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SDPB. Capabilities to strengthen the support of local ambulance services. You may recall when we talked about last time, ambulance service directors have a lot of responsibility on their shoulders, but they may not have the expertise such as HR and billing support and things of that nature. So that's where this is getting at. Specialty functions such as supporting staffing pools, medical direction, that human resource support, data and technology expertise, and the sharing of those resources rather than individual service constraints, you know, due to the limited personnel and their individual expertise. So, I hope that frames that up a little bit, and I'll turn it over to Emily. There, take off.

Yeah, so again, you know, kind of going back to my earlier comment, you're going to see the word regionalization quite a bit just because that's how we framed this up to be able to have the conversation, start this conversation. What it's called long-term, if it's called this or if it's more of that, you know, what did you just say, Marty, shared system or integrated— integration something. But we, you know, truly believe a stronger, more sustainable workforce statewide is what this could lead to. So that sustainable EMS system begins with a strong workforce. I think the data that was looked at in the first hour kind of ties back into some of the things I'm going to say now, but regionalization invests in recruitment, retention, education, leadership development, the simulation-based training, and workforce collaboration to address the staffing shortages and strengthen our pipeline of EMTs, paramedics, and volunteer responders. A strong A strong workforce doesn't simply mean obtaining a magic number of people on a roster. It's one that functions at the top of their license. It understands complex systems of care and their role in that system. A strong workforce understands a patient's needs and anticipates downstream care priorities. A strong workforce envisions alternative care delivery models at a local level and leads change. A strong workforce also empowers, mentors, communicates, and sets an example of professionalism. With regional coordination, you know, it really strengthens collaboration among the ambulance services with the hospitals, the dispatch centers, first responders, the tribal communities, and healthcare partners to improve emergency response, increase system reliability, and expand access to life-saving care across rural frontier and underserved communities. Through expanded community responders, volunteer fire departments, law enforcement, emergency medical responders, and other local partners. The regional EMS hubs could strengthen local response capabilities by supporting additional first responder agencies, satellite response locations, and coordinated regional response networks throughout our state. Ultimately, when we strengthen the workforce, patient care and response times will improve. And I'll turn it back to Marty to further explain the how of that last statement there.

So when you look at the, the picture on the screen, it's 15 minutes to life. This really casts the vision for South Dakota. It challenges every community and region to consider how, how they can help ensure that regardless of where an emergency occurs, a person can receive meaningful care within that 15-minute time frame or less. This is not a vision that belongs solely to EMS. This is a shared vision. This is an invitation to communities, to regions, to EMS agencies, health systems, policymakers, and partners to really shape the future of EMS across the state. The beauty of the vision, it brings everybody together so they can take part of that. Importantly, 15 Minutes to Life is not a destination. It's simply a roadmap. It does not prescribe a single solution to suggest that every community must look the same, because we know that's not going to happen. Instead, it creates a common vision and invites each community and region to ask, how could we maybe make this successful in our area? What do we need to do to accomplish that? Achieving this vision will require many pieces to come together. It's going to require people, funding, system redesign like we talked about last time. It's going to require technology investments, training, partnerships, and new ways of thinking, most importantly. No single organization can accomplish this alone, but everyone has an opportunity to contribute, to shape what comes next, and to someday look back and saying, I was really a part of making something great. Throughout this vision, we can preserve local EMS, build regional strength, and help bring trained help closer to every patient. Creating a stronger emergency medical service for South Dakota together. When you look at the infographic on the screen, the goal here is not to promise that we're going to have an ambulance in every driveway within 15 minutes. That's unrealistic. But in rural South Dakota, the goal here is to really design a system where the closest appropriately trained resource can begin life-saving action early. and connect with that patient and then enter into that broader healthcare system through EMS down the line. So we may see not an ambulance arrive at a patient site first, might be a trained responder, and then move that throughout that process. This is really what that regional infrastructure looks like, or that infrastructure in general, you know, really getting to the patient, providing that care as quickly as possible.

Thank you.

So when we look at the system requirements that are going to have to take part to make this successful, it's really the infrastructure set and capabilities that make access possible to the people. It's the response coordination. It's the clinical support, the data and technology that we've— that we bring to the table and we can use effectively in its sustainable operations. 15 minutes to life is really an outcome. Regional infrastructure is what makes that possible. The regional hub model that we've been talking about really connects those capabilities so every community does not have to build them alone. And really from the June conversation, again, leveraging and understanding that not every service director has the expertise to be able to carry all these things forward, and we want to be able to help them.

Great points, Marty. And again, going back to the people and the workforce, all roads leading back to that workforce. And the infrastructure or the system remodel should support staffing pools, schedule support, recruitment, retention, training, leadership development, and succession planning. And it's worth repeating too that the workforce strength is more than roster size. It's about capability, the confidence, the training access, the ability to cover the gaps before they become crisis. You see a leadership bucket here. And so from succession planning to instructor development and training and provider confidence.

Thank you.

All while having to make the decisions quickly in an emergency care situation. You know, stay calm under pressure, coordinate the resources and support the team. That's, you know, that's where the fatigue and, you know, folks who may be overwhelmed or need assistance come into play. And so, you know, at every level from an EMT on the scene to the field supervisor to an ambulance director, you know, it doesn't matter. where you're at in the rankings for leadership. It can happen at any level there. And so I think this pillar piece is one of the most critical when we look at the people who are behind the scenes of EMS.

So building upon pillar 1, people, we've got to talk about the response component. So when you look at these— when you look at this infographic, we have the dispatch awareness, we have the first response mutual aid, and then ultimately the transfers. The hub component, the hub model, can support that dispatch coordination. That is critical when we look at emergency communications. Also supports the first responder and the EMR satellite coordination, mutual aid that was talked about earlier today, and response zones, transfer planning, and strategic placement of resources. Remember, we have our patients all over South Dakota. We want to make sure that we can get them to the tertiary care as quickly as possible. Takes the people, and then in this pillar, it takes the response and looking at that dispatch component. So the people— a patient should never have to understand where one district ends and another one begins. It should be seamless across the entire state of South Dakota. We expect the same level of care wherever we are, and the system should be a part of solving that problem for them. So, we look at the 3rd pillar, clinical excellence. This is where the hubs really become about patient outcomes, not just the operations. Okay, we're looking at big picture here. Small, low-volume services may have limited exposure to what we call high-acuity patients, those patients that are very critical and need time-sensitive care. But patients still need, even though they are limited to the patients that have that high-quality need or have that high—

Critical need.

Acuity patients need aggressive care as quickly as possible. They don't always see those patients on a regular basis. So providing this clinical excellence, it really brings to, brings to front and center that we still need the training because we, like we talked about in June, we don't know what kind of an emergency is going to come. It might be a major trauma, it might be a cardiac arrest. So the regional clinical infrastructure, that support with medical direction, Statewide protocols, credentialing expectations that we have, always continuous quality improvement is key to emergency medical services and healthcare in general, and then targeted performance improvement are all key to this process. When we look at Pillar 4, data and technology, this is— it's absolute that we We'll look at the data that's coming in on a day-to-day basis and we use it effectively. Several components that we're using currently and we will be using into the future when we look at the data and technology is the components of GIS mapping. We touched briefly on that last time we met in June. We continue to develop that and we're excited to move that forward almost on a weekly basis. Electronic patient care report, the data collection from each and every ambulance service. This is something that we pull those reports on. We're very thankful that we're able to provide much better reporting now through some advancements in that process that's going to help ambulance services. Certainly, we have our dashboards, health information exchange, and then telemedicine, communications, interoperability, and the cybersecurity are all part of that data and technology component. We cannot manage a regional EMS system if we cannot see it clearly. That's really the expectation of looking at all the data at our disposal and using that effectively. So when we look at the 5th pillar, sustainable operations, many local ambulance services are expected to handle, like we mentioned in June, the human resource component, the billing, grants, grant compliance, all the contracts, purchasing, and sustainability planning on their own, and that can be exhausting. It's difficult. It's often ineffective. The hub model throughout this approach will allow building those capabilities once and for all and to make them available throughout that geographical area. So not one service director has that whole responsibility. It's a shared responsibility. So that would make the process much easier for all. When we look at what does this look like for the real patient, 911 should not activate— 911 should activate a coordinated system that identifies the closest appropriate resources, brings trained help to the patient, and connects with EMS care and moves the patient through that pathway. So again, wherever you are in the state of South Dakota, We want to make sure that there's timely EMS, there's timely response. It may not be an ambulance showing up at the doorstep to take care of you initially. It might be a trained responder. But they can start that process, pass that information on to the responding ambulance service so that your care can be better now than it was before. When we use transformational funding to build, not to create dependency, and this is an important slide and distinction when we look at rural health transformation. Our department can set the vision, we can set the guardrails, data expectations, and accountability, but regional partners must really shape— help shape that local design and help build that system at a local level. Readiness is going to vary from one community to the other.

Right.

The model should expect local conditions to— the model should respect local conditions as we move forward because that local ambulance service has been working with their local communities for a long time. We want to have that historic presence awarded. Rural Health Transformation funding should be presented as a capital to build upon. The funding. Measure, refine, and transition proven functions. It should not be framed as an assumption of permanent operating subsidy. The question is not whether we spend— how we spend transformational dollars, is what infrastructure South Dakota still has after the dollars have been invested.

Thank you, Marty. So how will we know this is working? We're only beginning here, the building of this and sharing with you all what we know. You know, we're just laying out some information here to help inform your decision-making authority. But of course, like any large project or program, we are certainly going to measure access, the workforce disability, the clinical quality, the technology adoption. The financial sustainability and system reliability together with our partners and our stakeholders throughout. This is— I'm defining it as an adventure. There's lots of rocks we're uncovering, we're learning along the way, and we're getting input as we move forward too. So, and with any adventure, we're going to assess as we go, you know, what's working will continue, And what isn't working, you know, can be modified or stopped, or we'll pivot along the way to make sure we course correct. And then I think, Marty, this is our final slide maybe, and then we can certainly turn it back to you, Mr. Chair. But really, you know, the future of sustaining EMS in South Dakota is is kind of going back to June and what we talked about, the need to reimagine EMS. You know, we've showed you today what it could begin to look like, what it's called. You know, I think that's something to be determined. You've heard us at the State Department say this before, especially more in the last couple of years. You know, the opportunity here is bigger than just purchasing equipment. Or funding individual programs. We've done that already. And by focusing on a refined system, regional collaboration, the implementation of hubs to support more people and more access to care, South Dakota is really building a modern EMS system then capable of adapting to future healthcare challenges while preserving those local services that communities rely upon every day. And the state of South Dakota's role is to help launch that. Not operated, and success will be measured by the ability of regional partnerships to become locally led, financially sustainable, and capable of continuing long after rural health transformation funding has ended. And so we have the opportunity right now to really build the infrastructure of an EMS system again—one that is preserving work locally, building the capabilities regionally, and giving every South Dakotan. greater confidence that when the worst happens, life-saving help is within reach. And that is true today. It's just a system that needs a little bit more support for sustainability into the future. And so that, you know, 10 years from now, 20 years from now, they're not having the same conversation. Hopefully it's built on pillars that we've explained today and that vision of that 15 minutes to life that Marty defined as an outcome of regionalization. You know, it's got the patient at the center of it all because we're all gonna need EMS access in some way. We rely on that. And I'm grateful for what we have in my own rural community and the folks that are behind me today and listening online as well. But building that stronger, more resilient workforce for EMS, It's there through the potential hub model and that 15 Minutes to Life initiative that we talked about today. So those are some of my closing points. I'll turn it to you, Marty, if you've got anything more to add. Would love to hear from you too.

Yeah, you've covered it very well. Again, it's overarching vision that's going to take everybody to really make this successful. I appreciate your time. We'll stand by for questions.

Great. Well, thank you. I think this really laid it out well. What you're trying to accomplish. I appreciate that. I also like this last slide. If I just leave, I know if we get somebody on remotely, but I think this last slide really shows it. And the concept of figuring out how to regionalize the best way, I think, is what we're talking about here. I guess we'll ask some questions, but I think then we should try to get ourselves forward to a place that we can have a discussion earlier or later on today about how do we actually do this. You know, first of all, is it something that we need, which I'll start out by saying yes, but then how do we get there, right? And what's the roles between the administration and between, you know, the legislative side of getting something like this completed? So I saw that Representative Hughes has his hand up. And so we'll go to our online folks first. Go ahead, Representative Hughes.

Thank you, Mr. Chair. What an excellent, inspiring presentation. I want to commend you all, both you, Ms. Keel, and Mr. Link, and all those who you have worked with to put this together, including, I'm sure, the Secretary. I have one specific And one general question, and then I also want to share 25 years of part-time city attorney service for a small municipality not far from Sioux Falls, and just the annual struggles working with a voluntary fire department and constantly having funding shortfalls, staffing shortfalls, and, and yet here we are. In, in an area where we have 2 superb healthcare systems. So one of the general questions I have is, what barriers can you identify that will make regionalization difficult? The second would be, what, what role are the healthcare systems, and in some cases the community hospitals, That are independent. What is their role that you envision, and what is the role that they're playing, if any, to this point? And how can we tap into all of that expertise in implementing this really fascinating program? Thank you.

Representative Hughes, thank you very much for that. I'll start with the barriers. It's something that I find very interesting is in EMS, we've always done something a certain way. We're very scripted as far as a 911 call comes in, we go on the response, pick up the patient, do the treatment modalities, bring them to the hospital, and then come back. One of the most significant barriers that I see in this whole process is we're really going to have to stop doing what we've always done and reconsider the future. Yeah. For the next generation of EMS responders. It's not present day, how do I respond to a medical emergency, or how do these teams respond to a medical emergency. We've got that covered. What we need to do is be looking out for the babies that they may be delivering in the back of an ambulance now, today, might be up here in 30 years. So how do we set up the future of healthcare, prehospital healthcare together, not by focusing on what is occurring today, because we can get into that rut. And that's like that old country road where the tires are going to fall into that and it's going to be difficult to get out. That's one of the biggest challenges that we're going to face, but it's one that I'm most optimistic about, because if we can come in and we can be in one accord and we can say we can truly make a difference here, boy, it's going to take one person to start a wildfire that are really going to transform, truly transform how we do things into the future. It's going to require us to look at a different process when we look at taking care of a patient. Again, that robotic nature of going to an ambulance call, having a patient right in front of us and saying, okay, now we got to prepare to bring this patient to the hospital. We've got to look at different Treatment pathways. So if we're in North Central or wherever we are, we don't always have to transport that patient to a definitive care center because they may not need it. Now the way it is right now, that's just our nature, right? But as we look into the future, we've got to look at what are those alternative care delivery models. As Mr. Rendon said in Rapid City, they've got a mobile integrated health component. That's a very Intuitive, right? That's that's next level thinking. They can continue to expand upon that, but it still requires somebody going to that patient rendering care and then really triaging them. Do they need an ambulance or can we can we get them in another component of the healthcare system? So I love that concept, but really even taking it further, like it was mentioned before about a potential triage from that 911 call, you know, and that can all. Develop over time. So those are some of the barriers that I see. And again, I've been doing this for 24 years, and sometimes I can myself can be in a rut, and that might be a barrier to me, right? I need to look outside the box. But I think I'm very open and transparent to that respect. As far as the healthcare systems, you know, we embrace that open conversation with them. You know, we want them coming to the table, and I think they've been very open In part of that dialogue. And we're going to have to further expound upon that, because when we look at prehospital care, it's not just simply prehospital care. We talked about the 15 Minutes to Life vision that specifically called out EMS, hospitals, policymakers, funders, and things of that nature. So it's really going to take that collective group of people to sit in a room and say, how do we make a difference here? How do we make a true difference?

Thank you.

And yes, I think Ms. Keel and I are very biased when we look at the next 5 years of rural healthcare transformation funding. We have 5 years really to capitalize on that amount of money, that investment, to really make true sustainable change. And we want to make that happen. And that's why we want to look at that infrastructure build and look at how do we reset that foundation. And if there's holes in the foundation, how do we repair that. But with everybody coming together, not with exactly how are we doing it today arguments, but how are we going to do it in the future for our future kids that are out there or that will be out there. So, Emily, anything you wanted to add?

No, just a comment on, you know, we have really great relationships with those healthcare systems and the critical access hospitals today. And I, you know, I foresee that continuing and making sure that they're part of the conversation, just like all of you are here today, as we move forward, however we move forward. So they're part of our stakeholders.

Thank you. Representative Hughes.

Mr. Chair, brief follow-up. I just want to personalize this a bit too, because I've had 2 close family members who have required EMS services, and one One didn't survive, but one did. And so I've lived this. I was in a car crash that was pretty serious myself and was in the back of an ambulance in Sioux Falls. So this is a real situation that we all need to address because, you know, that 15 minutes for life, I love your presentation, but I also wanted to ask, is there Is there a conflict of any kind with, for example, the healthcare systems with the requirements of the EMTALA as it pertains to EMS services? Is there— how does that work, for example? I'm just thinking, if I'm running an ER department or a trauma department, I'm thinking to myself, how do we screen people Because I'm sure our healthcare system deals with what I'll call, I guess, frequent flyers, people that for one reason or another, perhaps, you know, reach out for EMS services. And perhaps you've already answered that in terms of the triaging and perhaps the, you know, the non-admission to a hospital approach that is being looked at. But, and I'm, again, I apologize, To a certain degree, because I'm learning so much. I'm just soaking all of this up, and many of these issues are relatively new to me. So can you help me better understand the EMTALA, if it factors into how a healthcare system may look at, for example, a role in this process, if at all? Does that apply? And again, I, you know, we have such, we've had such philanthropy and generosity in this state in the area of healthcare. And I'm just wondering, how do we really engage the healthcare systems? And perhaps they're already engaged, but I'm not talking just about support and encouragement. I'm looking at the money side of this as well. Do you have some comments on that?

Yeah, Representative Hughes, thank you for that. So when it comes to EMTALA, I mean, that's certainly, certainly something the health systems are going to appreciate, right? Because they want to make sure that they're staying in the lanes there. And I don't want to get into too much in-depth with EMTALA. Just know that if a patient shows up at a hospital's doorstep, they're going to be treated. And if they're not, for whatever reason, that's another conversation for another agency within the Department of Health. But certainly the EMTALA guidelines are going to be part of those conversations. But when we, when we look at potentially triaging patients by a 911 call, or we look at triaging patients with a mobile integrated health component like Rapid City Fire Department is doing, they have that structure in place as far as the mobile integrated health. When we talk about 911 and potentially triaging, that's a whole other conversation that's going to have to have key stakeholders come to the table and really flesh that out. We don't have a package that says here's how that needs to happen because that would be inappropriate because we haven't had a seat at the table with all the vested stakeholders. And that's really where we're getting at here when we look at this concept and we appreciate the comments of the regionalization tag name, if you will. Part of this, as Emily mentioned, is getting that message out, is starting to flesh this out a little bit more. But when we truly want stakeholder engagement and stakeholder buy-in, we're going to start to see that in the next level and the next level by inviting those key stakeholders together and saying, help us really form this process, right? We've got a statewide vision. We kind of know where we want to go. We've got rural healthcare Yes. We want to make sure that we have everybody's support. As we've said back and forth and back and forth, we want to make sure that local— the time, the blood, the sweat, the attention that Representative Emery has given his community, we don't want to take that away. We'll never take that away. But we want to build upon that. So we want to make sure that we have that buy-in. And that goes back to And maybe one of the barriers that I missed is not getting the appropriate buy-in. That's something we're very sensitive to, because we have to say moving forward, we do need everybody's voice. We want everybody's voice. As a representative of the survey, though, and one thing that we'd love to see assistance with is 47% response rate, although it may be good from an academic perspective, Yes. And I think from a public perspective in a survey, in these high-stakes environments, we want to see 100%. And that's something that we'll go— probably go back to the drawing boards and identify why didn't we get that 100%, how do we get there. Because again, we want to make sure we have everybody's voice. We're here advocating for the ambulance services. We want to make sure they're at the seat of the table, have a seat at the table, if not physically, on paper, whatever we need.

So Thank you. Thank you. Tim Rave couldn't be here from SDAHO physically, but he is online. I know that if we started talking about kind of the systems and how they interact with this, that he was available. So I'm going to go ahead and go to Mr. Rave if you have comments on Representative Hughes's questions.

Sure.

Thanks, Senator Reed. Can you hear me okay?

Yes, we can.

Good. Thanks. I apologize for not being there. Again, I have a commitment late this afternoon I had to be back for. So I think Representative Hughes, you bring up some good points. I think Marty just did a fantastic job of really kind of touching on EMTALA and the fact that, and I don't think we can stress this enough, somebody shows up to the door of a hospital, they're getting in and they're gonna get the best care that they can get regardless of whether they can pay or not. And those are discussions for probably Another day. I think when you kind of touch on support and maybe just— this is Tim Reed's opinion, but I think when you talk about EMS and maybe we don't talk about it enough in so much as if government does anything, government takes care of people and protects them. And so obviously we do that with law enforcement. Nobody talks about the hospitals paying for that. We talk about fire.

Right.

That's supported by government. Nobody talks about hospitals paying for that. I really think EMS is in that same bucket. It's one of our 3 pillars of protecting the public. And I think as you go down this road, I would focus more on that. I mean, if you went to the hospital, so who's gonna pay for it? Well, do all of them pay for it? Do none of them? I think it just, it really muddies the waters when you start going down that road. And the kind of dollars that you could end up talking about depending upon what level of air quote regionalization or what that looks like 5, 10, 15, 20 years down the road. I think those are just some really fast— I love where we're at. I love having this discussion. I was in EMS for 23 years. It's very close to my heart. I'm somewhat passionate about the topic. Certainly not an expert, just did it for a really long time. So I don't know, I don't know what that makes me, but old, I guess. But I think, you know, it's— I'm glad we're having these discussions, and I think it's a good kind of jumping-off place. Thank you, Representative Peterson.

Thank you, Mr. Chair. And before—

if, Mr. Chair, if I may, I have a couple questions. One might steer us off to get some background, and I'll come right back to this conversation. But before I say that again, I want to Thank you for your sincerity and passion and thoroughness for your presentation today. It's really, really been good. And everybody, every other stakeholder that's talking today as well. The first question, we keep talking about Rural Health Transformation Program funds. We haven't really actually talked about the funds yet. Have we applied? Is there maybe grant money coming into this area for this year? Or yes, no, and then for the next 4 years? What do we need to have in line to make those applications? Because we really would be on a funding standpoint, which is a lot of what we're doing in this deal, is what's the basis on what we can expect or hope for from that big pool of money?

Thank you, Representative. So first and foremost, when we talk about RHTP funding, I equate this to building a house. So you have the land that has been It's surveyed, it's leveled, and you're starting to envision that house being built. You've got to start with that foundation. And that's exactly what we've done with rural healthcare transformation. So we have up to $64 million that has been part of an application we submitted to CMS for EMS alone. Now, does that mean we're going to have $64 million at the end of 5 years? No. Maybe, maybe not. There's a lot of variables that go into that, such as CMS scoring, how we do as far as our spend down for year 1 through year 5. So nobody would be on mic saying it's an absolute guarantee. It's just not. But we are going to do our due diligence to make sure that we get to that point we can spend and obligate the $64 million. So to your question, when we talk about where we are in it right now with the MS-10 task force and RHTP funding. There's been a couple RFPs that have already been posted. One of them was for that regional hub model. So it's an oversight. So we did award just recently the South Dakota Foundation for Medical Care that contract, and that'll be on OpenSD within the week. Just finalized, ink's still wet. Once that's posted, they're going to be instrumental in helping us really build this concept up. When I talk about build, it's being able to go out into the communities, share the vision that we have, and be able to start soliciting that feedback of, okay, we're on the right track, or no, we need to tweak this a little bit here or there. Again, making sure that we preserve that local buy-in. We have a second RFP that's been— that was out there. It has since closed. We're in the process of doing a final scoring of that. We had over 50 submissions that came in, 50 proposals, and we're in the— again, we're in the process of making sure that, okay, of these 50, how many are we going to award? So I really can't speak to that too much. Just early on in the process.

But the 4 buckets of that RFP, Marty, were workforce development, right?

Mm-hmm.

Leadership and system sustainability. Is that correct?

Right, right.

Training in there? Okay.

Yeah, so I mean, when we look at that, we— the dollars we want that to be invested in and make sure that we can move EMS forward, but by building the foundation. So I talk about if a foundation has some holes in it, how do we patch it up? If there's no foundation whatsoever, well, we need to start digging and putting And the footing so we can build upon that, build that foundation. So when we talk about things like the dispatch component, if we don't have optimal dispatch systems or if there's an improved way we can communicate with our EMS providers, we want to be able to do that. You might say, Marty, I have no idea what you're talking about whatsoever. If you were to look at, say, Rapid City, if they get toned out to an emergency, everybody's going to have a pager, they're going to be— or a radio, they're going to have bidirectional feedback instantaneously. When you look in our smaller communities, they might have a pager that's one-way, so voice is going through that pager saying here's where the emergency is, but we really don't have a defined way of having that two-way communication. That's a potential barrier when we look at time-sensitive We want to have an ambulance be dispatched out by 911. We want to have almost immediately, as Representative Emery can attest to, I want to know who's going on this ambulance response. I want to know if I have 1 person. I want to know if I have 5 people. That way I can start making that decision-making of how I'm going to respond and so forth. So that's just one basic example of a foundational principle where we need to improve.

Thank you.

We mentioned before equipment's going to be a big thing in this. Equipment's a big thing in EMS in general. But is equipment a piece of equipment that functions day to day, or is equipment a piece of infrastructure that will have longstanding growth, we'll be able to build that house upon? And there's a clear distinction between those 2 things. So we're sensitive that there's There's going to be requests in for various pieces of equipment, but right now when we're building this, we've got to make sure that we have a solid foundation. We've got to make sure the bones of that house are constructed well. Then we can start putting in the wiring and we can start putting in the plumbing. And if we want a few extra gadgets that give us additional bells and whistles, then we can maybe look into that, but we've got to appreciate what that ROI is going to be ultimately. So a lot to unpack there, but I'm confident we're going to be able to do the work throughout the next 5 years. It is— we have 10 initiatives across the entire state, so we're all kind of working together along those lines. But did I help address your question?

Yeah, thank you. And if I may do— thank you, that's a really good background on, you know, what the goal is and where we're at on the funding side on that program. So to bring it back to more Yes. So, as I've been hearing more of the regionalization, the hub and spoke, the service area conversation, one thought I've had right away is the mutual aid component of how this regionalization could help. And in comparison to, you know, an area that might need 2 vehicles or 3 or 4 or 5, but if there's more of a standard mutual aid, they might not need quite as much overhead. For equipment and vehicles, have you ran any numbers to those things? Is is my assumption that we could maybe have a little more efficient use of these machines in the rural areas? Is that a is that a place that we could have some cost savings? And and or am I being a little wishful in my thinking there?

Yeah, okay. So, great question. A lot in there too. And like Emily was saying, that might be a further conversation, because here when we look at preserving that local integrity, if we were to start saying there's more efficient ways of doing this, and maybe we can consolidate, maybe we need to further decrease the number of agencies, ambulance service, that becomes a very sensitive subject matter. It might be writing on the wall, quite frankly. I mean, we— when, when we look at, you know, the 47% of ambulance services that submitted to that survey, I don't want to speculate on why the other didn't, the other percent didn't, but that's where we're gonna have to have those conversations at a local level. And truly, as I said before, I think we have to look for— envision the future, not envision the present day. We've gone out to services with 3 people around the room and they say, we're doing really good and we have no problem going on an ambulance call. That's focusing on present day. If we focus on the future of one of you breaks your ankle and you're out for 3 weeks, that's a completely different story on the sustainability of that ambulance service in that particular time period. So it is part of the conversations, but it's going to require that mature conversation at a local level with local buy-in to make sure that we do it right. And I hope you understand the sensitivity of that. It's a great question. It's one that we're going to have to have those conversations on, and we've started those. But have we done that full analysis quite yet? No, not quite yet, because we want to make sure that we get that buy-in from the rest of the services in that region.

You good, Representative Peterson? We're going to go to Senator Otten and then to Senator Jensen.

Thank you, Mr.

Chair. This is our first installment of money that is being sent out from the feds, is that correct?

Mr. Chair, Emily Keel. So yes, there's 3 RFPs for the EMS initiative. We have 2 RFPs that we're working on. Okay. We have 2 RFPs that we're working on. We have 2 RFPs that we're working on under Rural Health Transformation. And so the first one that Marty mentioned, we have a contract signed with South Dakota Foundation for Medical Care to help us with this big concept that we just talked about. Nothing's been done yet. No work's been done. No invoices have been sent yet. We've talked about a lot of the purpose and the setup for that. The second RFP that was posted has since closed. Or proposals, excuse me. Still going through all of those in assessing where the dollars are going, and then potentially would have a third RFP. But we're holding off on that as conversations are ongoing right now with you guys.

Out of the billion dollars that the government was throwing into this, though, there's a possibility that we might have extra funds into the future.

Senator Hunt, are you talking specifically to RHTP funds?

For the total rural transformation.

Right. Yeah.

Correct. I'll just repeat what— thank you, Secretary Magstadt. We're rounding out year 1 of that funding right now. And so August 31st is the due date for the budget narrative and all the essentials there for the budget for year 2. And so some of— or part of your question there I can't answer because there's so many unknowns just yet. We'll know more hopefully September, October-ish, right?

We're supposed to get funding in years 2, 3, 4, 5. Melissa Magstadt, Secretary of Health. Yes, we are supposed— I think I'm reading your question, Senator. We are supposed to get funding years 2, 3, 4, and 5 yet to come to the state of South Dakota. We are just putting our budget together on that. And yes, we have tagged EMS services as one of our key initiatives, yet years 2, 3, 4, and 5 still. So when she said, you know, the 3 initiatives, that's just year 1. We've got work to do in 2, 3, 4, and 5, and funding in 2, 3, 4, and 5 as well. Does that— that will be—

answer the question— our initial—

beyond this first year, the $70 million?

Yep, yep, beyond year 1.

Thank you.

Sorry, one of the first times that being an appropriator that I'm actually ahead on policy, and plus I've heard this thing maybe 3 4 times already. Just a general— I guess I'll stop using regionalization. I'll just use a district because that's the only word I can come up with that we've got fire districts. We've got a variety of different districts. So I'll use that. But as I've thought about this process, as we go on, you know, we could end up with an ambulance in each district, whatever, that is fully maxed out. It's got every known technological thing known to man. It's a go-go gadget. But if we've got an area that also is doing a lot of just shipping people from old people homes to whatnot, you don't need that. So I think that there is within this structure as we move forward, I think there is great savings to be made as we would start to formulate going to a a district mentality of how we do things. Going back to what Senator Hughes and a lot of our observations in life is how we walk it and having my spouse having a severe stroke and whatnot and knowing that we've got to get people to a hospital the quicker the better because it will save ongoing costs in the future. This is actually cost savings as we move this thought process forward. And then having to sit into rehab and look at all the different scenarios of people that are out there, that their lives matter to their loved ones. And so that's, I think, what we're really looking at. So my mindset on all this and coming up with with a solution has always been in that realm of, you know, can we get a format set of 80% of getting there? Because we've got 5 years to work on this as the monies come in from the federal government to begin to fill in the holes, as you were, that we've got. As you look into districts, you know, the Sioux Falls metro hub with Lincoln County and whatnot may look Our funding source is a whole lot different than others, but our funding source, as we start to drop all this into place, this EMS money coming from the feds is just for things, structure. Whatever we set up, we have to have that backfunded with. And so we'll have to come up with funding sources for this, but I think that we can do it. And I think it's imperative that we do do it. And for even those listening over the last 20-some years that we've had this discussion, even maybe going into 30 years, in my time being up here, I've always been the no. We're not doing this. You're not going to put this burden on the counties. And now I'm in one of those situations where enough is enough. We have to solve this. And this is the group that has to solve it. And I'm not going to accept no for an answer. So I will be the burr in everybody's bonnet. We will have to come up with funding. We are going to have to do this. And I think the citizens of South Dakota deserve something better than a conversation going on up here in the legislature for over 20 years, and the best that we've got is to come up with a model that is destroying in front of us. It is self-destructing in front of us. It cannot continue. So we're going to have to think out of the box. We're going to have to bite our own tongues. And at the end of the day, we're going to have to make votes and do decisions that 3 years ago you never would have done. So thank you, Mr. Chair.

Thank you, Senator. Senator Jensen.

Okay, thank you. And I'll just piggyback a little bit on that, but go back to the slide presentation a little bit. But, you know, you can have a a golden autonomous ambulance, but it doesn't do any good if there's no EMT in it. At the last meeting, I know we talked extensively about the aging pool of EMS— EMTs and paramedics and trying to figure out a recruitment process. And I noticed on one of the slides, I think it was pillar 1, the very first thing that stuck out to me was regional staffing pool. And I wonder if there's a concept or a model or what that actually means because recruitment is going to still be a huge thing. But I'm just curious what the regional staffing pool, what that concept was.

Thank you, Senator. So we're discovering, we're in that process of discovery. So we've been talking with both some rural services and some very large services in the state to say How could we how could we benefit where we have maybe some rural providers like we mentioned before when we talked about high acuity and low acuity calls? High acuity calls are the the cardiac arrests, the traumas, things of that nature. When we live in a small rural community, the number of high acuity calls that we see is very very low traditionally. By partnering with the staffing pools, part of that is can we take some of those folks? That say, I want to further my education, I want to be a better EMS provider, I'm willing to go to, say, Sioux Falls or Rapid City for a weekend, and I want to work on that ambulance service as a third person, gather valuable insight and experience, further enhance my network as an EMS provider, because now I know this Robert guy in the back and I can call upon him. The same is true retrospectively when we look at— We have We have some services that— larger services that want to contribute to local smaller services where they might say, I'm willing to take a weekend, go out to Bowdoin, and invest 24, 48 hours into that crew, working with the crew, providing education, bringing what my 3 years of experience in, say, a Sioux Falls area into a rural area is going to be invaluable, right? Because they're going to learn so much. Through that networking, the goal is to be able to say, how do we expand that further so that we can have some of those shared pooling? One of the ultimate goals, Senator, is how do we devise a website or some kind of structure that says, I'm a paramedic, I'm available the last weekend of June. Who wants me? Who needs me? And I can go out to that website and I can say, I've got 3 rural communities communities that would really need help. They're doing 2 standbys for rodeo, things of that nature. I want to go there. Am I going to make the amount of money I want to make? Maybe not. But it's an investment of my time. It's going to help. They got a bed and a shower and a bathroom. And that's all I need because I want to be able to help them. But those are the kind of structures. And again, that is something that we're building upon. We've had some preliminary conversations, but it's It's not, again, a full-fledged plan. But that would be the overarching goal of how do we establish something like that.

Mr. Chair, I'm just going to add a little piece onto that too. I find it— and I don't know the answer to it— but there's sometimes 30 people on the roster, 7 people active. And so, you know, what's that 23 people that have volunteered to want to be on the roster but are not actually coming to the calls? Why is that? Is it a scheduling? Is it a confidence? Is it, I really don't want to be on the roster? I mean, I don't know what it is. I don't know if we know that yet. But going back to that local stakeholder conversations to, yes, we know at this level, but now we need to know the deep dives into these things, including why 7 active and 30 are on the roster. And I don't know what that is, but I'm really interested in finding out because I think that will be Yeah. You know, if you have 7 active, but for whatever barriers there are, we add 10 more, now it's 17 active on the rolls rather than just 7. What does that happen when you have people who are interested but have not yet gone on the runs? Why is that? They were interested, but what's the gap there? So I'm really— yeah, I'm interested in those deep dives into those local conversations about why I said I was interested, but I'm not going on the runs. Why is that? I don't know. We'll find out.

You wait.

Senator Otten. I'll just tap on to what Senator Jensen was talking about. Last year we had reestablished a wildfire suppression for East River and the training for it. And we had a training deal over in T, and I stopped in to it, and I expected 10 people there. I mean, who's going to give their time for this kind of thing? I did not expect over 50 people there. I did not expect even people from Pennsylvania driving all the way over here To Sue, or well, actually to T, to learn about wildfire suppression. And I think that's what we will end up getting into, is that we know that we can't continue with volunteers. I mean, they're dying off on us, and the new generation just isn't willing to. But I think that there are concepts that at this moment in time we can't fathom. But I do know that in five years. They will be there for us, and they will manifest themselves. I was never so impressed with the wildfire group of these men. I mean, this was their life. They wanted to learn. They wanted to share. And the same is with the medical personnel out there. I'm sure Senator Representative Emery—I mean, there's a passion that you mentioned about getting in an EMS truck. I mean, you know, there's a passion behind that. That I don't have.

Representative Weems.

Thank you. I really don't have a question, but I have kind of more comments because I really like this idea and I look around the room and I might see some skepticism, but I really think tagging off what Senator Otten said is we have to think outside the box. Because you don't need EMS until you need EMS. And then whoever is in that ambulance, you guys are the ones who supply all of those services to keep that individual alive, and you need to be prepared for it. So you might need an ambulance with all the bells and whistles because no matter where you are in the State, you might have that accident that needs all those things to help prepare the patient to get the best service that they can. But what I also would like to see is, you know, we heard last meeting about how— and I'm going to get the wrong county— somebody in a county was already doing some of what you have on I saw on this slide where they had trained community response people. And so I loved seeing that because I think that was kind of out of the box. And so that's really a great thing for us to see what can we expand on for that, where else can we put that. And then I'm assuming because you have 50 proposals right now, you can't tell us What all those proposals are. And so, like, I just can't wait to see what they're going to be. And I hope— I know you've said you've talked to stakeholders, so I hope there's been a lot of interaction with stakeholders on what can we do to make this better. And then in our next meeting, I think we'll see some of that. And— but we have to figure out the funding. I mean— We do have to figure out the funding. Because when you look at all of this data, it's great data, and like you said, Secretary Magstadt, we need more deep dives on some of this. Because I looked at the revenue and went, okay, but that doesn't really tell me how much they're getting reimbursed by providers. How much are they getting for donations? How much are they getting from the city? How much are they getting from the county? I think that's a great point. County, and we need more information on several things like that. So I look forward to the discussion we're going to have today and just really encourage everybody listening online, everybody participating in EMS to try and think outside of the box, not how we've always done it, but how could we do it? And how can it be better?

Thank you, Representative. Representative Emery.

So I had a whole list of questions, but I think a lot of my counterparts here on the task force had asked them and gave some really good questions, especially from Marty.

I guess my biggest ask here, our question I guess is from you all, is like, what do you need from us as a task both sides of legislators to help achieve these goals that are listed in this?

Mr. Chair, Melissa Magstadt. I think first off, the attention that has been brought to EMS in this legislative body in the last 2 years I think has been very, very helpful for us. I know Representative Emery, you have brought things forward and started the conversation more than once. I think that is a piece of it that we didn't have before. I think that's really good information. And I think diving into this funding, I mean, the courage that it takes to dive into funding of how do you fund ambulance services and really dive into it is really powerful. Another piece that we have never had before is a $1 billion investment in the state of South Dakota for rural and frontier healthcare. I mean, we might have been able to talk about this 5 years ago, but we would not have had this kind of level of seed funding mechanism to invest in infrastructure. We've never had that and will not likely have that again. So how we steward this and manage this right now is huge. And on our piece, it's how to manage those dollars with good purpose.

Mm-hmm.

So on the backside of 5 years that we We have something that we can lean in for the rest of this time. One of the pieces I was that was real challenging this last session is I don't know if you remember House Bill 1044. It's federal authority to spend these dollars, and I think it was a struggle getting that across the finish line to because you guys have to give me permission to to spend those dollars. I think part of the pieces were it was new. We had not heard about it. This was a new concept, and. You know, using those dollars, what does that mean? And I hope that when we come back again, because we've got to get permission again yet again this year, that maybe because this legislative body is familiar with these dollars and that we're stewarding them well and we bring those to you, that it maybe will be less of a challenge or conversation to have this next legislative session. I think from this piece, I appreciate that this group is looking at creative ways to make sure there's a nurse triage. I'm really interested in that concept and how we can help support that and use these dollars to help develop that. I think that we have some great models already that are— I think of Rapid City Fire and Rescue. They have been innovative, breaking through boundaries kind of folks Yes. Answering some of their own challenges about triage and in treatment at the site with their mobile medic and their community health workers. I think that's a big piece. I think you're going to hear from today, if I— Senator, from Redfield Ambulance. They're answering some of their challenges and they may have some real practical things for you as they are going through some of these and saying, hey, here's Here's the one piece that we really could use some assistance with. So I think now that you're going to be hearing from some of the nuts and bolts of some of these folks that you might find, hey, there's a piece that needs to be fixed. I think of last year's EMS task force, you know, making sure that nurses can serve in ambulance services. That was one of those pieces that came out of it. So I think as we dive through, there might be some of those issues that we find too in the nuts and bolts of this journey over the next 5 years. So I would also ask the body to have that kind of willingness to continue to listen in on these too. I think that— I think we're not done at the end of even this summer. I think this is going to be continuing for quite some time. So hopefully the rest of you will keep coming back over the next 5 years and keep running for election again, and then we have this group of well-informed legislators to help us with this journey. So That's my two cents. Anything else you want to add?

I think you covered it well. I think, you know, asking the tough questions, I think that's the big part. It challenges us. Maybe not ask us the tough questions, but—

Ask somebody else the tough questions.

But, you know, if we really want to build that foundation, we've got to get to the bottom of it. And sometimes that comes just with broader conversations and asking some difficult questions that we may not have been asked before. We always learn something new. So that's all that— you covered it very well, Secretary.

Thank you. Representative Peterson.

Yeah, thank you. I wanted to give some other folks a chance to ask a few questions. I do have 2 more, and maybe it's been approached and maybe it's out there, but do we know how many paid Medicaid ambulance calls there are annually, or if we knew how many there were in '24-'25? Because if we adjust, for instance, a Medicaid reimbursement rate, we need to do $10 times How many calls there are in a year? Do we have that data, or can we get close to that data anytime soon?

So when we're doing our budget math on appropriations stuff, well, I think we'd have to get with Department of Social Services as Medicaid you know sits in that space. But so I don't know if Matthew's is he still in here? Oh, he he just stepped out. Okay, but I think that. Maybe it would be a question for them that they might have the ability to answer.

Thank you. And we've talked about that. We would love to get that number kind of tightened up a little bit as we can move forward with that. And then the second question, my terminology is going to be off on this, but last meeting we talked about the non-transferred calls, right? You make the call, you care for the patient, and then you make a determination. Do we leave them at home and not get any money, or do we haul them into town because they need more care, etc. Have we made any progress on the idea of getting some reimbursement for those calls without having to haul that patient to a hospital? And if we haven't, is that something that this task force is going to have to put into a plan, or can we just take care of that administratively?

Mr. Chair, I think the 2 pieces of treatment in place is what you're talking about is the reimbursement to treat in place and the allowability to treat in place. And so there's the piece of allowing it and there's the piece of reimbursing it. But I would also say that even if it's a Medicaid reimbursement piece, there's also other payers that are part of the mix too. And so it's not only just treatment in place allowed, treatment in place reimbursed, treatment in place reimbursed by multiple payers as well to consider.

Mr. Chair, hold on one second. Yeah, but I'll come to you next. Yeah, Commander, can we wait till after we kind of get some of this or for treatment in place? Okay, why don't we kind of— okay, let's— yeah, let's hold on that. We'll make sure we get a chance. Oh, I'm sorry, I'm going to go to Representative Fosness. He's kind of in line.

Okay, just to comment on what was just said, just a comment, not a question.

You go for it.

Um, last meeting after last meeting, I met with Lieutenant Governor Venhuizen, and he said that we could do— we would have the authority to do something with treatment in place already administratively as a legislative body.

So we could already address that. Thank you. Representative Fosness.

Thank you, Mr. Chair. So I was just looking at Senate Bill 89, why we exist as a task force, and there's, you know, there's 5 things in Section 1 we were to do. 2 of them happen to be essential service related. One is reimbursement for EMS services. But the 5th one I want to talk about is, it says specifically, review planned expenditures of the Rural Health Transformation Program and evaluate opportunities to incorporate the funds into EMS funding strategies. Okay. I'm going to ask a tough question.

Okay.

Relative to RHTF, are we looking at true I mean, is it 75% of these dollars, if you were to throw a dart at the board, that are going to go to impact EMS, whether that be in the form of equipment, training, some sort of seed funding, you know, maybe new ambulance, for example, or technology within an ambulance that all ambulances can have? Is it things of that nature? Is there 75% of the RHTF money going to that? Or the really tough question, how much of this is consultant payment? Is there anything that we— because it says we're supposed to review planned expenditures of the Rural Health Transformation Program. So I'm not— this is not a gotcha. This is just maybe plays into Secretary Magstadt, some of the— some of a comment you made about some of the apprehension and just appropriating the funding. What I heard in the hallways is fear of, you know, these dollars turning into ongoing expenses for the state. And so if it is true investment in technology and in equipment, et cetera. I want to know how that impacts our, specifically our rural ambulances across the state, and what percentage of these funds in this first year are looking to help with that. And maybe that's a tough question, but I think we're challenged to ask them.

Mr. Chair, that's not a tough question at all. Absolutely, I know the answer to that. So for administrative We were allowed up to, I think it was up to 20% administrative costs. We're using, in the state of South Dakota, doing about 3% for administrative costs. Other states have hired 15 to 20 people. We've hired nobody. Because we know at the end of 5 years I have to give the pink slip to everyone who I hired for this and let them go. Other states did things differently. Some have designed programs at the state level and pushed it down. We actually put the RFPs out and said, what ideas do you have? So every idea that comes to us is not a forced from the state down, you must do it this way. It's, here's the guardrails, here's what we have to accomplish, how is it going to happen? And there has been no shortage, to your point, Representative Weems, of exciting innovative things coming from health systems, critical access hospitals, nursing homes, chiropractic clinics, Ambulance services. Ambulance services. I mean, the amount of creative, innovative things that have been waiting on the shelf for funding, and it's an abundance of in the state. Now, one of the things that we're looking when we get an application, an RFP response to our opportunity, we're looking at outcomes. Who are you impacting? And the third one, sustainability. Because it was made very clear, and I completely agree with this, is that we do not want to create things that we have to come up with the funding on year 6. Because in year 5, 4, 3, 2, and 1, we created this monster that now has to be funded. There are ideas that looked like really good ideas that we did not fund and said no to because they did not have a sustainability plan. And so everything that happens with these rural health transformation funds, the question we ask ourselves and we make it very clear in our opportunity that if you do not have sustainability, then we cannot fund this. Not to say that you can't come back next year and come up with a better idea, because we still got years 2, 3, 4, and 5. But sustainability is a very big piece of that. And the federal government made that very clear. When our project officers were on site with us this summer, they made that very clear. We have translated that to those who are asking for those dollars. To make it very clear as well. And some of these things are equipment pieces that are the one critical mammogram piece of equipment that needs to happen at a critical access hospital to keep mammogram services local. Some, it's technology builds. And so it's this software, electronic health records that allows information to be transferred from the EMS services to the hospital seamlessly. And some have been investing it into an infrastructure build. The maternal and infant child health hubs are a piece of this. This EMS regionalization is a piece of a one-time infrastructure build. So there's all different varieties that I've seen come through. Now, transparency. When this is all said and done, everything must be displayed on our website. This is a transparent and open government. That there's nothing I can hide from you of who did got who did not get funding or who didn't or or who got funding. That is all transparent on on open.sd.gov. Everything has to be brought out this. Now, open.sd.gov can be an daunting website, and so in our on our ruralhealthtransformation.sd.gov website, we will be releasing all of that information, and there will be a map. Of the state of South Dakota on where all of these things went. So you'll be able to see what came to your hometown. You'll be able to see what came to someone else's hometown. And it will be very transparent on there. So I think that map will be really telling. And what I've seen in the fundings of not only EMS but the TEC grants and the maternal health grants, all of those things, is that It's spread out over the entire state. I can guarantee that in your area, that someone in your district benefited already from the Rural Health Transformation Funds that we have released. Now, I can't let you know all the secrets of that yet until it's made public and we sign the contracts. But the minute we can do that, it goes on there and that map will be interactive for the rest of the 5 years of where that funding went.

Great. Thank you. We're heading up on lunch. Maynard, just got a quick— why don't we go ahead and bring Maynard up now? When we come back, we are— Eric, are you in the room? That's what I thought, back there. You're kind of behind the post. So we're gonna have a presentation. I think it's what you were talking about, Representative Weems. But Maynard, do you want to make a comment on treatment in place? And then I just kind of got a comment as we head into our— the rest of the afternoon.

Thank you. Maynard Konechne from Kimball representing the EMS Association. As far as TIP on Medicaid, the state can work on that and increase that. But Medicare, it's on a national level. And being an advocacy coordinator for the state of South Dakota with the National EMT Association, We are working strongly. There is an avenue that Medicare could put this in without legislation, but they have not moved on it yet. About 9 months ago, I think it was, or so, maybe about a year ago now, coming up 9 months to a year, they asked for services in South Dakota to support Tip, and I believe I had 88 services out of the 127 that signed that letter. And we sent that to the National Medicare Office along with other states, and they have not acted on that at this point yet. But we are working on that. One of the things that come out in a class I took too, and other people have taken, is. When we do a treatment in place and we don't haul the person, we can still bill Medicare and get a denial letter. And maybe the more of those that are done, it will tell them that, hey, this is happening. You need to support those services and increase and do that tip that they're asking for. But the legislator in Washington can go ahead and do this also. And there are a couple of bills out there. I don't have the numbers with me, but encourage them to support that on the national level that they would pay for that tip. There are some insurance companies that do pay for tip, but not all of them. So you can bill and see where they go and go from there. But there is— it's on the national level as far as the Medicare goes. Great.

Thank you, Maynard. Okay. As we're going to have lunch until 1:30, give everybody a little bit more time. So I know it gets kind of stressed and we've been doing really good on time. Pretty satisfied that we're going to have some good time for discussion. Representative Emery asked what can we do as a legislature. I think that's what we really have to think about. What do we want to do on this concept? We talked about what we really— it's to regionalize. I don't think regionalization is where— but what we're talking about is how do we get to that point of getting regionalized? Because we sat here today and even got— it got more complicated in the data that we're given. And you start bringing that down to a smaller area that where they can figure out the information, what to do. Think about the benefits of that. My question then is, what needs to be put in for a structure? To make sure we can get there because there will be labor involved. We're going to have to have some labor involved in that. Is that something short-term that at least we can do short-term with the funds from the Rural Health Care Transformation Funds? Or is it something we need to build in right away into a budget? But we can't just do this kind of, you know, just say, well, here you go, you guys all figure this out. And we don't— we can't— we got to fund it, right, if we do that. So these are things to be thinking about. Yeah, I think those were the main things I had there. I just kept writing down governance. How is this going to be governed if we do have these service areas and then these greater service areas, and how can they work together? So with that, we will come back to order at 1:30, and I thank everybody for some great participation and great information this morning. Good afternoon, everyone. Thanks for coming back. We will go ahead and get started again for the afternoon with the Emergency Medical Services Funding Task Force. For the agenda, we had down at 1:30 continued discussion of regionalization of emergency medical services. We pretty much got that taken care of, although we may have more discussions what's now slotted as the 3:30 time. So we'll be able to get started earlier with a presentation on emergency medical services and Spink County. And so Eric Schueth— close enough. You say what you— you go ahead and introduce yourself. He's the director of Spink County Ambulance Service. And this will also kind of work into the concept of these service areas and what can be done, a lot of what Marty talked about. So go ahead. If you just introduce yourself and then go ahead with your presentation.

Well, thank you, members of the committee, for having me here today. My name is Eric Schueth. I'm from Redfield. I'm also the EMS Association District 4 president. So I'm going to just do, at the beginning of this PowerPoint, just a little background information about Spink County so you guys can kind of get a feel of kind of what we've been doing or our service area. And then I'm going to talk about kind of the things that we're kind of moving forward with. So if you don't know, Spink County is up in the northeast portion of the state, 40 miles from Aberdeen, 70 from Watertown for a reference point. In our area, we have 5 colonies as well that we service, and 1,500 square miles is Spink County. There's 2 transporting ambulances, ourselves based in Redfield and Conde Ambulance in the northeast corner of Spink County. Our ambulance structure is probably a little bit different than what you guys have probably seen before. We are, and this is a mouthful, city-owned, Hospital-based, and county-managed. So we have 3 different people in the game here. So the fiscal responsibility to purchase a new ambulance is part of all 3 entities having to pay a total sum. So, and just a little information about our pay scale. We are a paid volunteer, 24/7, 365 service. Paid volunteer means that you get paid while you're on call, but you volunteer for the shifts that you do. How we do that is basically anybody can pick up as much or as little as they want to. So we have an on-call rate of $6 an hour. If you're an EMT basic, it's $35 an hour. And advanced EMT, registered nurse, or paramedic is $40 an hour. Those hourly rates are all based on if you actually go out on a call. So this is our actual call coverage area for Spink County. As you can see, this is part of our trauma transportation plan, and we're broke up into 3 zones. Zone 2, if we're up that portion of the county, we go to Aberdeen, either to St. Luke's or Sanford. In the Zone 1 there, that's usually we take them back to Redfield. In Zone 3, that's the southern part, a lot of those patients go to Huron. So we transfer to a couple different places. As an ambulance service, we're staffed 90% of the time ALS. What ALS is, is Advanced Life Services, which means an IV can be started by the provider. We ran 565 calls in 2025, and in July of 2026, we were at 350 with an average response time from in the ambulance or getting to the ambulance to leaving the garage at 5.2 minutes. So this is just a graph. This is from Justin Faber and Faber Analytics. They provided us with this information. As you can see, our second referring hospital is 40 miles away. Our third leading one is 172 miles away. So we go a lot of different places. And here's just a list of the towns that we go to and how many runs we've had there in certain years and year-to-date. This is accurate to July. Just a little bit about our service because I like to brag on them. We run 3 ambulances. We have 32 staff members. Out of these 32, probably about 16 of them do take full-time call. And we have this nice EMS facility with 14 members staying there during their shift. The reason I bring this up is if you see below the towns that are represented on our crew, That's gonna make a difference here in the next portion of this conversation. So this is inside our building. Very nice facility. 3-stall garage, stairway for training, utility room, training room, laundry. This is our training room. We hold our EMT classes here. We've had as many as 60 people in here for a hospital training, critical access hospital training with us. Our living quarters for our staff, and each one of them has their own— we have 3 bedrooms, and each one of them have their own bathroom in it. So very nice facility. What came with that was we had $300,000 that we raised as a crew. We did a 911 jackpot, kind of like the Chase the Ace that Faulkner had, and we raised $249,000, and that was a split pot. So Our building also holds community events, blood drives, flu shot clinics, CPR classes, EMT classes, heart and stroke screenings for the community. This gives buy-in for people. People come see our facilities, they like what they see, they might come back and be EMTs. We get ourselves out there in the community. As you can see right here, this is a large class. We had 20 EMTs 2 years ago. 14 of them passed. 14 out of 20. And we actually had 4 from a colony, which is very big. It was a husband and wife and 2 other members. So they respond and they go to Faulkton, and Faulkton has had nothing but good things to say about them. So we've also produced 2 paramedics out of these 29 students in 4 years. We also do clinical ride time for the School of EMS. Lake Area Technical College, Beadle County EMS, and we've had some members from Sanford EMS class also reach out to us. So this is kind of the meat and the potatoes of the whole presentation. This is why I'm here. How do you make 15 minutes to life possible with such a wide response area? Within 1,800 square miles, how do you make 15 minutes to life?

We are—

we have 2 major highways, 281 and 212, that run through Redfield. If anyone's ever went to Aberdeen on 281, there's Highway 20 right there where Millett and Northville is. There's a lot of accidents at that intersection. It's a very dangerous one. I'll take it back. A couple weeks ago, we had an accident up there. We are 20 miles away. Our responding unit was there in 7 minutes. We had an anaphylactic emergency. A guy got stung by a bee. Never had an anaphylactic reaction. Didn't know he was allergic. We're 25 miles away. Somebody was there in 7 minutes. And in that 7 minutes, that guy was starting to go black. He started to— his vision started to blur. He was sweating, very diaphoretic. One of those responders brought an EpiPen.

Wow.

EpiPen resolved the issues. We got there. We took him the rest of the way. I want to go 10 miles south in Tulare. We had a patient that was in cardiac arrest. One of our EMTs was out walking her dog, heard the page come in, goes to the house and starts CPR. Ambulance is driving. We're 10 minutes out. There's a train running through the middle of town. You can't get to the residence. That patient was getting CPR already by a member of our crew, and they obtained ROSC on the way back to Redfield. So is 15 minutes to life possible? Absolutely. It's how you strategically place it and how you're willing to do things. We're not the first place that's done responding units before, and we won't be the last, but we took our own special spin on it. So I give a lot of credit and I'll talk about them here a little bit later. So Wildcat Rescue is considered a secondary site of the Spink County Ambulance. What that means is they're a non-transport unit and they're a first responding unit. However, being a secondary site for us, in the future, if they get people who say, okay, let's get a call schedule going, we want to fund this full-time, we want to be on this service full-time, answer the call. They have that opportunity then. In the case of mass casualty incident, they can transfer patients to us. We can call and say, hey, bring the ambulance down. We need to get these people to places. So... So this serves the communities of Mellette, Northville, Brentford, and Mansfield. They started getting some revenue for providing standby for the Northwestern School for football games. That was their first revenue that they had. That was generated by the ambulance. The second revenue they had before they were county-funded was they had pull tabs at the local bar, and each dollar that went in that pull tabs machine went back to the ambulance service for those members, so they don't have to pay for gas out of their own pockets. They are generating revenue. They've done— bartended at local events to try to raise money as well. These guys really took it upon themselves to get the funding they need to provide for their communities. They also respond sometimes to Conde's ambulance district when they are short. So how Wildcat Rescue kind of came to be. I'm going to talk about him a lot. He deserves a lot of this credit. His name is Austin Fishback. He is from Aberdeen Fire and Rescue. He is a Mellette, Northville native and he was working at Fire and Rescue when I went and did my paramedic ride-alongs. We met, we kind of talked, and eventually we started teaching EMT classes together. Well, we started getting some more people from that area that started taking EMT classes. And Austin having experience with responding units working for Aberdeen Fire and Rescue, it was kind of a no-brainer. Like, hey, let's see if we can get this going here for Our citizens. So we were able to do that. We took our idea to the medical director at the time, Dr. Matthew Owens. If you haven't heard of him before, he was a very big advocate for EMS in the state of South Dakota. He really wanted to get out there and teach people just basic things to sustain life. And this can be his Dakota Responder Program. which includes stop the bleed, Narcan administration, AED placement, and EpiPen administration. Basic things that people could do. And this was initially tailored to rural co-ops, AgTegras, anybody that would be on the road that covers a lot of miles. They would have these kits in their car and they'd be able to first respond and possibly save a life. So as of This last year, we had 250 people trained in this training. So a lot of people. Initially, before there was Wildcat Rescue, our sheriff's office would just call individuals on a call list and say, hey, there's a call in your area. Can you go to it? They would call us back and let us know if they were there or not. This has all changed and we'll get to that on the next slide. So right now on Wildcat Rescue, there's 11 members. These members are volunteers. They get a call, they go, no questions asked. There are a couple of them that are part of our crew in Spink County. There's a couple of them that are also part of the crew in Conde. But there's one paramedic, one registered nurse or nurse practitioner, So you might get an NP that comes on the scene, which changes your whole scope of practice. One registered nurse who is also a paramedic, and then one just regular registered nurse, and 7 EMT basics. So now you have 11 people in your community that might get the first responder call to an accident, to a cardiac arrest, to all these different things. You have 11 people now. That might show up and start the process before an ambulance service gets there. Within that 15 minutes, they are gonna have somebody by their side. Wildcat Rescue took it upon themselves to become their own 501. So they obtained nonprofit status. They went in and got that done as well. Just so that way, they can be able to keep doing this type of stuff, have a bank account. They took it upon themselves to hold their own regular meetings for continuing education to keep their crew trained And what the newest stuff in EMS is. So everyone's operating under the same set of things. They also come down to Redfield with our crew and we will all work together. And we all get our continuing education. We keep people in the field. They established their own leadership committee. This was voted on by the members. They are creating their own bylaws. They have their own elections every 2 years. And they're in the process of establishing a governing board made up of stakeholders in Spink County. Excuse me. This includes our emergency manager, our sheriff, the— so this would be the Northville Fire Department chief, myself. They're in the process of getting this worked out so everybody knows what's going on in that part of the county. Very big deal. Not a lot of places are doing it this way.

Thank you.

So how they operate. So I previously mentioned they used to just get a call from dispatch and say, hey, you have something going on in your area. Can you respond? Yep, I can, or nope, sorry, I'm out of town. Now they have 11 people. So what they did was they use what's called a mobile dispatch and they run it off the Northville Fire Department. So they get pages on their phone. So they know when there's a call. They operate under the medical license of our medical director in Spink County. We're all under— operating under the same person to be able to do the same things. They use the same policies and procedures as us at the Spink County Ambulance. Now we're all together. We know what we can do. We know what's expected out of each of us when we're on the way. They respond and provide primary care until we arrive to transport the patient. And we're gonna get to their equipment that they have here soon. Members can be utilized by Spink County Ambulance to assist with care and transport of patients. One time we had a car accident on Highway 20, just to the east of town, and we had one of their EMTs drive. We had a registered nurse and 2 paramedics in the back. We had enough hands to care for this patient. And everybody's doing a different job. And that's all because we work together, we trust each other, we know what's expected out of each of us. And each member of their crew has ImageTrend account so they can do their own patient charts. How does this help us? Let's say they get a lift assist at 2:00 in the morning. It takes us 5 minutes to get to the station. It's going to take us 20 minutes to get there. They're there in, let's say, 7 minutes. They get the patient checked, picked up, checked out. They don't want to go in. They call us back and say, hey, go ahead and turn around. You can go back to Redfield. We turn around and come back. How we work at the ambulance in Spink County is every time we leave city limits, we have to have a backup crew. We have to have 2 members, 2 more EMTs on a second ambulance in case another call comes in. Well, now you just saved it from having to possibly find 2 people in the middle of the night and hope they answer the phone. And you get our crew back in service quicker. Members of Wildcat Rescue then, they get on their ImageTrend, they complete the patient chart, we get the paperwork, we turn it in, it goes down as a refusal for us, and everybody goes about their day. So Just another way that they operate that kind of helps everyone to keep EMS services up and going with no lag time in between calls. So like I said, they're activated in conjunction with us. They're on the Northville Fire Department e-dispatch software and receive an alert on their phone. What they used to have to do before they got an ambulance that you saw on the first slide, was they would have to go to the fire station in Northville, get a fire truck, and then drive to the scene. Or if somebody was close, they would just drive their own car there and let each other know what's going on. Now, they have a fully furnished ambulance that they use. One person— or they meet at the station now, they drive to where it's at. There's no congestion on scene now. There's no additional vehicles that can mess up an investigation, and here we are. So there used to be multiple medical supplies in their towns. So you didn't know if somebody's going to go get the bag in Mellette, somebody's going to go get the bag in Northville, somebody has a bag in their car. Now all their supplies are in one vehicle. They're in one central spot to be able to go to. But to get to that point, you had to get buy-in from numerous agencies and departments. You had to have the Northville Fire Department say, yes, you can be on our dispatch service so you can get this page to go help our community. You had to get the Spink County Sheriff's Office to say, yes, we will dispatch you out to these calls so that way you can get there first. You had to get the buy-in from not only our ambulance but our hospital that says, yes, you can operate underneath our medical license and be able to work to help better our patients in our county. You had to get a lot of buy-in from everyone. I also give a lot of credit when we talk about the medical supply caches that they had on hand. A lot of that came from Corolla Lauck at SD EMS Children's. If you had people who lived farther than 10 miles from your ambulance service, you can apply and get a bag. And in that bag is full of medical supplies that you would need to care for a patient. And all it took? You just had to apply. That's a big deal. That's a lot of money saved by not only these services, the responding units, from having to pay out to get that stuff. It's equipment to treat these patients. So the equipment that they got, that ambulance that you saw, when Spink County Ambulance was Supposed to get a new ambulance in April of 2025. Ambulances don't go for very much, refurbished ones, if you haven't seen them before. That's why they might end up as electrical vehicles, service vehicles. They don't go for very much. So instead, taking the minimum amount of money we were going to get for a trade-in, we said, no, let's surplus this ambulance and get it to Wildcat Rescue so they can respond. And that's what we did. They got radios from the emergency manager in Spink County. That way they can communicate with dispatch, let them know they're on their way, and they can also get a hold of us on the ambulance and say, hey, we're on the way, we'll give you our baseline vitals when we get there, or who's on the call, we'll call them with information. The good thing was Wildcat Rescue did have some equipment. They had their own backboard extrication equipment in their fire vehicle. But at Spink County Ambulance, we were able to provide some supplies for patient care and ability to restock supplies when they were used. We don't want them to have to pay for something and try to keep their costs down. So if you use some gauze, some ACE bandage, here, take this. That saves you $10. $10 can go a lot of ways. Could be 2 gallons of gas, 2 gallons of diesel. And one thing that we did was in 2022, when the state did the LifePak initiative, state got $11.6 million to give out new LifePaks and services. Spink County Ambulance got 3 new LifePaks. Instead of saying, hey, we'll send you all 3 of 'em back, we just asked the question, can we resurplus these LifePaks?

Yeah.

We got the blessing from Will at Stryker and they said, yep, go ahead. So what we did is we gave Wildcat Rescue one LifePak and we gave our volunteer responder in Doland, which is 20 miles to the east, we gave him a LifePak too. So that way, now he's got an AED, he's got blood pressure, he's able to do these things to get patient vitals before we get there. Then when we get there, He prints us a strip, we get the report, we get their vitals, and off we go. So, there's a lot of good things happening in the state that you guys might not hear about. Willette Stryker is one of them, I just talked about. Getting the LifePak initiative, being able to send these vitals to places, to your next stop, so that way they know what's going on. Sending these EKGs to Avel Telemedicine in Motion, so a— That's a great example. So a trained physician can read these strips and give you a read on the TV that's in the corner of your ambulance that says, yep, this is what's going on. It helps guide your next steps to treatment. These are big deals that's going on and it's not going on anywhere. It's going on here in South Dakota, which I give those people a lot of credit. So we have some mutual aid agreements out there already. You guys saw the chart earlier where Spink County is located. Around us we have Clark County, Conde Ambulance, obviously in Spink County, Hand County, Faulk County, Wolsey, and Huron Ambulance. We have mutual aid with all these people because there might be times where we are ALS staffed and some of them might not be, and we might need to intercept them. We might have to get in there, start a line for them, maybe give glucose to a patient. Maybe that saves their life if we're able to do that. So we have these mutual aid agreements with these services to help them provide the care for not only us but for their patients as well. We also have Aberdeen Fire and Rescue and Aberdeen Ambulance in our trauma transportation plan in case of mass casualty incidents. I can't tell you how many times I've called Aberdeen Fire and Rescue and said, hey, We got a bad crash or we have something going on. We have one paramedic, but we might need 2 because we don't know how many patients. And they say, where's it at? How— we'll be there in 10 minutes or 20 minutes. Having those type of relationships around are huge, especially in the rural setting. You just don't know what you're going to have on each crew. So when this came out a couple years ago, Or last year about the regionalization for EMS in the state. We kind of took the bull by the horns and said, okay, let's get ready to do this. This is going to happen. Let's start doing it. And how do we do it? Let's reach out to the people we have mutual aid agreements with already. That's a good starting point because there might be a possibility we all end up in a hub together. So let's just start talking. So we held our first meeting On March 27th, 2026. So barely into the year, we started talking to these people and say, hey, this is what the state's looking at, this is what they're looking for, let's introduce ourselves, let's see what we can do and kind of form a plan. We met additional times in May, June, July in preparation for the RFPs coming out to say, okay, what does everybody need? How can we make each one of our services successful? What equipment can we get in case we all get hubbed together? What can we do to make us stronger together? So things we talked about. We call ourselves a coalition just because regionalization was kind of long and let's just go coalition for a little bit. So some of the discussions that we had was equipment purchasing as a group. Going in together on an RFP and saying, okay, what do you guys have here? What works well there? Okay, you got Lucases? We all do. Perfect. Do you have a power stair chair? This one does, but this one doesn't. Okay, let's see if we can get you a power stair chair so we all do the same thing in case we all go to the same incident. We know how to run each other's equipment then. The power cots, essentially. Training equipment such as mannequins to share between all parties. Mannequins cost, you know, you can get one for $20,000. You can get some that are interactive for $100,000. So you say, okay, let's look at these big mannequins and say the buy-in is $20,000 apiece. Or if we get it as a group, we can figure out where to store it. Everybody gets a chance to use this mannequin together.

Okay.

You say, we have a training this night, we need the mannequin. Perfect. We'll do that. What goes along with that mannequin is continuing education. Keeping all our staff trained in the hands-on skills as well as getting the continuing education hours. So we said, hey, we have monthly meetings. Why don't we invite each other to monthly meetings and you can come up, you can train with each other. You have the mannequin here one night. Maybe our staff wants to go there and run on the mannequin for a little bit. That's the biggest thing is trying to keep your license current. For the National Registry, it's 40 hours that you have to get if you want to keep that. For the state, it's 20 hours. If you go to meetings, you might get those hours, but you might need continuing education at the end of the year. We talked about EMT class sharing. Sharing of instructors. There's going to be a time here in the next couple years where you have to be a certified instructor to teach an EMT class. So we said, okay, if we share instructors, we might be able to share one person who's a certified instructor. We have 3 certified instructors. And now you're able to share that instructor, share their knowledge to different groups of people, people that they specialize in, an area that they really like to teach. Now you have different perspectives from different agencies. Sharing services to provide ride time. We talked about the different places that we have agreements with and people that come to us for ride time. So being able to, you know, we might be a busier service than another place. Well, come to Redfield. We'll get you some ride time. We'll do what we can. Get you some training. And just an opportunity to support each other with providing staff with advanced education certifications. When we talk about this, we talk about Possibly doing an advanced class this fall. So you go from EMT basic to the next step up to an EMT advanced where you can start IVs. We talked about maybe getting an ACLS class, Advanced Cardiac Life Support, being able to take that course somewhere. A PHTLS class, which is a Prehospital Trauma Life Support class. We might be able to have instructors here to teach that to other crews. So that way, they can look at things from a different perspective when it comes to these scenarios. Policy and staff sharing. It's hard to get a medical director on your ambulance service in some places. They made it so nurse practitioners can be medical directors. So, what if we all share one? And these medical directors say, okay, all of us are gonna do this for protocols.

Okay.

You guys are gonna train like this. If you're gonna do medications, this is your dose, this is how often you can give them. And we all meet together and do consistent policies for patient care. Everybody functions as one. One band, one sound. We also look at QA/QI with the medical directors. They look at our cases and say, okay, why did you do it like this? Not saying it's wrong, We just want to be able to show everyone's thought process. Everybody thinks differently. So maybe that's something we can do as well. And then the biggest thing that everyone always talks about, everyone always thinks about technology. The latest— one thing we talked about is the latest in charting systems to ensure patient care reports are done on time. This would be getting an upgraded ImageTrend so that way you can do reports offline.

Okay.

The state requires them to be done in 72 hours. Now you can get it done in 48. Or you— before you leave the station, you log on, you get your report done. That cuts down on waiting to bill. That cuts down on just the continuation of care all around. With this ImageTrend software, you get the ability to send vitals from your LifePak To your image trend. What that means is you're not writing each vital down and writing it down on a piece of paper, then retyping it in the computer. It's one step. You press a button, it's in your computer, it's ready to be charted on and confirmed. You can do calls. You can write your reports on the way home from calls. And in the future, I know the state's working on it as well, being able to integrate with hospital electronic records to show outcomes. and provide the best care. A lot of the hospital runs on Epic, the software. Well, now you can transmit into your hospital. That goes in the patient chart. Now, when your doctor looks in your chart and says, you had an ambulance ride here, what was going on? They click in it and your stuff is there. Now the hospital knows what your past medical history looks like. So, just things that this coalition has thought about and kind of tried to be forward-thinking.

Thank you.

There's gonna be changes. And honestly, this is a field that if you don't adapt, you're not gonna go very far. You need to adapt. You need to stay on par. You need to be able to provide the best care to patients that you can. And that's what we're all trying to do. As Dr. Owens said before, was we're just trying to save lives. And I think that's the ultimate goal here. And However way we can do it, I think is going to be best, not only for our counties and our places, but for the state as well. So again, thank you for letting me come today and kind of talk about what we have going on. And yeah, any questions you guys might have?

Great. Thanks, Eric. This is good. Really good presentation. A lot of hard work and a lot of benefits that you've created. So that's, that's awesome to see.

Committee members in the room, I just want to see the slide again of what area you're covering, that you guys put that together on your own?

So this was in place— this one are you talking about?

Well, this one and then the one where you're collaborating with everybody.

Yeah. So this one here was kind of— this one's kind of been in place for quite a while. How this one kind of came to be was Rockham and Zell are closer for us to go to from Redfield than it is from Faulk County and Faulkton. It's going to take us probably 15, 20 minutes to get to either one of those, where it may take them 35 to 40. So we kind of said, we'll take that area and be able to respond to it. Um, we also go to Mansfield, which is the county line, and it's kind of a coin flip. If it's on the north side of the highway, it's Aberdeen, but if it's on the south, it's us. So, and then we also go to, at the bottom there, Highway 20— I think that's 28— that is, um, Hitchcock. So kind of the same thing. If it's north, we go. If it's south, somebody else goes. We are kind of different as well. We have 2 paging systems. We have a 911 system and a hospital system. Hospital is primarily used for some patient care to nursing homes and taking back or for transfers. But there are people that call the hospital directly and say, hey, I need the ambulance. I live at this place. And it might be, you know, down past the county line, but they called us. We only get We're the only ones that got the call, so we go. And then how we came up with our kind of coalition area. So, Huron, Wolsey, Iroquois, and Wessington, they're all part of what's called Beadle County EMS. They all kind of formed together so that way they're functioning kind of together. They were already in place. We transfer quite a bit to Huron. We've had some doctors from Huron that have locum worked in Redfield. So that kind of helps us kind of include them in the coalition with continuing medical providers as well. Lake Norden kind of joined when they were on the call with us. But Falk, Hand, and then obviously Wildcat Rescue is in Spink County and so is Conde. But Faulkton is— we have some members of our crew that go to Faulkton. We've trained some EMTs for Faulkton. And Miller, we used to have a relationship, or we have a relationship with them from our previous administrator going there and teaching continuing education classes. So we intercept Miller around Cottonwood Lake. That's kind of where the county line is over there.

So. Is that what you need, Representative Weems? Good. Go ahead, Representative Peterson.

Eric, first of all, great presentation, what you're doing. I could ask you a lot of questions. The first question I for sure will ask is, are other communities, regions doing something like this? I mean, do you have the folks that are driving straight to the— or do other areas have people driving straight to the scene? while the ambulance is on its way, or is this a unique thing to what you guys do up there?

There are some that drive directly to the scenes. There's quite a few responding agencies in our area. Over in Groton, they have one, and Warner also has one off the top of my head. But there are some that they drive directly to the scene, meet the ambulance there. There's actually some services too that are staffed that they go directly to the scene. Somebody drives the ambulance there and then the rest of the crew meets them there and they jump in.

And I didn't know, you know, I could ask this to the broader room if they wanted to respond, if anybody wanted to step up and give us an idea because this is a great— I mean, I live in a rural area. I hate to repeat my background, but this is a great thing that I think could do really good things in the rest of the state too if it's not already being done.

Go ahead and introduce yourself again.

Hi, Nicole Neugebauer. I'm in Douglas County. And we do something similar, not as grand as Eric, but we do that similar thing because we have 2 ambulances in our county, Armor and Corsica. And Delmont, which is 10, 11 miles away, has a first responder unit. And one of my EMT One of the communities lives in that vicinity, another one a little bit further away. But as soon as a call goes out, if able, she goes with their fire department as the first responder unit, and then we bring the ambulance to do the transport of that. But many times they call us with vitals, we— the patient is ready to go by the time we get there. We basically have to load and go because they've did everything, and it saves the patient a lot of time. And then we also transport to, depending on where they're at and who their primary is. We're very close to all the hospitals, so we might go to Armour, Wagner, Parkston are basically our 3 main ones, but it depends on— they're all pretty close to the same, if that answers your question.

Thank you. Anything else? I'll come back to you with— do you want to answer this specific question? Oh, okay.

Maynard Konechne with the Kimball Ambulance. Been director for 30-plus years, been there 52. We do the same thing, only not as broad as what Eric is, but for the last 20 years I've had 2 EMTs that live on the reservation 28 miles north of here. Northwest of Kimball. They have an AD, they have a bag with oxygen, and they actually have our old Lucas. And if something happens in that area, day or night, if they're around, they respond. And now with the VAL, they can actually pull the VAL up if they need to on their phones and talk to a VAL. And then I've also got another EMT that lives half Halfway between them and Kimball, who also has a bag and an AED, and she responds if she's home when she's not in Chamberlain working. And then 28 miles southwest of Kimball, I have another EMT that's got a bag with oxygen and an AED, and he works down there, farms down there, but he does work in Kimball during the day. But if it's at night or on a weekend, why, if He's around why he does the same thing. We've done that for quite a few years in our areas too, so. And we go to various hospitals. Depends on where we're at in our service area. We can go to Miller Springs, Platt, Chamberlain is our primary, but depends on where we're at in our service area where we go.

So thank you, Maynard. Any other questions for Eric?

I can ask another one.

Please do. Go ahead.

A little more broadly, I mean, again, great, amazing model. I'd love to see if we could repeat this other places. It takes a lot of volunteers to do that, and you've really inspired your community, I can tell, to want to do this. I mean, and I hope that we can get some coverage of this across the state. Because maybe there'd be more people interested if they knew they could do something like this. But more broadly, so you're a rural area. Can I ask you, like, how, how was your revenue compared to your expenses and things like that? How are those things going for Spink County?

So ours are probably a little more skewed towards— compared to a lot of people because we are hospital-based. So a lot of the billing comes from the hospital. We don't have to pay A service to do our billing for us. The hospital does all that. Our people are volunteers, or they're paid volunteers, so they don't get benefits. They're on a PRN status, so we don't have to pay any money there. But generally, kind of like everyone, we have the Medicare, the self-pays. We do a lot of—

Referrals.

We do refusals, and the treatment in place eventually will be a nice thing for us, you know, just with the community that we have. I can get you more down-to-the-wire things. I know we did a state review for the state about our finances and stuff last year after the regional service designation grant. So we kind of have some stuff on file with the state that would— Show a little bit more. And we can—

I can follow up with you or anybody else. We might have that on hand too. So because every kind of in the rural areas, the more volunteer-based it is, normally the numbers work a little better naturally. And the more it's paid, the more challenging it is to get reimbursed for the costs. And so I can tell you're kind of a model that has a little bit of both in it. And so it'll be interesting to and see how it's going for you.

Yeah, absolutely. And I know, uh, being able to, to use services and refurbish things like we have to reuse them have really helped with our finances and not having to buy that new equipment all the time. Um, and then obviously using like what Corolla does, that saves us about $500 a bag instead of having to pay them out and buy everyone a bag. You apply for them and that saves you a nice amount of money as well.

Representative Fosness, I think you have a question.

Yeah, just maybe more, more of a comment than a question, but to Eric, uh, you know, Mr. Link and Ms. Keel were, uh, were singing your praises of this model at our first meeting, and I can see why. Um, I'm, I'm your friendly neighbor up to the north in Marshall County, so I've been involved In the ambulance world, but Dade County most recently has had a changeover in ownership. I just heard Milbank is looking to sell. Just learned that Friday. I think there's 6 different ambulances or something that that company owns, and in a large turnover, we're in a lot of communities in rural are in what appear to be dire straits in the upcoming years. What you guys have done is proactive, and you put some teeth to it. And Maybe this is helpful for the rest of those in the room, but, you know, to me reacting to this, just being around it for a lot of years and seeing our own successes with first responder units in our smaller towns like Veblen, for example, Hecla, we had it. So we're in Britton, and so we had those kind of fringe areas that had our first responder units. But what we didn't have was a separate 501 setup. We didn't have the continuing education that you guys are doing. We didn't have the education collaborative.

Right.

With it. And ultimately, those services, I don't know if failed is the right word, but, you know, the ambulance just, you know, broke down, or, you know, or the people changed, right? Or you have systematic changes that I think are going to be, that should be modeled, frankly, for a regionalized— but this is a big, I think, component when it's run right. So leadership matters. I wanted to thank you for your leadership and Seeing this through, and you you passed that on to another member up in Aberdeen that was helpful to you. So Austin, I think his name was. And so you know you guys are doing you're doing it right. And I think this is a model that I found to be very educational for how we can react and get to someone within 15 minutes that needs care in a big geographic area. And so just mostly a compliment and thank you for sharing. And when it's done right, like you guys have done, we can learn from this statewide. And so. If I— okay, I will ask a question. How do we help other ambulance directors statewide understand the benefits of what you guys have done? Have you presented at a state level with this, or is this the first time you've kind of presented this about what you guys are doing? Thanks.

Thank you for your question, and thanks for the compliments. I think this is probably about the This is the 4th presentation I think we've done. We've done one to all the service directors for the state. We started with the South Dakota Healthcare Foundation. We started there, then went to the state, and then had some other meetings. So we've tried our best to kind of get this model out there and just being able just to provide ourselves out there and say, hey, if you guys have any questions on how this is— how we did this or what we're doing, just reach out to us and we're happy to help. It takes a village and it takes people and getting the right people in place to say, okay, let's make a difference. Let's do a change, and figuring out what the steps are. And it might just be you have some people interested and maybe it's not just an EMT class they need to take. Maybe start with an EMR class. So that's a responder class. And then maybe Maybe that piques their interest to go on more. And just getting people the education and letting them know what's out there and what we can and can't do. There's a lot of places that don't know some things that have changed at the state level. And I think that's just educational— education to give to people that you guys can do this now. We can do this. And just don't be afraid to reach out because we might not have the answers, but we can sure find I'm with you on that.

And I want to just again say thank you. Interestingly enough, our fire department is just gung-ho, right? We're crawling with fire department members. EMS just seems different for some reason, but you guys have the recipe figured out. So keep sharing your information, and I know I will be here regionally with the ambulance districts on it. Thank you. Thank you.

Thank you, Representative. Further questions? Representative Weems.

Thank you, Mr. Chairman. Um, thanks, Eric. Great presentation. This is exciting, very exciting. Representative Fosness just asked my first question, so I'll go on with my second. Um, so when I look at this region that you put together, the coalition, are you Are you looking at expanding that even further, or is this kind of where you're sitting? Like, where do you view this is going to go in the future?

Thank you very much to start. You know, we just wanted to start small, and we wanted to forward think of what could possibly be the hub and spoke stuff. But, you know, there's always Aberdeen. They're a great resource to have. Being able to call Aberdeen Fire Rescue and just say, hey, Mariah, I don't have a policy for this. Do you have an idea? And them being responsive to us and letting us know, yep, here's what we got. And, you know, I've had lots of conversations with Clark County. I've talked to Dade County. And just, I've talked to a lot of services. And I don't think— There's no limit. Of what you can do. And I think everybody would— everyone will play ball. I know not play ball, but I think everybody's kind of in it together. Like, we want to provide the best service that we can. We want to provide the best patient care we can. We just might need a little help with it. And we are gladly able to do that and do whatever we can. If that means going there and do education, or if that means, you know, Us having to respond and help them with a transfer. I mean, we got staff that can do that. We're just you know getting the next steps on how we can make this possible to help others.

Good. Okay. I think with that, Van Lee, we're good online. Well, thank you very much. Yeah, this has been terrific. As you can probably tell, it's kind of got us thinking about. You know, I thought it was a good way of after talking about. regionalization that you'd come in and talk about some of the things you're doing. So, so exactly what I was hoping. So I really appreciate your time.

Yes, thank you guys. Thank you for all you're doing as well.

Hey, uh, Eric, can I ask Eric one more— Mr. Chair, one more question? Um, if you have a—

if, if you have the—

that's not Coyote, what's it called? Wildcat. If Wildcat is out and it, uh, sees that you were talking about Highway 20 and, um, say, a motor vehicle, and they react, they're there on the scene first, provide care, and then ambulance shows up and does the transport. There's just one bill involved, right? I'm just getting kind of technical here. There's not a real strong billing mechanism for the wildcat rescue. Is that correct?

That's correct. Yep. There's no billing involved with that. We would take care of the billing from the transfer from the scene to the hospital. In our other mutual aid agreements, we do have on there, if we would intercept, there is a percentage split in there of the revenue of how everybody gets paid out.

I see that, and that makes sense. I mean, I see the other mechanisms in which revenue is generated. I just am wondering if there's— I guess, got my mind thinking of If they're not the one hauling a patient to a hospital for the technicality to get paid, what does it take to drive revenue for sustainability? But I think it has to be creative other things is the answer.

Yeah, and that's kind of why they did the bartending to try to pay some bills. They did the pull tabs to pay some bills. And recently, so Spink County also funds, they give a, A small monetary check to all 3 members, Redfield, Conde, and Wildcat Rescue Now. So that helps kind of also offset some finance— financial issues.

Thank you. Thank you. Okay. Thank you very much. Okay. Our next Item on our agenda is public comments. I think what we'll do is we'll start in the room. This is your time after with all the stuff that we've talked about, all the items we've talked about. If you have any general comments on that, because we're going to go into a discussion after this. So we just want to hear from everybody in the audience that would like to speak. Come on up, and then everybody should you know should register. So if you come up and you haven't, please go ahead and register in the back on the iPad.

Chair, members of the task force, Dustin Willett. I'm the Rapid City-Pennington County Emergency Manager. Here to learn and listen, so I probably shouldn't sit down and speak. But just a couple of things. We do some amazing things in this state and we have some amazing people. I came up in the volunteer fire and EMS world as a paramedic for 17 years, critical care paramedic, flight paramedic. I've been with Rapid City Fire Department for 23 years. The services we have and what we just heard about Spink County and Redfield are a testament to the people that we have in South Dakota. But when I hear, you know, we don't have to pay out benefits, we're paying $6 an hour, $40 an hour on call, the question that comes into my mind is sustainability. How many hospitals, how many clinics, how many law enforcement organizations do we run on volunteers? How many people can work? How do we intend to recruit and retain people without benefits? Without a living wage, so I would just ask this task force to keep that in mind. These are awesome stories and awesome communities and people doing what they need to do to serve their fellow person, which is incredible. But if we're talking about sustainment, if we're building that on the back of volunteerism, I'd be careful going down that path. So Pennington County, 2.7 million square miles, but in Pennington County, we don't have any volunteer ambulance services left. Not a one. They are all in some way, shape, or form paid. So the I would just— I'll leave it at that. I need to learn a lot more. I need to listen a lot more. But I would caution moving forward on the back of volunteers. It's amazing stories. They're amazing neighbors. I love living in South Dakota because of that. But if we're looking about— if we're talking about sustaining EMS service, I'd be careful doing that on the back of volunteers.

Thank you.

Thank you. Further testimony in the room. I wouldn't say your last name. We may call you back up for something else.

So Nicole Neugebauer, Douglas County Ambulance, representing SD EMSA and South Dakota Ambulance Association. I agree with Dustin. I come from a full volunteer service. We do get paid to go on a call as of now. Recently, we've had discussions with our county, and I do not envy you a bit having to make these decisions because it's very hard for them to decide if we should be paid to be on call. We're basically asking that because I have EMTs that would gladly take a call or take call for me, but they can go pick up an extra shift in the next town doing something else and get paid. So it's very hard to keep them in town to be on. Call and it comes up against law enforcement. Well, we can't pay you more than what we pay law, or we can't pay you— I mean, right now it's nothing, but trying to figure that out has even been hard for them. So that's my one point. My second point is sustainability. I understand that with this grant they have not been able to grant equipment, but to sustain a lot of our small rural ambulances. We were declined the $3.2 million we asked for for a Lucas device for every service in the state. And so it's going to be hard for our services to sustain to be doing cardiac when you have one person in the back trying to do CPR and your Lucas device doesn't work. And I don't know how we can afford another one. And last one, just one suggestion. When you were asking, I think it was Senator Otten asking about You know, if everybody responded on those surveys and whatnot. If people have questions, could we not maybe create a QR code or something that's confidential question on how does this happen? How do other people make these things work? Maybe we could ask some of those questions because I know a lot of people probably didn't answer the surveys. Again, they're surveyed out, honestly. And in a lot of our smaller services, the director changes frequently and maybe doesn't always get that updated email. To the state right away, or they just don't have time to answer their surveys. But maybe if another staff member could just say, hey, you know, in my ambulance service, by a QR code, you know, maybe it doesn't go just to the director or just to one person in the service. And a lot of places share directors and whatnot. So just a couple of points. Great.

Thank you. Thank you.

Please just come on up. If you've got— want to add to the discussion, if you go ahead and introduce yourself.

Thank you, Chair. Chief Roland from Watertown Fire Rescue. We are an ambulance service of roughly 40 full-time members, another 4 part-time members, and we run around 3,300, 3,400 ambulance calls a year. So kind of put that From my perspective, and I want to thank Eric for a wonderful presentation in regards to what they're doing up in Redfield area. That's roughly, you know, in 2 months we're doing that many calls or more. So that just tells you how much we're doing in our area. That stated, the cost is always going to be something that is going to be on everybody's minds when it comes to EMS essential service. And all of All of you in this room are— I applaud you for taking the time over the last 2 summers to take a look at this, because this is a big deal for not only volunteer departments, but just as importantly, career departments. We're basically putting out $3.7 million a year in invoices and getting back about $1.4 million. That's just not a lot in contractual write-offs that we're having to do from The mandated stuff through Medicare, Medicaid, like you heard earlier, IHS, VA. And then of course the insurances are writing off a lot as well. And so that stated, the numbers just don't compute anymore when it comes to providing the services in our county. We provide about 730 square miles of coverage in the Watertown area in Codington County. We do not have another volunteer service in our county. So provide protection to more than 17 townships in our, in our county. So, and we also have a lot of mutual aid pacts with the folks from Castlewood, Lake Norden, Clark County, Grant Roberts, which is up in the, the Milbank area that the senator alluded to earlier, that looking at cellins. So in the northeast, we're pretty much the, the, the big brothers and big sisters of that area. So that's As stated, we are just looking at any possible help from this committee to help us sustain financially. So thank you.

Thank you. Scott Larson, Highmore.

I actually work on 2 services, one in Highmore and the one in Miller. And I'll talk about Hand County first. They're a paid volunteer. And yes, they have EMTs that go to the scene. Some of them are out in the country. And they'll go that that way if there's something out that direction, or even if there's a call in town, they'll go straight to the scene while somebody else brings the ambulance. And in Highmore, we do the same thing. We have some that are out of town that go directly to the scene, and the other thing is we also have them. Come into town, the ones that are in town, when there's enough people on the ambulance, if there's one fireman, one driver, and one EMT, we like to have 2 EMTs in the back. And so they go to the scene. The one thing there is, is we need to leave our keys in the vehicles because the fire department will bring them back to the fire hall.

Thank you.

I forgot to say, but Miller's Ambulance Service, Hand County, that's actually a hospital-based service. On June 29th, I got an email from a paramedic from out west asking if we got enough ambulances for our disaster that we had that day. We lost the roof in our— in that storm that was the 2nd highest wind in the state of South Dakota, 5th nationally. We lost the roof off the nursing home. The nursing home staff had gotten all the residents out of their rooms and into the hallways, but We had to get all those patients, or residents, I guess, somewhere else. And she asked me if we had enough ambulances. And my comment back to her was, I believe there's more ambulances in Highmore than there are on the streets in Sioux Falls and in Rapid City together. So yeah, let me tell you what. In a time of need, they come together. The other thing that I'd like to mention is if you guys want to see a paid ambulance service that's really doing a good job, check out AMR here in Pierre. I think it would be worth your while. Matt has done a marvelous job, and Bob Hardwick, who used to be with the state, is his dad. They also brought 2 trucks over there, and then they took call for us for those 2 days, the 29th and the 30th. And then I believe he was there— Matt was there with one of us for the 2 other days.

Great, thank you. Oh, and if you'd sign in, please. And thank you for— or not thank you, but, you know, I think we all have heartfelt, you know, after seeing the damage, of course, you know, when we're heading here to Pierre from the eastern side of the state, how much that is. It's great to hear that people came together, and I always have wondered that, but I was actually in the area and there was ambulances coming from everywhere that were heading that way. So that was good to see. Got some more to add, Eric?

Yep. Eric Sheets, Spink County Ambulance. One thing that I learned from some of our stakeholders at the hospital, this would be our discharge nurse in our home health department. I know the state has talked a lot about community health workers and community paramedicine. One of the things that we have found out in our community is A lot of people call the ambulance just because they don't have a ride. I think what Rapid City is doing right now is right on course where they have people go there and kind of triage them out, or a triage nurse, if you have one available, able to do that. But some of the things for EMS might even be just finding a way to get a patient a ride to the hospital, and if you can get it billed that way.

Thank you.

That is one of the biggest things that we have heard. They just, they can't get to the hospital for their appointment or they didn't make it to dialysis in Huron because they didn't have a ride there and now they're getting flown to Sioux Falls for emergency dialysis. So that is one of the issues that I think is also part of what's going on in the state is just being able to find a ride there. And it doesn't have to be the $800 cost that it is for an ambulance ride. It can be something less. But being able to get patients to where they want to go. So I think that's where the community health worker and community paramedicine will greatly benefit the state in EMS because it is still driving revenue. And if you partner with the hospital and they're able to maybe get on staff or something like that, so you're covered by a medical director, that would be an opportunity to create a job as well to possibly help out with EMS. So that's just a comment from me, from some of the things that I've heard from our stakeholders as well.

Thank you, Eric. No, go ahead, Senator Jensen. Kind of a logistical question.

So if you have, um, if you have a responder, an EMT show up through the pager, they're first on scene, can you roll the ambulance with just an evac driver or Can you roll the ambulance with just one driver, I guess?

That's a very good question. How our crew is set up is we only use EVOC drivers for transfers only. So if we have to go to somebody and we can't find— we're having trouble finding backup, we'll get a driver and then we'll have whatever level of staff that needs to go on the transfer. That way we can maintain 2 EMTs in town to go on the run. I would be lying if I said I didn't go to a scene by myself and jump in with the person that's there, or they jump in with me. They already started the patient care and they just continue the patient care to the hospital.

Thank you, Eric. Anyone else in the room? We actually don't have any. I don't think we have anybody online. If you're online and want to speak, Please raise your hand. I guess with that then, well, come on up, Maynard.

Maynard Konechne from Kimball with the South Dakota EMS Association. Just to piggyback on what Eric just said about The individuals in our small communities that don't have family or anything and a way to get to a hospital or a doctor used to have rocks buses in all the little towns, and that was a federal program. I think that's pretty well fallen away, and those poor people now have nowhere, no way to catch a ride unless they've got a friend someplace. And in a time of need, sometimes they just. Need need help, and we end up having to haul them. But it could be something different if the rocks buses would come back. But that was another one of those programs that got cut through everything else. But that that put a burden on rural communities also.

So thank you, Mayor Stacy. That's online. If you'd go ahead and unmute. And come on.

Hi. Yeah. Good afternoon, Chairman and committee members. My name is Stacie Fredenburg. I work for the South Dakota Foundation for Medical Care. We have been doing an existing program with EMS regional service designation, and then we'll be supporting this ongoing work with the EMS hub development and oversight as the contractor for that. And I just wanted to bring up one more Yeah. And I think one of the rather innovative opportunities that are happening across the state up in Mobridge, that group up there, they have a similar multiple communities that have been working together, but they've been really focusing on the youth in that area. And they have multiple EMTs that are, have, they did a summer camp, and they're also implementing a curriculum that was part of their EMS RST Award, but one of the opportunities that exists there is that one of those EMTs actually serves as a CTE instructor at the school and provides those intro to EMS, intro to healthcare classes for the interested youth in those areas. And then those youth can take their EMT courses, and they become part of the ambulance. Crews, they do ride-alongs, or they become drivers. And it's just kind of a nice integration of introducing the youth to those EMS opportunities while there's still, they might be interested in a future healthcare career, but they can also serve their community in the EMS crew once they hit that high school age, 18 and over. Some of those crew members are part of that. So just something else I wanted to bring to your attention as another opportunity. And I know there's some regulations that are required. Those EMTs have to get certified to be CTE instructors. But job sharing has been one of the things that's come up with the stakeholders that we've been meeting with as well, saying, hey, it would be great if our crew could share jobs with the hospital, or if there was other ways that they could make up the difference so that they could be doing some of the—

Yeah.

volunteer ambulance work, or even part-time as an EMT crew member and part-time supporting, like, as a community health worker, or having a position within the school where they could be doing some of that CTE education. So another example of great work being done within the state, and we're really excited to hear more of these stories and find a way to share these ideas, like Eric was mentioning. Our EMS Extras webinars is one of the ways that we've been spreading the word, and we're trying to gather the shared policies. Cadet programs is another thing they've been doing, sharing all of that documentation to make it easier for others to implement. So thank you for your time today.

Thank you, Stacy. Okay, time to move on to our discussion and To give some direction on where we want to go as a committee. Let's go ahead just so we don't lose folks. Maybe walk through, you know, planning on two more meetings. Would like to have one about a month from now. Four days work out well so far between Matthew and I. Then I think I'll put see how everybody's doing. So I know this is a little tedious to do it this way, but I. We just we got to get it done before we before we move on. So get your calendar out, Representative Peterson. You ready to go? And then everybody else kind of take a look at these days. So for our next meeting September the 21st and 22nd, the 28th and 29th. They're both Mondays and Tuesdays.

28th and 29th.

I'm out. Okay. You're right. Like I said, if you're out, we need to know. So. How about 21st and 22nd? Is anyone— I'll go online also. Is anybody out for either of those 2 days? I'm out the 28th and 29th. Okay. 21st and 22nd. How about our committee members online? Does anybody have an issue with 21st or 22nd?

Nope. No problem.

Okay, it's gonna be one of those two days. No problem for our next meeting. Work all around.

I'd be okay on the 22nd, but I'd have to be online.

On the 22nd, you have to be online. Okay, well, let's do Monday the 21st then. Okay, well, it works well on Mondays for me. So okay, October, um, the 19th and 20th. The 26th and 27th. We have to be done by then to give enough time for the report for the executive board. So is anybody out on those four days? October 19th and 20th, 26th and 27th.

Good.

Senator Otten.

I think we have 21st through the 23rd to be out. those of us with day jobs, I think that might be a tough week, those first 2 days.

Okay.

For some reason, I have the 21st to 23rd for—

I think that's— is that Governor's Hunt weekend? Yeah.

The 19th is the first Monday of pheasant season.

I'm just wondering if we could pick a different week.

Sorry, sorry, I even thought about that day. Opener. Okay. So either the 26th or 27th. Sorry that I might have tramped on opening pheasant day. What's that? 26th. 26th. Well, that was really easy. Here we are worried about getting this done. I don't think it's been announced yet where it's at. Yeah, except yeah, we can see if comes along, but let's lock in the 26th, right? Okay, we got our two dates now. Now let's get to work. Let's go ahead and talk about you know kind of where we want to go next, and you know especially if we got to give some direction to. Our staff at the LRC, or if we need some information from the Department of Health. So I guess we got a few things that I was looking at that we talked about quite a bit. One of them being treatment in place. Kind of understanding that you got to set it up to allow an ambulance to go to a different location other than a hospital. That's one of the issues that have come up with it. And I also think we just need more research, maybe what other communities are doing. But it seems like something that we may want to bring a bill on. Thoughts?

I'd agree. I'd agree with that's a good starting place to make sure that we allow for payment in treatment in place and then also allow for payment for transportation. Senator Otten.

Since we brought up transport, when they mentioned that, that we used to do a variety of those things, and we start thinking about a diabetic episode and then it jumps up a scale And all of a sudden we've got instead of, I don't know what, let's just say $1,000 to get somebody, which would be high, most likely a whole lot less than that, and then all of a sudden that escalates to $1 million in a cost someplace. I think that we need to really think about covering some of that transport cost and Maybe even— maybe the health transformation, there's another vehicle that could be added to that to help do that sort of thing. You know, part of me bristles at that, that, you know, now we're a daycare center. But that's not really what we're talking about. We're talking about somebody with a definite physical need of getting them to a place to get help to them.

So with treatment in place, of course, we're at the mercy of the federal government for Medicare, which is our largest piece of the payer mix, which is too bad. Doesn't mean that we can't keep advocating for it, and I appreciate all the associations, you know, working hard to see what we can do there with the federal government. But we'd be talking about Medicaid. And then also we should bring in, if it's allowed to be billed, how we're going to bring the commercial insurance providers in on this too. We got to add that to it. Senator Jensen.

Yeah, thank you. I think along with that, we'd have to look at a realistic cost base for that service. Obviously mileage is going to get him. Somebody's in town versus they're 30 miles outside of town. But a reimbursement cost rate because of course if we utilize some of the Medicaid dollars, we also have to be concerned with FMAP wherever that goes in the future. And we'd be tying hands of future legislatures. So we've got to be really careful with that cost base that we set.

Mr. Chair. Go ahead.

And yeah, and just to give a little more background, I mean, I agree And as you know, I've been brainstorming. We've probably all been brainstorming. We need to have parameters in place, right? It's not just like a blanket one-size-fits-all treatment in place. It's got to qualify. We got to work through all those things. And then if I may, since I'm kind of clarifying that, I did also want to clarify on our excitement about the volunteering. You know, we haven't talked about that at all. Just know that I didn't see that. I don't want to speak for anybody else. We didn't see that and go, oh, there's our silver bullet. Not at all. It's just an exciting additional opportunity for our communities because we see a lot of people that might be interested in something like this that maybe that option's not there. They didn't know it's available. So that's more of our thing. But don't think that because we got excited about that at the end that that's somehow going to be our new path forward.

Okay.

Okay, go ahead, Senator Otten.

I guess on my things that jumped up, a mutual aid agreement. We'll have to do something in that arena to put teeth in it to make sure that everybody's going to be complying to that. And even though there is software out there, maybe for the Department of Health To make sure that the state would then pick up the billing on on a lot of this force it and on the up end of paying for that billing surge cost.

So let's dig a little deeper into that. So are you talking about if a service is if a service is going through a you know provider, right, an ambulance service is going through the billing process, that the state would help with that process?

Yes.

With making sure we can get the billing done?

Yeah.

Okay. Okay. And I, well, and we'll come back to that too a little bit when we talk about kind of the concept of how, you know, the whole idea of regionalization, these collaborations, a lot of good words that went around. I think that has to get added to that.

And then the last one would be to think about education in itself. I go back to the wildfire group, Coyote Task Force, and maybe coming up with something to help in that arena of educating.

I wonder if that's not kind of a good grant program to help something like that out. And it's it's wildcat. That way we stop saying coyotes. Just just a personal thing from Brookings, Mr.

Chair. Go ahead. Another idea we've all been discussing for months is just making sure that our our code allows for regionalization of services. You know, service areas. Shared costs, centralizing services, some of these things, we got to make sure that we can do them in our current code. And if we can't, we have to make sure that our— the legal language allows it to be done in the future.

Yeah, I think so. That— yeah, do we have the structure in our code to allow for or figure out some sort of a system for regionalization? And so I think we'll We'll make sure we're working with the Department of Health on how that best looks. Is there anything that anybody wants to add to that as we look through it to make sure that we're thinking of? Because we got 2 meetings. Next meeting we'll bring something forward, you know, that maybe force some changes. But I guess if there's anything that you'd like to see in that, even if you think about a little bit later, let's make sure you contact Matthew. Senator Otten.

I think that within— since we're talking about billing services, I'd like to know, you know, if we went to a regionalization, and that's where I'm at, having Department of Health come up actually with a couple different proposals, you know, 19, 26, 29, whatever it is, and then out of that group Grouping, what it would cost to make sure that we had just the very basic— not— you're still— we'd still be in that phase of using some volunteers, but getting it set up that we've got some actual paid staff in place, and so that we know what those numbers are and what we would have to come with for funding.

Yes, I guess that would Great. We have, if we are going to do some sort of collaboration service areas, greater service areas, yeah, to understand what what that would mean for staffing, and then take into account that we know we got the rural healthcare transformation funds. Does that get us going on this? And then beyond that, you know what what could it cost? Then we'll have to start talking about if there's sources for that because this cannot go back onto the counties or the Services themselves.

This has to be funded at a state level, and I totally agree on that. That a at some point there's going to have to be some mechanism of pay in at the local level. But I'm thinking at least you know anywhere from eighty to ninety percent of it on the state itself to to get that going.

Yeah, thank you. Anything else under the idea of regionalization hubs that we want to do. Mr. Chair, I think that's Representative Hughes. Yes, that's correct. Okay, sorry, I don't have the screen in front of me, so I wasn't sure who was talking.

No, I totally, totally understand. Thank you. Um, just one thing that keeps recurring in my mind is, especially when we're looking at sustainability over a period of years. And as a byproduct of regionalization, the thing that is different to me about EMS in terms of funding is that with respect to the, what would you call it, the destination facilities, there are revenue, they drive revenue for the destination facilities. And I think You know, it's okay to analogize EMS in a way to police and fire, but fires are not a revenue generator for anyone, and neither is crime or law enforcement. And so in my mind, again, and I study the Form 990s for our healthcare systems, and at least with respect to the major Healthcare systems and the regionalization. There's a very logical correlation between the regionalization and existing healthcare facilities, and I just think we'd be remiss if we aren't also looking at the revenues that are generated. Just remember, these are tax-exempt facilities, and the public, by foregoing opportunities, and I'm not suggesting we change that in the taxing structure, but in my mind, it's perfectly appropriate when you're looking at a healthcare system that is generating excess revenues of over $300 million a year. It certainly is not— I'm not shy to make an ask for the major healthcare systems to invest some of their some of their efforts, energies, and funds in developing a first-class regional EMS system. I just think it benefits everyone, because I keep thinking of the handoffs. You know, in healthcare, the concept of handing off a patient often is fraught with all kinds of different problems where there isn't good communication and good coordination. And I would, I would just think, you know, while I appreciate Mr. Rave's comments, um, and I understand that where he's coming from, I just, I don't see that there is a, uh, a consistency in viewing an essential service like fire and police and, and placing a funding obligation exclusively on the government because, you know, our budget As we all know, and as I learned from Senator Otten early on when I took my seat in the legislature, over 40% of our budget in South Dakota is federal funds. And I know also that with respect to the major healthcare systems, over 50% of the dollars that comprise patient revenues are federal funds. That's well established. So I think if we're going to be really good caretakers and provide for long, long-term sustainability once we lose these Rural Healthcare Initiative dollars, we just have to have every— everyone at the table that has skin in the game. And I don't think it's appropriate to simply externalize all of these costs onto the public sector. Because we know we've got all this money. It's kind of like COVID relief funds. Okay, what do you do? You can do all these things, but what happens when, when the funding is gone? So I really would like there to be a focused, transparent study on how patient revenue revenues are driven. By the destination facilities for the EMS services. So thank you.

Thank you. Go ahead, Senator Otten.

I concur with some of the stuff that was said, but with that, I think also insurance, you know, we were talking about that, making sure that that is looped within Within what we're doing, and I had one other thought, but not for this moment, I guess.

Yeah, Mr.

Chair. Go ahead. Is this? It's Nick.

They sound a lot like us here.

You know, to Representative Hughes, I can't speak for the systems, but I can speak that EMS services are owned. In some hospitals, small critical access hospitals too, across the state. And yes, Medicare heavily funds our critical access hospitals, but we run on very small margins, first of all. Second of all, it's not deemed a reimbursable service under the critical access hospital model. So there are inherent problems financially when owning an EMS service in critical access hospital. And so, although, yes, it's Medicare is Medicare, but they are different, and they can actually, you know, in my day job in this county hospital, owning their ambulance service financially would be a detriment to our success as a hospital. And so, and although it can work, and it does in some locations, it is usually better off not tied to critical access. So just a little clarifying point to that. I don't think you were even alluding to that necessarily, to be clear. You know, I think what you were saying is based on 990s from systems that there's some skin in the game on that. But we have to be careful in protecting our rural hospitals.

Yeah. Mr. Chair?

Yes, go ahead.

Yeah, I appreciate those comments, and I was not suggesting that hospitals take over EMS services in any way, shape, or form. But Simply that we factor in the economic realities of this, because again, we're looking at public funds and public benefits. And so I— but I appreciate your comments, Nick.

Thank you. Senator Otten, you talked about insurance. I think what we need to look at Is there a minimum that we want to make sure of Medicare that's paid? Is that a fair way of looking at it?

I think that is a fair statement. I've had this, I guess, just gnawing thought process that a lot of times the insurance companies, they look at what Medicare Medicaid is paying and that percentage, and instead of paying what actually the agreement that they've got with the provider that will provide a service, that all of a sudden what they would have paid now gets deducted to what they can get by with. And so I think we have to look at tightening some of that and making sure that we get that in its proper place.

And then I'll continue on. Do you have something else on that?

No.

Specifically? I think we had a discussion about Medicaid Advantage that we need to understand and how that could— is affecting the revenue model, the payer mix, because in some cases it was half. And we were hearing some issues with that with some providers, not with all, but But with some Medicare Advantage providers. So I think that's important.

I'd agree.

Go ahead, Senator Otten, if you've got more.

Just on that thought process, you— I've got a supplement to mine and I bought the very best that I could get my hands for a variety of different reasons. When you do that and you start getting into that private market of 10 different options out there and somebody chooses the actual lowest part, we've got to make sure that that individual, you know, they've got the skin in the game. That isn't the state's fault. It isn't the hospital. It isn't the EMS. Yes, they did that. And so there has to be some clarification, you know, as you start— we start working down that road, I think. I guess I might as well shift. I think just for everybody, if we try to do this per county, we just— again, we do not have the money. It would bankrupt the state. And so I only see one option for us is to move forward on regionalization. I think that there is savings to be had there. Spink has showed us that there is, and we can take a variety of things off their list and make it work. We still have what we have— our biggest asset is the people of South Dakota. They always step up. End up outdoing anything that— ideas that we can come up with. But I do think that we've got a good path forward for the next 2 meetings of coming up with decent legislation. And as I said before, when it comes to regionalization, I would have no problem of making that essential.

I agree. I think to make it essential and then to figure out the proper funding model and how we're going to do it, we're going to have to have the accountability that's within some sort of a, you know, service areas. And then there's a person there, and then, then we've got some oversight to figure out, okay, can't put it all on counties, right? Because make them, you know, they would go broke if we just say this is county responsibility. We have to figure out a way of doing some backfilling. Just late last week, I learned about North Dakota has a model, and that's something that I'll be working with Matthew to kind of take a look at too. They actually call them service funding areas, and that, that they look at, and there's some sort of backfilling they do. And then part of that's also figuring out what's the proper local effort. And I think that even varies by areas on how much government should be in, because some areas have more revenue than other areas on a per capita basis. And so we've got to figure that out in this whole model. So I agree with what you're saying, Senator Otten. Let's see, I think the only thing that I haven't checked off on the list, need to come take a look at the— I'm not sure who talked about this. IHS agreement. Was that— I think that was Representative Peters— Senator Peterson, I think, talked about that's something that we need to take a look at and review and find out, you know, what— if there's anything can be done there. I know it sounds like it's a fight with the hospitals too on a lot of those issues. But I think we better take a look at it. And then the last thing that I had down that we've talked about a little bit is nurse triage. And so I think next meeting we should delve into that a little bit more. I think that's a pretty complicated system, which also is a reason that you'd have to probably have some sort of service areas because it's not going to work in all service areas, right? But this whole concept of maybe an ambulance doesn't have to roll hot or things like that because there's a nurse triage happening. I think it's a You know, like you and I saw, Representative Williams and I saw out at NCSL. And so that's the other thing I had on my list. So that's what I had down. And I know you guys got your lists too. Is there anything else? Go ahead, Senator Jensen.

I didn't catch everything that Representative Hughes was saying, but I, you know, at one point we had kind of talked about in-network versus out-of-network. reimbursement because the patient doesn't always have a choice of which ambulance is going to show up. So I don't know if it's something at least to look at. I don't know if it's anything we can do about.

That's a good point, Senator. I think too, as we get to these, you know, if we can get to some sort of service areas and such, I think then we can start talking about, okay, now Wait a minute. That's a bad way of saying it, but what can we do to make sure as much as possible is in network? We're always going to have out-of-network, right? Because you could have an accident from somebody from an insurance company in a hospital from Delaware, right? But there too, you know, we just need to take a look at that when it happens. What's out of out-of-pocket? Anything else? And of course, we can always contact. You guys can always. Always contact Matthew or give me a call if there's anything else that you thought of afterwards. Yeah, Mr.

Chair. Representative Peterson. You know, we talked— thank you, Mr. Chair. We talked about this quite a bit the first meeting, maybe a little bit today. You know, the interstate-type calls, the out-of— the Wasta calls, the I-90, I-29 calls in small communities, that extra burden of those calls and maybe, maybe addressing that greater need there.

I agree. And that's again the areas that they're at. Is that a different— is there some sort of different funding model that helps with that? Totally agree. Representative Weems, you look like you're thinking.

All I, all I was going to say is maybe the Department of Health can give us more information on how— because I would think it varies greatly across the interstate areas who is really struggling and who is not. And maybe there is some information that they could give to add to if there is a— what really needs it, right? We know there are areas like the Wasta area that need support. But do all interstate areas need support? It's a good question.

Anything else? Sure, go ahead.

Yep, go ahead. Uh, yeah, so, uh, I keep going back to Senate Bill 89. I just was looking at our— the reason for our task force and deeming essential service Designation, and what do we really mean about it? We're talking a lot about reimbursement, which is— we've heard it time and time again. And if we're deeming essential service, does that open the door for new revenue mechanisms for the ambulance services in the state? And I think with only 2 meetings left, I believe we should start talking about what does that look like? What does that look like in the form of a bill? Is it, you know, a legislative designation we pass? And I'm just bringing it up. And I don't know, Colorado just had passed a bill last session but did not tie it, I don't believe, to revenue from what I could see in their bill. I wonder what ours looks like. Do we want that as a state? Just questions, I guess, more than anything. But I think we need to move towards that needle as well.

You know, I think if we're going to make it, if we're going to designate an essential service, we have to make sure it's funded. Those two are tied together. And we are trying to figure out, I mean, we got a lot of good data this time to start seeing some of the, where some of the issues are. But I think we're going to have to get that nailed down more. That way when we start talking about a funding mechanism, and I think that's why we've been talking about the, you know, the Service areas, the regionalization of the service, you know, then can we get to the cost so then we can say, yes, this is considered an essential service and this is how we're going to make sure we fund it. But I still think it should be on the agenda. I'm not saying it shouldn't be on the agenda, but I do think that's really part of the whole steps that has to happen to really solve this problem.

Did you want to We have talked about different items. Do you want that public now?

Which one?

On hotels and whatnot.

If it's a discussion point that you want to start at least gathering information on, that's up to you.

I have. I've already talked to LRC on it, and my idea is we have A lot of folks that drive into the state, I'm still not for sure exactly how many that have medical needs and actually pay those medical needs when they go out to Sturgis and a variety of other things. But anyway, I was thinking of hotels, motels, bedding and baths, people that come in to use the campgrounds, that there would be some sort of an EMS charge charge on there to raise funds for what we're trying to do. And so LRC is looking into that. And then an issue that we've tried the past few times, but there's something called vaping that we don't tax at all. And I think that would be a great idea. I mean, we're talking about vaping health, and this is health, so I think that would fall in. I think those would be 2 great ideas for generating revenue.

Yeah, so we can actually start that conversation at our next meeting also then, if you've got LRC already working on some of the information. Okay. I like where we are at. I think we had really good discussions today. I think we've got a plan kind of set forth. I hope we can get it done in 2 meetings. I think we can. Maybe we can try to bring some kind of shells of legislation so we have something to look over so that last meeting is more of a blessing of it. I think that's what we should work towards. So with that, I'll entertain a motion to adjourn. So we have a motion by Representative Weems, seconded by Senator Otten. All in favor say aye. We are adjourned. And full of wonder.