to start sweeping that in. But I think we can do it. I have every confidence that we can do it because we have to. Failure is not an option. And so that's where I come at this is just an opportunity to be able to serve even a generation not born yet, that they can look back and go, you know, go look at our pictures on the board and go, well, that old bird looked a little funny, but But, you know, he did all right by us. So if we get our attention just out of— off the politics end of this, put it on people, put it on a future generation, this is not a big lift. It's an easy lift.

Thank you, Senator. Representative Emery.

First, I want to start by thanking everybody that showed up today. I think this is a— was a true testament to what The EMS community here and just the emergency services community here in South Dakota really is. I mean, you guys show up every day. You guys, many of you guys have showed up for years and are very passionate about what you do. I look back at this from being that snot-nosed 18-year-old that I met Marty Link when I was taking my NREMT in Rapid City. And I look at it and I'm still here. You know, and I have no, no inkling to leave. I love EMS. I love public service. I love the, the everything that comes with it. And I think I share that camaraderie with many of you in that aspect. But, and I think just kind of something that Senator Otten said that I wanted to echo, that this is too big to fail. I mean, this, we have to come up with a solution to fix this because it won't be something that hurt us today. It'll be something that hurts us in the future if we don't come up with a solution. I think we're at a crossroads that we have to come up with a solution or we're going to go that crossroads of people will die. I mean, I think I've said this time and time again that if we don't come up with a solution, South Dakotans will die. That's the reality of it. And I think Representative Hunt testified to that exactly just a few minutes ago that she's seen people die from this, from that, because EMS just was not available. I think when I first brought this to the legislature for making EMS an essential service, one of the examples I used was if our governor was home on his ranch and he got hurt and he called 911, An ambulance isn't going to show up. There wasn't an ambulance within 20 miles of his ranch. And that's the reality for many of our South Dakota citizens, that if they dial 911, it's questionable whether an ambulance is going to get there in a timely manner.

And it—

I question on how we got there. I mean, we can't go back and fix what has happened. We can take that, look at it, and figure out what we need to do to fix that moving forward so that when somebody in South Dakota dials 911, whether they're our own taxpayers or tourists that are coming here to visit our great state, that we have emergency services available to them, whether that's a police officer, a firefighter, EMT, whatever that might be. And with this, I hope that we do come with a solution. I think I think the rural transformation is the dollars that come here are going to implode and they're going to do a lot for EMS, but rural health in general. I think rural health in South Dakota is lacking and it's been lacking for quite some time. But I think we've recognized that its time has come that we need to look at it and fix it. One of the things we talked about today was the maternal deserts that we have here. You know, it's— it is scary because it has a direct impact on EMS. Here in the central part of South Dakota, if you're in labor, if your your wife, your girlfriend, your your significant other, your your family members in labor, and they're in winter South Dakota, and there's not a an obstetrician there, and you're driving to Sioux Falls, and you have to drive on any one of our highways, whether that's in the winter or what, you know, you dial 911, an ambulance shows up, and those EMTs, that paramedic, that those first responders. Firefighters, they might be the ones that are delivering your family member because we don't have that. And I think that's a lot of what gets put on our EMS here that people don't realize. I think they take, a lot of times they just take EMS for granted that they're going to dial 911 and they're going to get an ambulance. And that's not always true. But I think we can fix it. I looked at the, kind of reflecting back in the the presentation that Marty gave this morning. Um, you know, and I think there is some, some great things that have come with that. My, my only hesitancy and my fear with that is that— and I know we have to move fast on this, and that's just the, the nature of the business— but I, I kind of take a step back on how much stakeholder engagement really is involved in a lot of the rural transformation. I know there's, you know, grant period closed for this first half. There's a second half that's closing within the next 15 days. The third half of that will close before the end of October or so. And those are— that's a fast-moving train. There's a lot of things that come with that. But sometimes when things move so fast, we forget things. And so I just kind of caution on that, that it might be something that we're moving a little bit too fast on. Like I said before, it's just the nature of how that funding works and we have to move really fast on it. But I just kind of throw that cautionary up there with that. But I do look forward to the rest of the summer. I think we, you know, Senator Reed intentionally put it so that we have more than 3 meetings that we can really come up with some really good solutions taken from what was testified last summer, moving that forward into this task force. And taking a lot of what, what we've already heard, what you guys have said today, what others I'm sure will bring in the next couple of weeks, and really taking that and formulating some good legislation, some good solutions to fix our broken system here in South Dakota and really bring it back up to where it needs to be. Thank you.

Thank you, Representative. A lot of good things here. I'm not going to go through kind of repeating. I'm going to agree with everybody said. The only thing I'll add is we always say that we're supporting our rural life. You know, in here we want to make sure our rural life stays, and this is a reason why we have to actually you know do some hard work, and it might mean that we have to sacrifice. We know when it comes to some sort of a funding mechanism, so I just wanted to add that. I want to what let's let's. What we say, let's do it. You know, if we really want to support rural life, then let's do it and let's figure out how to do it. So moving on to next meetings, I got one kind of bit of bad news, although we can discuss this. We talked about fuel taxes, and it's actually in the Constitution that it can only be used for maintenance, roads, and bridges. That doesn't mean we can't change the Constitution, right? But I mean, we'd have to put that forward. That's always, you know, we'd have to actually go to an election. And so, but just be thinking about that. So what I guess I'd like everybody to do, because I think we got so much information today, if you would communicate with myself and Representative Emery and Matthew here, is some of the things you'd like to see at the next meeting, like more things you'd like to hear about. Start shooting out some ideas so we can organize it. I just can see right now in everybody's faces that this isn't quite the time to start workshopping some of the things that we should do. But let's let's be hearing from everybody now. Let's go to what should we do for next meetings? I think I want I'd like to plan two out, knowing that would give us two more as as we go along. Probably want to try to meet once a month here through the interim because when do we have to have a final report done by?

November.

November. So I guess we got it looking back October, September, August, July. Doesn't take long, right, if we do have a meeting a month. So I'd like to try to plan out 2 meetings. Now we do have offers from Watertown and Rapid City that we could go out there if we want to get boots on the ground. If you think that's necessary, we can do that. There's always an added cost, obviously, with LRC. and staffing. And also with Watertown, I've been talking with Matthew today, we're not really set up to do a meeting there. We can't get on the internet, you know, through the state system. We'd probably have to do— if we were going to do something East River, we'd probably have to do it in Sioux Falls. So general thoughts on that. Do we want to go to each side of the state, or are we at a place where we just really need to workshop this issue?

I guess just comment.

I guess we've all driven across the state. We know how far I-90 goes without seeing anything. I, to be honest, I prefer to meet here.

Okay.

I mean, not, not to just discount the offers, but I think the purpose of going there is just to evaluate the ruralness, and I think all of us have already been there.

I concur with that.

Concur?

Agree.

Agree? Okay. Online, anything you'd like to say? We have concurrence in the room to meet in PEER. I don't think we have anything online. Okay, so we'll do that. Now is the fun time. Should we do doodle poll? First of all, do you guys agree that we should probably meet every month? Everybody thumbs up on that. Okay. Should we do some doodle polls to try to figure out— When we can meet. Is there anybody that's got certain times that they'd like to see us meet? Not hearing anything specific.

I think DoodlePoll would make sense.

You want— okay, I think DoodlePolls, and we'll try to figure the best time. Remote participation works. too, right? So if you can't make it kind of to Pierre, we can do remote participation. So we'll do that. I guess just to reiterate my ask, you know, give yourself, you know, some time here to, to re— review through this, but start shooting out ideas of things you'd like to talk about so we don't come in just staring at each other. Um, between Representative Emery and I, we can put together at least a starting point. Doesn't mean it has to be the way we're going to do it, But let's at least have a starting point. Okay? Anything else for the good of the order?

I just want to note that I'm disappointed. Pedro is where my family immigrated from Norway. And if you've never heard of Pedro, South Dakota, I've never thought of that as an urban center in South Dakota. So I'm a little disappointed we couldn't go up to Pedro for a meeting so I could show you How beautiful that country is up there.

Sounds good. I'll entertain a motion to adjourn. So I have a motion to adjourn by Representative Weems. We got a second by Senator Otten. All those in favor will say aye. We are adjourned.