This webcast is a service of SDPB.

Good, useful, and full of wonder.

SDPB.

Okay, a little different on how we're approaching the meeting today because, you know, we've had 2 meetings with kind of taking all the input in from everybody, and now it's really kind of the rubber hitting the road on what are we going to accomplish here in the next session and really the next several years. And so our initial part is really just discussion on a few topics that we've been discussing so we can kind of figure out how to go forward. And what I'll say is, you know, it's going to be a general discussion, and if there's something that we're talking about that you'd like to have input on from the audience, you know, just go ahead and try to get my attention or step closer up here, and we'll, you know, we'll also add that because I think it's going to have to be a little free-flowing of a discussion for today to To get our work done. So the— I guess what I'll do is I'll open it up. Anybody else have any comments or kind of questions or want— on how we're going to flow today or make sure the agenda is in good shape? Looks like we're in good shape there. Okay. So as the 9:10 portion— and we're really not doing too bad, 5 minutes late compared to everything we had to deal with, so we're in good shape. We've Some of the discussion items are going to be on regionalization of emergency medical services, and then that also ties into EMS as an essential service. And so I think we'll kind of take those two in the beginning. You know, I think I've had discussions with the committee members, task force members, that there has been discussion with the governor's office, and of course that's with the Department of Health also, and that we. We have an approach that we'd like to take that's kind of two-phased on this. And they're in agreement with that. And of course, now it's for us to discuss. And basically, the phase one approach is, you know, if we're to get to more regionalized or service areas within the state, We'd have to define that system, so we're gonna have to figure out how to do that. And then also, we need to determine the cost. What is the cost? And I think what's really important in this is that we establish minimal reasonable service standards for each region. And so that— with that, you have to understand the staffing, equipment coverage, and response expectations. So that's something that would have to be done here before you could really get regionalized. What's important about this time period too then is to determine the actual cost.

Okay.

of providing that minimum level of service. Recognize that costs may differ between our frontier, rural, and more populated areas in the state. Need to identify the local resources and funding currently supporting EMS with each region. I like to refer to that as more of the local effort that we have in each area. And of course, the overriding, probably first step in all this is to find regional EMS services Based on, you know, are they— we got to figure out the geography, the population, response times, existing providers, call volume, and other relevant factors. And so I think what we're heading to is that we're going to have to put together an ongoing committee to be able to do these, all of these functions. So besides that one-time setup, it's also going to be, you know, ongoing and continuing, I think, in this whole process. But I think there's a second phase to this then that's really important, and we have to understand what's our sustainable funding mechanism for this. And we know from all of the testimony that there are areas that are going to need more funding than the local effort can provide. That's just the fact of it all. And so we're going to have to figure out a way in the phase 2 of what's our funding mechanism going to be for all of this. And, but I think we have to, in my opinion, we got to figure this out at the same time that we're looking at setting up the committee, right? Because we can't just do half of this and then wait and see how we're going to fund it. I think we have to start talking about funding of it. Thank you. Right away, so the areas understand that we are going to have to do some backfilling. You know, at the state level, once we understand what all the costs are and such. Let's see my notes here to make sure. So we have before us in in the in the in our files of the North Dakota. The language that they used when they set this up. So it's a good comparison. Matthew's been working on some drafts for this and does have a few questions for us, and I think that'd be good to hear now. I guess let me— let's just pause there and say, does anybody have any comments on everything I've talked about before and kind of where we're heading? Oh, one other thing is, and I Secretary Magstadt said, "Did I lose you behind?" There you are behind a column. Why don't you move over just a little bit to the left so I can see you? We have talked about using. I'm sorry, to the right. You're right. Yeah, you're right. Either that's good too. I can see you there. There you go. There you go. And of course, to get to this point, and the Department of Health talked about this, there's some rural healthcare transformation funds that could be used along this process to get there. So comments from committee members on this whole concept that I presented? Representative Weems?

I'll comment. Well, I really like the idea of regionalization, and I also had conversations with some of the committee members a couple months ago about the fact that when we have rural transformation dollars available, That are going to be ongoing for the next 5 years potentially. We don't know where this is all going to settle out, so we have to— it's hard for us as a committee to decide here's how we need to totally fund it. So I think what we have to do is we have to have a commitment that we're going to fund, but we also want to— have a group that looks at this ongoing because it is going to be really important for the sustainability of EMS in the long term.

Thank you, Representative. Other comments? Senator Jensen.

Thank you, Mr. Chair. I think, you know, I I registered a little of my disappointment at the last meeting with only 47% responding to the surveys. I did go and travel to a couple smaller services in my district, and the general feeling was, we have to do this survey over and over and over and over again, and nothing's ever happened. It takes us about 20 hours of volunteer time to put the report together. We're not going to do it anymore. Of course, that's their comment, not mine. So again, I find it so hard to figure out how we're going to bring this all together to help every service when we still don't know all of the issues. I guess I'll just leave it at that. I just— it seems so frustrating that we don't have just an overall better picture of what the actual problem is. I know what the problem is— money.

Money.

But how do we get there? With the money, with the rural health money, if we can't actually spend any of it.

Further comments? Representative Fosness, to you.

I would just add to that, I think we also have a people problem in addition to the money side of it. And looking forward, I applaud a committee to ongoingly address this because we're going to define reasonable and We meet 4 times as a summer study. I think it's more effective ongoing to actually get some traction. And so I just wanted to applaud that, but, and add, it's not just a money problem, but also a people. If we're gonna be reasonable expectations statewide on delivery of service, we have to be upfront with them. I like the idea of regionalization for just that purpose, but we'll talk more about regionalization in a minute.

Representative Peterson.

Yeah, thank you. Thanks for— it's good. I think we're kicking it off talking about our overall goals, and that's kind of where I want to go with this because we do have some bullet points on the agenda. But I agree, I want to bring it back to, you know, my intention of being on this committee was to help bring costs down, to find some efficiencies, help some of these rural ambulance services with potentially billing collections, HR, all— and negotiating All these different things to help them be able to provide a quality level of service potentially at a lower, lower cost. And then at the same time, we want to figure out ways that we can bring revenues up. And we want to be able to find revenues potentially within our rural health funds or wherever that would be because I do not want to have an unfunded mandate being sent down to these local governments. And I'm saying that out loud on the record because I want all those local governments to know that that is not our objective and we will work hard to We cannot do that. And so as we continue to go down this path, I hope we can shore up the revenues and the expenses, because even within my own district where there's more volunteer-based EMS, that gap is not that wide in some instances. In other places, it is way more expensive to provide a similar level of service. And we might have interstates and things like that that maybe require extra vehicles and things like that for that what-if scenario. And so I just wanted to put that out there and know that we're all working together on this. And I look forward— again, the rubber's hitting the road right now. We had to wait a little bit for data, so it kind of got us back into the fall a little bit more, but we are going hard and fast, unfortunately, right now. But we do want to do this right. And so that's— I'm looking forward to working with everybody today and over the next 45 days to get this done right.

Thank you.

Thank you, Representative. Senator Otten.

One thing I do want to make sure everybody is aware of, I see us setting up guardrails, some structure on how things are going to be done. We're not going to be setting up on how each one of the regionalizations, how you guys figure that end of it out. That's why the, the 2 phases will work great. You know, if we get the first part done, We can hit a pause button. We can actually do another study next year, begin to bring correlate from each regionalization area on how you guys want to run it. It is not my intent to tell anybody how to run it when I've never been in an ambulance except to be transported. You guys know what, what you got to do. It's just setting up the baseline of where we go. Yeah. I do think, though, that at the end of the day, as I've been on this page for quite some time, we can't let over 20 years of conversation on this topic and the best that we've got to offer the citizens of South Dakota is a total failure, a system that has just totally fallen apart. That is unacceptable. So within that, there's going to be people that are upset. There's going to be people that aren't upset. There's gonna be some that are upset more than others. And that's where you come up with good legislation, finding and hunting for that sweet spot where nobody's getting everything that they wanted, but everybody is gonna end up with something that is gonna help the citizens of South Dakota. And that's why I asked to be on this thing. Enough is enough. I've, I've been the one that has always voted no on this stuff. All you're doing is putting a doggone tax on— Mr. Althoff, I have to interrupt you.

Don't make noise.

All you're doing is putting a tax on the local folks, and they're already being taxed out of oblivion. So this is going to be a state issue. The state's going to have to pick up, I think, you know, 90% of it. But then we're going to have to have a mix on to make sure that everybody's got skin in the game. And that's going to be the wrestling match.

Thank you, Senator. Representative Hughes, I see you have your hand up.

Yes, thank you, Mr.

Chair.

I don't want to belabor this because there are excellent comments from everyone who's spoken. I just want to offer this perspective in terms of a sustainable funding mechanism and understanding the geography and population. I make several trips to Eagle Butte to appear in tribal court every year. Now, if something happens to me or a family member or somebody I care about, On the way to Eagle Butte on the rez, I've learned from Representative Jana Hunt that you can wait an hour, an hour and a half for an emergency vehicle to arrive with people. When we— I just can't emphasize this enough with respect to the people of South Dakota that we are trying to serve. We must have some type of parity regardless of geography, because all of us use the roads, all of us travel, all of us have those what-ifs, and occasionally they happen. And when they happen, it's 100% for those that experience that need for emergency services. So I was thinking too, and I don't want to get ahead, But in terms of the lodging tax, for example, everyone who comes into South Dakota is a potential candidate for EMS service. We're really— it's kind of like the fire department. We have to have a— and I love that— a minimum service level, Mr. Chair, that you mentioned. That's such a helpful way for me To look at this, so we're really helping all of us, and we're helping all of our guests who we invite into South Dakota as tourists. And we all need to participate in this. So that's really all I have, Mr.

Chair.

But thank you.

Thank you, Representative. I think we've been kind of through everybody that wants to speak. And so I think one of the first concerns or work that we have to do is really what. What's kind of the setup of the committee? Because we've got a really good model, I think, with North Dakota. But Matthew had some questions here as he's been working through the drafting that I'll actually kind of talk through with everybody. So the first is, you know, we we need to you know how are these regions to be determined? And I don't think that's necessarily something we can do up here. But is there anything that we need? to take into account when that's being done, right? If that's something that we do need to give some structure around or, or some like guardrails, as President Otten was talking about. And then as we're thinking through that, is this to be done in conjunction with some sort of advisory board that we talked about being ongoing? And then maybe some ideas on who comprises the board, and then what authority are we giving that board? Along with, you know, are there any factors— this kind of comes back to the first one— the factors must be considered when determining the boundaries of each service area and how specific that criteria needs to be. I think we're really going to— we got to figure out that local control versus we got an overall state funding method that we're looking at. So we're going to have to have a discussion about that. And then I think there, then we have to talk about you know, statutorily, you know, setting that committee up and such. So let's start there and try to get input from everybody. And Secretary, at any point, just if you want to speak to any of these things, please, please just come up. So thoughts on that? Thoughts on the task force or the ongoing advisory committee? Committee, maybe, maybe start there. What's the name of it? What kind of a committee is it? BD.

Thoughts?

Representative Fosness, do you have a—

Sure. I'll just add a few thoughts. If this ongoing committee— again, we meet 4 times. So I think we need to have a task from the legislature to say the composure of the committee is a few folks from the ambulance association's representation, Department of Health, maybe to the discretion of the secretary on who that would be to represent. Maybe it is a secretary, you know, whoever that would come from. You know, I think the governor's office may want an appointee to this committee as well. And we set it up that way, someone from finance, from a finance standpoint, and then a regulatory standpoint. So we have a nice balance that can make recommendations past RHTF. But it gives us time to do that, and we can make that recommendation, I think, as an action for the e-board to consider.

Yeah. Senator Jensen.

Yeah, thank you. You know, I concur. This is a big problem. It's been a big problem for a long time. This committee is not going to fix everything in these few short meetings. I do believe we have to have an ongoing the ongoing ability to keep monitoring as we go and offering new solutions that we see as things come up. You know, there's a lot of things our summer studies try to accomplish, and sometimes the few meetings that we have just, you know, we make a couple recommendations and then we walk away and we do something else for a while. This is so important that I believe we really do need an ongoing— Thank you. Some type of a structure ongoing from the administration, the legislature, from the healthcare industry. This, like I say, this problem is not going to go away with a couple resolutions out of this committee. So keeping it going, I think, is a— if not this committee, but a structure is very important that we— and if that's only— I don't think that's the only thing we'll resolve with this committee, but I think that's a big one. Thank you.

Other thoughts on an ongoing— I think Matthew is taking some good notes here. Representative Peterson.

Thank you, Mr. Chair. One question that I have, I guess, is I think service will be regional or geographic areas. I do want to pose the question, I guess, for the whole room. I don't know how many service areas there's going to be, things like that. When it comes to billing, collections, HR, does it— are we going to have— I don't even want to throw out a number, but X number of different groups all doing those same things? Or do we want to have that more centralized where there's one unit across the state doing billing, collections, HR, things like that? As far as an efficiency standpoint goes, because I would— it would seem to me like those things could be done in one office by one team, and that would create a lot of efficiency there.

Representative Weems, just come on up, Secretary, and just— we'll have you ready, queue you up, ready to go. So let the, uh, the task force members talk first. So go ahead, Representative Weems.

Thank you. Mr. Chair, I, I, I, I am on the same lines as you.

It's on.

It's on. Can you hear me?

Oh, it's Representative Weems. No, Representative Weems is talking right now. Yeah, I just called her to sit down.

So the, the— I'm on the same lines as Representative Peterson in that you can regionalize things, but some things may be able to be totally centralized. And so it may be better efficiencies in that. But sometimes you have to do baby steps before you get to the grand picture, which is kind of what rural transformation is all-encompassing, is getting us to the end goal in baby steps. So I really don't have a question, but more of a statement. Maybe if I asked it in the point of a question is how would you guys view regionalization and centralization?

Go ahead, Secretary.

Mr.

Chair, thank you. Melissa Magstadt, Department of Health. I think that's a really good topic for this task force or committee or whatever it sort of gets called when it's all said and done, is that, you know, is it more centralized? Is it more— is it smaller, larger regions within regions? Collaboratives within regions, that could be 8 different regions but 6 collaboratives in each one of those. I think that's all possibilities. And I think this task force, I think, is very wise to sort of tackle this a little bit more than in 4 visits. I think what you probably have learned a lot is that there's a lot about EMS and the complexity is wider than you maybe thought it was. So I think this committee's done a really good job of digging into this. One thing I want to just throw up there for consideration is representatives on the task force. Some of our ambulance services are county-owned, some are city-owned, some are tribal-owned, some are private. And I would throw that out there as consideration of that sort of representation in the discussion. And then the other piece, and you mentioned it too, Representative Fosness, workforce. So, you know, think about your education pipeline. Yes.

People.

People who work in the space of EMT education or paramedicine population. And then consideration of potential regulatory pieces of this. I think of the Board of Medicine, which houses the paramedics and EMTs in that. So just because there's a lot of moving parts, just things to consider about your committee makeup.

Do you want to just hang out up here for a little bit for us? Thank you. Just so that we don't have to have you coming back and forth. I think Representative Weems' comments and Representative Peterson's too are things that maybe we put into the bill to create the committee that, you know, is, hey, on a high level, is this going to be very centralized or decentralized or to what point? I think that would be up to that committee to originally set up. And at that point then it could It could change as more is learned about it. So other thoughts? Go ahead, Representative Jensen.

Thank you.

Senator Jensen.

Thank you for giving me time to think. I think having one central location would be problematic in a lot of ways. Who's going to pay for it? And everything has to be sustainable when we're done. So, and some, some billing departments do a good job now and some struggle. I think having it under one roof— the other thing I know from, you know, hearing a lot of things about people that have contracts with the state, they get paid once a month and sometimes it's 4 or 5 weeks after the fact. Is it going to— if we centralize The billing, is that going to really slow down the cash flow for the local agencies to keep their doors open, to pay their heats and lights and everything if they're not funded by a city or by a county? I guess I would favor more of a decentralized assistance than a centralized department.

Representative Weems.

Thank you. Thank you, Mr.

Chair.

Maybe I should clarify, because when I think of centralized, I don't necessarily think centralized under one building. I think of centralizing the services under one person doing it, or, you know, one area. So it might not be a separate building. It might be somebody that's already really strong in that, that we work on that. I don't know what it looks Like, and I don't know that we, as a task force, should define exactly what that looks like, because you need all of the people that we were just talking about on how to make that work. And I— but I think we're going to find out that doing billing centralized might be more cost-effective for everybody.

Okay.

Doing some of the trainings may be more cost-effective for everybody. And hopefully this would be taking on all the things that we're doing positively in different areas across our state and spreading it around. So, um, so making it available to more people. I, I'm just using 2 examples.

Okay. That's fair.

Senator Otten.

Yeah, as I've done a little research on this, and of course you'd look at the rural transformation monies. So by doing it in 2 phases, we would have that money set out there. It would also have the task force being able to talk with the locales. What kind of software do you guys need? There are outfits out there that do billings. If we can come up with something in the manner of software where you've got feature, you know, you got 12 features on your dashboard as the ambulance has gone out and they've hit, yeah, we've given them gauze, we've given them this, we've given them that, you're clicking them down. And then at the end, you take it back to the— Where they're coming out of. And they're going back through it. Are we good to send? They can click a button; it sends over, and another individual hits it, and it just goes to a central area, and it's being billed immediately. I don't think we have to be afraid of technology in itself. We should be embracing it more in order to get this done. I think that is about the only way that we can do it. I've been a fan of, as I had conversations with the.

Mr. Chairman.

Mr. Gosch.

Mr. Chairman and others, if you look at this as trying to get something across the goal line as one package, we're going to fail, and we'll fail big time, because you've got 105 people that have to— you've got to convince on taxation and a variety of other things. But if we can do this as a phase-in, slowly, methodically begin to build, having background with DMS folks out there, we might be thinking of one thing and you guys just in one meeting can say, no, this is how why it won't work. You've solved it in your region, and I think that we can streamline it. I know that when I worked for the lumber companies, each format of of where it came out of, we would do things differently, and stuff was billed. It was billed correctly. So I don't think that there's that much of a consider or. I don't have a whole lot of consternation, I guess, over looking at technology and doing it. But I think that if we can find someplace that we can actually have them bill it, and so that we're getting making sure that we're getting everything that we're required to get, would be one of the better parts of this.

Thank you, Senator. Representative Hunt.

Thank you. Um, I just want to comment in addition to this. I hope that we stress the importance of communication with our EMS teams because we're on a really fragile system as it is, and if we ostracize our volunteer members, that people issue is going to get a lot more significant. So I hope that we come up with a mechanism for open feed— like an open feedback system where an everyday volunteer running the EMS guy can log on to something and say, hey, This part isn't working, or there's there's obstacles here in our region. Something that can create a lot of open communication because this is a big job and we kind of need everybody hands on. And I know there's a lot of ways to do that in the hospital setting. So I'm hoping maybe the Department of Health can help figure out like a a link that could just make it really easy where it's not such a huge form. Monster, um, because I think this communication thing is going to be big, and, and our volunteer EMTs don't have a lot of time to go in and sit down and communicate with the state on a frequent level. But maybe they'd be willing to do a quick type-up, if that makes any sense. I'm just— I'm concerned about my region if we ostracize our volunteer ambulance services that are doing the billing, that are doing all of this, and there's too many changes too quickly and they don't feel like they're being heard, we're going to lose a lot more volunteers.

I think it's really a good point and actually something that probably should be put into the structure of the committee, you know, is holding hearings and then maybe, uh, anytime there's a hearing, you got the ability to have written comment into the committees. I think that would be something that would be good to actually get into the Um, into the, into the bill. Any other comments? Do you have anything? And then we'll have you come up next, Maynard.

Sure. I think my final comment is, hey, isn't this a cool time, right? Isn't this like— what a fantastic moment in time to be a part of solution creating and creative ideas with a little funding to help execute those. And so, um, I'm excited about this. So, you know, I've I hope that we, at the end of the day, that it doesn't feel like, oh, here, you know, we're not going to— yeah, we are. We are going to get through this. This is going to be a great time. It's a great opportunity. And just hearing the debate back and forth demonstrates a lot of breadth and depth that you folks have really became— got your arms around this. So I'm excited about this.

Right, Maynard?

Yeah, you too. Yeah, absolutely. Thank you.

Thank you, Secretary. Go ahead, Maynard.

I'm Maynard Konechne, representing the EMS Association, part of Kimball Ambulance. Just wanted to make you aware that there are billing companies out there that do billing for ambulances. I'm not sure how many in the state. I know PCC is one that does a lot of services, and Ambu out of Tyndall also does a bunch of services, and I'm not sure if there's others out there, but— Thank you. When you're talking about that centralized billing, I mean, there are companies that are doing billing for your local ambulances now because of the complexity of the challenge with Medicare and Medicaid changing codes continually. The local people can't keep up with that, but these companies do, and that's made a big difference in reimbursement for our ambulances. But just so you know that there are companies out there that do that in the state.

Sorry, Maynard. Thank you. Any other comments? Because I— just to let you know, I think next thing we actually move on to funding a little bit.

Right. No question, but thank you. That's— and I appreciate your comments because that was what I was going to say is that's the whole goal is to make it easier. Especially like for these volunteer services. If at any point in this process down the road a local volunteer service says this is a challenge and it's not working right, well then we got to fix that. I mean, we're trying to take it off their plate, not make a burden on their plate. And then as far as this whatever centralized service, my hope that this is an assistance package, so to speak, to the local EMSs. Not again, not an unfunded mandate that then they got to turn around and pay for someday. I think this is supposed to be helpful in every regard, whether it's financially or time. Because again, I can't even imagine trying to do collections some with some of these organizations. And to be a volunteer EMS person, as many are, or paid one, I hope that it would help take some of that off their plate. And And potentially the outcomes as far as collections could go should be better. And if they aren't, then again, we got to sit down at the table and figure out how to make it better.

Go ahead, Representative Fosness.

Thank you, Chairman. I just would make a comment. I really appreciate what Representative Hunt said about the sensitivity to the volunteer-driven system across the state. And I'll spin it to win it here. And when I say what we heard from Spink County and the examples that they have given us on how they've used that same volunteer mechanism, but increased the outreach in the smaller communities around it, that improves the volunteerism. I'll say up in our country, the pride of the fire department level, you could almost sense that in Spink County's pride in their EMS services. And I think we can build on that statewide. I think regionalization works when we have a more efficient mechanism for education, Maybe it's onboarding, maybe it's recruiting in the high schools, maybe it's centralized billing. I'm actually not as attached to that because, you know, PCC does a nice job in the couple of districts that I work, the ambulance districts I work with. PCC is great. So appreciate you bringing that up. I guess I don't personally feel we need to force the billing component as much as we do, not force it, that sounds weird, but appreciate the efficiencies in a regionalized model. I didn't come to this committee right away thinking that that would really make sense in South Dakota. I thought this would just belong local and that's it, but the more I see it, the more efficiencies. I think we've just encouraged everyone to be open-minded that regionalization could actually work to our benefit as a whole state. So whether we have quadrants, 15-minute, or we shouldn't even tie it, reasonable response is the correct verbiage with that to calls. We can do better when we're regionalized. And I think if we just keep our eye on that target and find ways to be efficient. in all those different areas, we'll win this. And that the task force can say we did our job and a committee can take over and see it through after 4 years.

Okay. I think we did pretty good there getting to maybe— I guess just in a high level that we're talking about, you know, the task force would really be responsible. I mean, we'd give high-level things that they're responsible for. But it's not us to determine the reasonable service level. It's not up to us to determine the regions, although we may want to at least talk about their geographical regions and the counties have to be part of this whole process and such. And so I think I'm getting a good idea of forcing— creating the committee, but being a little— give them some runway. on how they develop these regions and what's important about them. So with that, I think I'd like to move on to the funding aspect of it, because we cannot just— 2 things. We can't just throw this on the counties and the cities, right? And secondarily, we also— I'm sorry. We still need local effort, and but yet I still we're going to have to have a mechanism to backfill, and that's how North Dakota talks about it. Actually backfill because some of our areas because of the the rural super rural nation or situation with them, we're going to have to figure this out. So comments on kind of funding and how we tie this in to the whole process in a in a kind of a two-phase operation. Thoughts on that? Senator Otten?

Mr. Chair?

Oh, is that Senator Peterson?

Yeah, thank you, Mr. Chair. May I just make a general comment?

Yes, please.

I think it's prudent, you know, what you're talking about related to making sure that we don't have a top-down approach and just lay something on the counties that doesn't work for them or where they feel like they have no input. And the other piece of that is I also feel like if we are a part of the funding mechanism, we also need to be a part of the accountability mechanism. So I don't think we should just be seen as a pass-through for dollars. There needs to be some balance of, you know, and it's tricky, but we try to do it in education. And I don't know that we always succeed, but we do our best to have a certain amount of local control. But then the state also has to have a certain amount of accountability so that there's that balance and that teamwork there.

I think that's excellent comments, Senator Peterson. And with funding, accountability is always needed with state funding. So Senator Otten, do you have a comment?

Yeah. Jeff Mehlhaff had finished analysis on a couple taxing mechanisms. And let me just— while we are in fairly good shape, our revenue coming in looked strong again this quarter or this month. So we've got two months that have been fairly decent, and I've always thought of that as we get our fingers around all this, that depending on where we're at with the budget itself, some of that could come out of the general budget. But anyway, if you look, one of my deals was just as Senator, I believe it was Hughes, had mentioned on. On people coming into the state. We've got tourists coming into the state, and I considered it a lodging/camping/mechanism for generating funds coming into the state for this. And for that, I didn't want it to be onerous, so I asked him to do it as, you know, a buck a night. Wherever you're staying. So if you were staying at the Holiday Inn, it'd be a buck. It would say right on your, your invoice, EMS service, $1. Trying to keep it down to a point where when somebody saw it, they'd go, I'm a little miffed about that, I'm paying a buck for EMS, I've got insurance, but I'm not going to lose any consternation over a lousy dollar. And then cap it at $5. So if you were staying there for for 5 nights, it'd be just $5, a buck a night. Also didn't want— as you start looking at a lot of contractors running around and they're in, in areas for 30, 60 days, and I didn't want it to be onerous on them. So they would still be under the— still the buck and the $5 of locking it down there, making sure that bed and baths are also included in this. So you'd have any place that's Somebody would be coming in and staying. We would have it also at our campgrounds, same rules, and try to generate income there. Anyway, we would be generating right around $7 million. The next tax that I was thinking about is the vape tax, and that I believe was right around that $3 million mark.

Okay.

It's not in front of me right now. So we, you know, we should be able to come up with $10 million. Vape, I thought, would fit right into it. We're not taxing vape. It should be taxed, and we haven't been able to get our hands around it, but it still would fall under the— my thought process of that we are providing healthcare to individuals. You know, the quicker you can get them to the hospital, the quicker that we can get help for those folks.

Thank you.

The cheaper the doggone things will end up being. So we've got 2 there that I think could work, um, and I think it would— it's, it's being laid out, or at least I've kind of thought of it being laid out as soft as hand as we can get to get the 105 to go along with something. Because at the end of the day, you're now taking it to 2 chambers and you're presenting a, a tax for folks. And, you know, you've got people running on that, you know, no tax. Well, I've done those campaigns too, no tax. But at the end of the day, we're going to have to just come to the realization that State A has to pick up a lot of this. We cannot throw it at the county level. The thing will implode. And I've been very clear even back at home that if we're going to go to allowing the counties to set up their own ambulance services, I will I will not go along with it. I haven't gone along with it in the past. I won't go along with it today. I think that our savings is in regionalization. That is where where all the other states that have started to go into regionalization have found traction to be able to get this across the finish line. But having said that, a yes, it can. Some of it can come out of out of the general budget. But I think that's also going to have to have a mechanism there that we also can. Backfill a lot of this. Because when you start looking at, as it was mentioned, with a lot of the expertise that, you know, we're going to end up in a place in time into the future where a lot of our volunteers are going to end up going away, or we're going to have to have a find-if funding mechanism for them to maybe even pay for insurance, a variety of different things to help those individuals come on into it that, uh, um, geez, I'll pay my insurance or whatnot. All this has to be put on the table, but at the end of the day, we also have to have funds for this. And so, uh, you can't throw it on the counties, you can't throw it on the municipalities, although there's going to have to be a degree of, as the chairman said, they're going to have to have skin in the game so that everybody's on the same page of, of we want to watch how we're We're pushing this thing forward. We want to watch our, our billing and, and all of our expenses that we've got in this, but work for a point where we can get this thing settled. So, and that's on your— it was just passed out.

So it's on the screen. Thank you, Senator Otten. I think it's just a concept, right, on the amount. It could be 50 cents, it could be a dollar. It's just the whole idea of giving us an idea, right? what it could be. So thoughts?

Mr.

Chair?

Representative Hughes.

I touched on this at the last meeting. I hope that we don't overlook our 3 major healthcare systems in terms of a sustainable funding mechanism. In Sioux Falls, we are the beneficiary, of course, of many, many Millions of dollars of philanthropy, and I have to think to myself, you know, from a human-to-human basis, what greater philanthropy is there than creating a difference between a life or a death with an EMS patient? And we can't forget that the people that are transported, by and large, I mean, we hope they make it to the. You know, to the ER or the trauma department, and they become patients of the healthcare provider. And I mean, literally, I guess I'm— maybe I'm remiss here, but it does seem like we're sort of overlooking our good partners in our major— 3 major healthcare systems to try to put together a sustainable model to make this work. And maybe the Secretary can at some point, Mr. Chair, address that because they're not here. I don't— I mean, I know we have Representative Fosness, and that's great, and he's probably got a terrific perspective on that, but it doesn't seem to me that they're at the table here with us. And perhaps that's something that Mr. Rave can take up as well. Again, I mean, I read the Form 990s for our healthcare systems, and we know that there are hundreds of millions of dollars in excess— well, I don't want to maybe say excess revenues, but certainly net revenues. And perhaps instead of building another building, we could have our healthcare systems work off part of their charitable duty, obligation really, for their tax-exempt status and help us as a state help our people. I mean, that would be improving the human condition in my mind, is having achieved a level of parity so that if you're on Pine Ridge or on the Standing Rock rez or the Cheyenne River Sioux rez, That you, and you're in an accident or a crash, some trauma-based event or other healthcare crisis, that where this happens to the person, which could be any of us, is not going to determine life or death, but there's going to be a basic minimum, you know, as the Chair said, a minimum service level. that exists across the state. And I can't think of any more invested community than our healthcare providers. So thank you, Mr. Chair.

Thank you, Representative Hughes. And that's why we do have at 11 o'clock Mr. Rave will be here to, to discuss some of those items. So we made sure we had him available. So discussing funding at this time, maybe to throw question out. Is this something that we want to have done at base as a, like, an option that the committee could suggest be done? You know, the committee we're talking about setting up, I'm not sure what the structure would be there, but is this something we want to try to kind of get in place here during this coming session so as that committee set up and they start looking at things, they know that there is an option of Hey, this is some funding that we could suggest. Thoughts? Senator Otten?

Yes, I— if we're going to be really genuine about this and not try to soft-shoe this thing through, we're going to have to face that up front and make sure that both chambers understand that. Somehow we're going to be talking about either a revenue coming out of the general. If the general does hold hold firm, we can take that out, or we're going to have to have revenue that is set aside that is just specially marked for EMS, so that everybody understands across the state when they when they make a payment and they they see that that on there that it's for EMS, and we don't go through this thing of of you know well you said this for education one time and. And now here we sit, that it's, it's marked specifically for EMS. And I, I don't think that you'll get a lot of pushback. I mean, nobody likes to raise a tax or a fee, but at the end of the day, in order to get this to work and have the state pick this thing up, we're going to have no other choice but to face it up front.

Other thoughts? Representative Weems.

Thank you, Mr.

Chair.

Well, I, I do think we have to, um, do it up front. I'm, I'm not sure that we know what that dollar amount is, so that, you know, the idea of raising a tax and then putting it in a fund and backfilling seems like an appropriate option, even if we don't I don't like it, but I think we have to have some way to do this. I think we might need a subcommittee to discuss more on this, but I think it's a little bit inappropriate at that time to say that, because we haven't finished our whole meeting.

Okay.

Does that make sense?

Yep.

Nope, I think we can direct his at the end. That's fine, Representative Weems. Representative Peterson, or— okay, Senator Otten.

A back thought to put everything back in perspective. A, you have to have the votes in 2 chambers to get it to move. B, you also have to have a governor to sign it. And that's where this comes into the next phase of actually sitting down with the governor. Representative Peterson.

Thank you, Mr. Chair. Yeah, to echo those comments, it— I mean, we need to lean on our appropriators and the whole legislative body on where funding could come from. We also are creating new Funds, you know, as we speak too, which will have a lot of interest coming off them as well. So, but again, I would not want to assume anything until we talk to the appropriators and what plans are for different funds of money. The other, the question that I was going to pose is if anybody in the room could speak to this, the Rural Health Transformation Program funds can, you know, how much of those funds can be used for creating this system and maybe operating it? Do we know what those parameters are right now that we could operate within that for at least a handful of years? If anybody wanted to address that.

Secretary, is that something that you could address at this point?

Just a few concepts. Melissa Magstadt, Department of Health. A few concepts with the Rural Health Transformation Fund keep in mind. First things is it cannot supplant something that is already being paid for by something else. That's one of the rules. The second one has to have a transformative piece to it. That's one of the other rules. And the third one is the sustainability piece. So anything that we bring forward has to come through that set of lens. So, you know, as we're listening back here thinking about rural health transformation funds, we're fully in support of how we can use those to leverage. But just keep in mind those 3 lenses that have to exist.

Thank you, Secretary. Senator Otten.

One of the things that I think that with the step-in approach That we're considering. You can set a format as of this, but as we go into then the second part of this, that's where each regionalization on the county level, where those folks can get together and start talking about it. This will work, that won't work. Because, you know, at the end of the day, yes, on the guardrails, we set that up. And Yes, you know, there won't be, you know, some will not be happy with the guardrails. But at the end of the day, in order to get this to work, you're going to have to have the county officials sitting down in a room saying this will work, that won't work. And as long as we can get ourselves to that point where the county officials are chiming in, I don't think that it'll be that big of a deal. The one thing that I have learned, that as you go in there and you've asked, you know, some of the county officials, why haven't you Move some of this forward, and it's the same thing. Well, I don't want to raise a tax. Well, then fine. I'll be your huckleberry. We'll raise a tax on our end. But at the end of the day, we're going to have to work our way through that of getting the county officials at some point in in this as in the regionalization to be able to sit down and go, all right. I like what Spink has done. You know, we can have one major. We've got all of our computer systems work. We can have 2 hubs where we're doing transports and whatnot and all that. That can be figured out on their end, and we can just say, well, that's nice. Way to go, guys. So—

Thank you, Senator. I think we've kind of discussed this. I mean, we're going to let it kind of think through some things for our directions at the end, but I think we've had a good discussion. And if we what we go forward with, I think we've given our LRC folks some good direction in this. So, so we as far as the regionalization and then you know the second bullet point I had EMS as an essential service basically is that service reasonable service level. You know I think that's what we were discussing there. So kind of combine those two. Does anybody in the room have any comments that they'd like to? share on this portion of the meeting. Okay, I guess we're perfect then. We don't have to worry about a thing. Just kidding, just kidding. So, okay, I guess with that, the other item that we have in front of us is treatment in place and alternate destinations, something that we've had both meetings that we've had some discussions on. There is the idea of a draft, and that's in the— that's in our documents. Is that out on the public one too?

Okay.

Would you like to make it public?

Yeah, let's make that public. And I think it's draft 83. So we do have a draft in front of us. That could be approved at the next meeting. I'm not saying we have to approve it now because I think we'd want some time for input, but it is draft 83. Give people a little time to look at it.

Let me grab— yeah, let me get it up over here.

And again, we'll have this fully public for the next meeting when we actually approve it, but I just wanted to get people's input. So the basics of it is, and we're getting it up here, that the ground tran— that that an ambulance service— that Department of Social Service— of course, this is for Medicaid. I should bring that out. This section, the first section here is for Medicaid. And then we would also look at group health insurance. But that ground transportation by an ambulance to a hospital or other destination as deemed appropriate by the ambulance service medical director or program director and healthcare services that are delivered at the scene would also be reimbursable.

Thank you.

And then each policy for health insurance that is delivered would do the same. So it would basically allow the billing to be done for treatment in place. Thoughts on that as we look at having that as a draft that we would Proposed to the e-board to approve. Like I say, we'll have a whole other meeting on it. I just wanted to see if there's any input. Representative Fosness.

Thank you, Chair. These are just questions, not for or against, just questions I think we need to think about. Medicare likely will not pay. It's a reminder we learned that Medicare is the giant payer in the room, something out of our control. I also think we need to understand, are we going to put up guardrails— or not guardrails, but, you know, are we going to require what commercials pay? And if that is the case, and then Medicaid specifically, those are just for clarity, those would be the 2 things within our control, correct? If we did guardrails for commercial, and then if we directed Medicaid to pay for treatment in place, is that a safe understanding? Okay, thank you.

And the draft is on the website, so if anybody wants to take a look at it. Oh, Matthew, please come on up and go ahead and introduce yourself, please.

Good morning. Matthew Ballard, Deputy Director with South Dakota Medicaid. I did just want to clarify that Medicaid already does pay for treatment in place. So if an ambulance is dispatched and services are provided at the pickup point but the individual is not transported, Medicaid would pay the BLS base rate for those services.

Thank you. I guess that's something that was— has been in question as we've collected information, so that's good to know. Senator Otten, and then I'll come to you, Representative Weems.

Question for you: when we stay paying in place, exactly what are the fees, or what are the structure That would pay in place besides the transport?

So the BLS base rate is paid. Uh, let me just double-check the fee schedule. I believe the reimbursement for that would be— excuse me— $448.15.

And that would include mileage?

Also, so if they're— the mileage for Medicaid is for loaded mileage. So if somebody is not transported, there is no mileage reimbursed.

So there's no mileage going to, but it's coming.

Correct.

Okay.

Representative Weems.

Thank you, Mr.

Chair.

I have a question, and I'm not sure if you can answer it, but are all EMSs billing for I cannot answer that question.

I know this has come up numerous times. We changed this policy, I think, around 2018 or 2019, and we do hear it come up where there's questions. I, you know, I don't know that everybody fully understands this. It's certainly documented in our provider manual, and I think every time we're asked about it, we've communicated Yes, that is a service that we pay for, and I've personally seen claims with this build where there's no associated mileage. I cannot say that we've done an exhaustive review to see if everybody bills it today.

Go ahead, Representative Weems.

Thank you. Do you know how many— how much you're paying out in treatment in place?

I do not know that, but we could analyze that and report back.

Representative Fosness.

Just a question. Is that only if there's treatment provided to the patient from EMS, or is that just if you would go to a scene but no treatment is given, is that still a billing option?

Deibert. I believe they have to provide medically necessary services. I would need to double-check. I believe if they're called to the scene and the individual is deceased when they arrive, I believe the BLS base rate can also be reimbursed in that scenario, but I would want to confirm that.

One second. Representative Hughes, did you have A question?

Thank you, Mr. Chair. I just— and perhaps I wasn't listening as closely as I should have. Draft 83, you are not looking for comments at this point, substantive comments?

Yes. Well, right now we actually have Mr. Ballard here that we're asking questions of. So if you want to just make a general comment, how about we hold off here and then I'll call on you again. Thank you.

So we're proceeding to Section 2 and Section 3 of Draft 83 then?

We will here, yeah. I mean, right now it's just questions, questions from Mr. Ballard.

So, yep, thanks for the clarification. That was my question, Mr. Chair. Thank you.

You're welcome. Representative Weems.

Thank you. I'm, I'm, um, thank you, Mr. Chair. I'm a little bit confused. So as— and I'm not an EMS biller, I'm— I have no background, but can you help me understand what all is covered for treatment in place by Medicaid?

Yes, so generally speaking, when an ambulance— how we reimburse ambulances is there's a base fee paid, and then on top of the base fee we pay loaded mileage. So if If an ambulance is called to the scene and provides medically necessary services, they receive reimbursement for that BLS base fee, but they don't receive loaded mileage because there is no transport.

I'm sorry, Mr.

Chair. Go ahead if you want to continue.

Yeah, thank you.

Just for some information is— well, do you want— you know what, before you go, I'm going to have our co-chair speak.

Thank you, Mr.

Chair.

Um, and thank you for coming today. I mean, this is kind of eye-opening. And so as somebody who does this for a living, um, you know, and I have the, the South Dakota Medicaid fee schedule pulled up for me right here, and I don't see this anywhere on here. And I, and I, and I know that this is something that was talked about, and I know maybe this is an education thing that needs to go out for the EMS, that this is something that's even allowed to be billed for. Because I looked it up, did a quick Google search to try to find the A code that would correspond to this, and I can't find that anywhere.

Yes.

So some— so for example, when we review other states' billing policies, there is an alternative code that some states use, but it also wouldn't be uncommon to use the BLS base fee that we use. So in South Dakota, with South Dakota Medicaid, We reimburse in the BLS base fee. That is noted in our provider manual. I would agree with you, that's an accurate assessment that there isn't— some states do use this alternative code that specifically states it is for that purpose, and we don't have that code on our fee schedule. You know, I think that's a reasonable point that based on the confusion, maybe it would make sense for us to reevaluate that and use that code. So it's clear to everyone that that is a reimbursable service.

Yeah, and I think that's probably a good assumption to make, that this is something that I don't think a lot of the EMS providers here in the state know that they can even bill for at the Medicaid level. I know there's a big push for this for Medicare, and we know that this has not happened at the Medicare level. And I think for most of medical billing, whatever happens at the Medicare level will always trickle down. But in this case, it's the other way around here in South Dakota, which is a good statement for the state that we are proactively trying to help our EMS providers. But I think maybe some reeducation or education on the matter is probably needed to happen.

Thank you.

Yes, I would agree with that assessment.

Thank you. Everybody here. Let's—I'm gonna go. I'm gonna go all the way to Senator Otten, and then I'll work back this way. Senator Otten.

Well, from what I just heard, I think that makes a strong point to have some sort of a billing system set up where all this is on a computer. They're familiar with it because you know times I've talked to. Our providers down there, you know, sometimes lack of a better phrase, but sometimes you're listening to them and they're talking in tongues. I've got no concept of what they're actually saying. So if you would go to a billing system and lock that in place, I mean, those people all the time, they you know they know the jargon. They know what is allowed, what isn't allowed, and you know then. We may make sure that that donut hole, if we will, and we don't know how the size of that donut hole gets actually filled.

Thank you, Senator Otten. Go ahead.

Thank you, Mr. Chair. Thank you, Mr. Chair. Yeah, I was just— maybe we could, if it wasn't already asked, just get maybe a summary of what treatment in place is and isn't for— because I don't want to do the what-if scenarios, but one of the natural ones that comes to mind is If somebody has fallen down, cannot get up, they get up, everything is fine, is that a medically necessary service or would that not qualify for reimbursement?

You know, that is a good question. I don't know if I have a direct answer without thinking about that and consulting with others in the department. Certainly we define medically necessary So in the definition we say medically necessary services. We have a definition of medical necessity that would generally be interpreted by our clinical staff. So I don't have an answer right at this second.

So just as a follow-up, I think we should get into that a little bit and figure it out. And obviously we don't want to have, you know, a scenario where I get an ambulance and drive to every house and write a bill, right? It needs to be medically necessary, but we're trying to find where that middle ground is on that. Thank you.

Yes, Mr. Ballard, if you could provide that to Matthew and he can share it, or if— yeah, how would you like to proceed with that?

So I think in considering it a little bit further, there's a definition of when a BLS service can can be provided. And so they have to have basic noninvasive interventions to reduce morbidity and mortality associated with the medical response. And I believe there's a list of those services. So I think if we reviewed the list, we could determine if it would meet that definition or not.

It would be helpful for us to have that information. You asked about the dollars, which we had asked about earlier. Thank you. Representative Fosness.

Yeah, maybe more of a comment. I think I'm glad to hear we're receiving more. I'm disappointed it's our 3rd meeting and I'm just learning this. And I wonder if there's a delta in who has and hasn't billed just by basic not having knowledge of what is, you know, noninvasive intervention. But I do worry, you know, there's There's lines with licensure too of the potential of treatment in place and then leaving thinking we got it, everything's okay. Then if it isn't, what's liability look like for the provider? You know, and then what level is, what isn't billed for BLS? Noninvasive intervention is good clarity. But I think we need to— I want to see volume, frankly, and how many Medicaid claims are billed.

Thank you.

I'd also be curious, this would be harder and I don't think the department would know this, but maybe the associations would, of how many visits aren't billed that could have been billed that are Medicaid. That's helpful data. I would have appreciated it a couple meetings ago, actually.

Senator Jensen.

Yeah, thank you. I've got to admit one thing. I was in the hills this weekend and my ears haven't popped. I remember really struggling to hear, and maybe this was commented on before, but I think at least I, if not we, have been working under the assumption that Medicaid does not pay for treatment in place. So this, to me, it's kind of a little bit of a news flash here. So for the requirements to get paid by Medicaid, is that a federal regulation or is that state that we can work with? I'll just make a quick Comment. You know, we're talking to the administration. I was informed that we could find ways in the state Medicaid code to be able to pay for treatment in place. So which— I guess just a comment, or what's your opinion on that?

So the provision I'm speaking about is an administrative rule today. It was Put into administrative rule. I don't know the exact time frame, but I think it was around 2018 or 2019. And so within Medicaid, there is the Medicaid state plan, and then there's also, which is an agreement with the federal government. In this case, I don't believe there were right. We already have the coverage in place. So when we do make updates in general, though, we have to consider whether it requires a Medicaid state plan update or whether it can just be done. Through administrative rules at the state level, so it usually involves an analysis of both documents, and and then we have to make a determination if there's any kind of conflict with the terminology in the state plan.

Thank you. Do I? Yeah, go ahead. Thank you, Miss Reller. We'll kind of those two items would be. great to have that for the committee. Sir, come on up. Go ahead and introduce yourself, please.

Chief Rowland from Watertown Fire Rescue. I was just going to ask the gentleman here, when it comes to ALS interventions, such as like we've had cardiac arrest code that we provide on scene and unfortunately the patient does not make it And we, you know, we have quite a bit of dollars invested in that specific call. But if it's a Medicaid patient, is it only a BLS cost or is it an ALS cost?

If you could answer that, Mr. Ballard, that'd be terrific.

Current policy is for BLS.

Okay. So there's no differentiating of ALS versus BLS at this time with Medicaid codes?

So we do have obviously ALS, uh, if there's transportation for just services provided at the pickup point where there is no transportation, that is just BLS reimbursement.

Okay, thank you. We are actually going to be starting to charge this as well.

Hold on, sorry. Thank you, Mr. Ballard.

Oh, I'm sorry.

That's okay.

We are going to be working with our provider. Actually, Maynard was correct, we are going to be transitioning to PCC billing. We were using EMSMC It's a national billing company, and we ran into some unreasonable collections issues that weren't going on very well. So we're making this transition starting October 1st, and that was one of the things that PCC actually shared, that we're going to be starting charging for Medicaid no-transport calls. So we're looking forward to that. I will tell you though, roughly speaking, we're transporting about 15 to 20% of On Medicaid for all our ambulance transports and no transports. So it's significant but not as significant. So think about, we, we have about 800 no transports per calendar year in the Watertown vicinity and the whole Codington County area. So that's a lot of dollars, of course, that we're not able to regenerate back into our department. So if The Medicaid thing works for us. We actually just created some new ambulance fee structures just within the last city council meeting, and we're going to be looking at doing ALS versus BLS, no transport fees for the patient, which is difficult for the patients. And we hope that that would help out a little bit. So thank you, Chair.

Thank you. If you hold on a second here. So if I'm understanding correctly though, if you do have a patient that you don't transport This gets a little morbid in the discussion of it. I mean, there are times where you would still take the patient, right? I mean, even though they may have, you know, they may have been pronounced dead on the site, do you guys still take the patient to the hospital or not?

We will actually. We have critical care paramedics, obviously, at Watertown Fire Rescue, actually at the very advanced level. So they'll make that call to the medical director or their emergency room physician at our Sanford Medical Center now in Watertown, and they'll make that determination that the patient is not going to be transported. We then will call the coroner. They would come in and they would take the patient away.

I understand. So what we're— what has been said here though is, but you, you may have done all the, the work that needed to be done kind of for advanced life, but you only get paid for the basic.

We don't get paid anything at this time because we haven't ever billed ever. So we're just going to start that October 1st.

Okay, so thank you.

For Medicaid only.

For Medicaid only, yes, I understood that. Okay, thank you.

Thank you, Chair.

So Mr. Balla, did I understand that correctly, that if that happens they would just get for the basic life support?

That is correct, that the policy is to pay the BLS rate.

Okay, thank you. Thank you.

Okay. Mr. Chair?

Yes, please go ahead.

I do have a brief question. Thank you, Mr. Chair. I just was a little startled. Okay, so basic life support would be reimbursed by Medicaid, but if the patient needs advanced cardiac life support, that's going to be provided, correct? It's just that there won't be a billing Opportunity, is that correct?

Correct.

Mr.

Ballard is going to go ahead and answer your question.

So it's correct. There would be a billing opportunity and it would be reimbursed at the BLS rate. So it would be reimbursed at that $448 rate I indicated. It wouldn't be paid at the ALS rate that is higher. I think the ALS rate is Thank you.

Okay. So as you can tell, we're a little trying to get this figured out here. So I think we'll need more information before we do the Medicaid side of this, which the department will provide for us. Dylan, can you— could you explain how it's handled If you would be okay with Sanford, you know, how they handle treatment in place. And thank you. And if you would introduce yourself, please.

Excuse me. Good morning, Mr. Chair, members of the committee. Dylan Wheeler with Sanford Health Plan. So treatment in place, we do not currently reimburse for treatment in place, but are certainly open to that discussion in the broader context of where this committee is going.

Thank you. I just wanted to make sure. So that is a section that we do have in this bill that we'll have— that we can think about. Really, it's Section 2 and 3. Representative Hughes, did you have a question or want to discuss something with 2 and 3, Sections 2 and 3?

Well, I did, and I commend You know, I have to say, I mean, I've said yes to every opportunity to serve on either interim study committees or commissions. And I— one of the real striking takeaways for me, Mr. Chair, and I think this is due in no small part to you, this is the most solution-driven efficient body that I— and not to, you know, not to cast aspersions at anyone else, but I am thrilled that a concept like exploring third-party reimbursement, which was thriving— I mentioned that in the first meeting— was seized upon, and here we have draft legislation. I mean, I have to remind this group When we're looking at private health plans, we're talking about reimbursement. I mean, here we are talking about funding. And in— I mean, as I was trained in law way back when, my torts law professor was a big proponent of enterprise liability, and he was a renowned antitrust Assistant attorney in D.C., which at that time was kind of the top of the food chain in terms of intellect for law school graduates. So anyway, not to belabor that, but the point is that we need to spread the cost. And I guess that's my whole— that's my orientation. And I'm thrilled to have the health plan people here. We need to have more of that input. Because the stakes are high. We're talking about people that file medical bankruptcy because of unreimbursed medical expenses, and the percentage of that in our country is extremely high. And so to me, what is more fundamental in terms of a core service than EMS? I mean, I can't think of anything else other than perhaps having a surgeon available You know, to treat an acute condition that requires surgical intervention or death is going to result. So I want some time to study draft 83 a little bit more, but I'm very encouraged by the language that I'm seeing, and I think it reflects not only the letter but the intention of one of the options that we started. with, you know, at our first meeting. So that— I mean, that's where I'm at. And I know we're not going to take action on this today, but I wanted to affirm based on an initial review of what I'm reading, and I hope to have some more dialogue with our stakeholders between now and the next meeting. Thank you.

Thank you, Representative. Okay. I think we've— is there a comment? Please come up. Yes, please. If you'd introduce yourself, please.

Good morning. Nicole Neugebauer representing SD EMSA. I just wanted to make the comment that although it is wonderful, and I did know that Medicaid reimbursed, that's a very, very small percentage In a lot of our areas. So not having the health plans— and I agree, Medicare is not going to be on board for a while— but having health plans and stuff get on board with this, it's very hard to go into someone's house. You don't look at insurance until after the fact. A lot of times we don't even get it until days later. Not that we would treat them any differently. So there is that fine line of what is payable. But I just wanted to make the comment that that it is wonderful that Medicaid does that and the state does that, but that's a small portion. So if there's any way to get these insurance companies to reimburse appropriately, that would be huge.

Great, thank you.

Thank you.

Representative Fosness.

Maybe, maybe Wellmark could speak to thoughts on that. They're here too.

Good morning. Melissa Clayman, Wellmark Blue Cross and Blue Shield. I'll echo the comments of some of the other previous speakers. Wellmark, this is a non-covered benefit for the most part, seeing Draft 83 for the first time today, but willing to have further conversations on what this could look like and what treatment in place is and what those covered services could look like in the future. So thank you.

Thank you. Thank you, Representative Fosness. Mr.

Johnson, congratulations on your hole-in-one.

Mr. Chair, members of the committee, Mark Johnston with Avel, and I was really—

You got a pretty good smile. That smile was even bigger than normal.

Well, the best part, I was playing golf with my good friend Tim Rave and And as I told my family, I've been playing golf for 51 years or so and finally got a swing that I liked.

So, thank you. Okay, so go ahead, please.

Yeah, sorry, I wasn't planning on coming up today, but the conversation has generally tripped a trigger in my mind about this topic of treatment in place, and we're very grateful for the opportunity to partner with the Department of Health now for a number of years on an initiative called Telemedicine in Motion. But Avel has been in the virtual care business for 30, almost 35 years now. Many of the healthcare enterprises here in the state utilize our services. And, you know, we've been following this discussion. And recently I was out in the state of Montana with one of our customers and we were talking about our behavioral health tool called Crisis Care, but then the conversation turned to how can you help me with EMS? And specifically around the question of nursing home transports because in this community in Montana, the city manager was commiserating about their ambulance Being nothing more than an Uber service for their nursing home. Well, it led to a conversation with our senior care team that provides telemedicine support to dozens of nursing homes around the state of South Dakota, and I just want to drop this little bit of information into your consideration. So in 2025. Our senior care team, who is a multidisciplinary team of MDs, NPs, nurses, pharmacists, psychiatry, and social work— those, all of those elements support nursing homes throughout our state. And in 2025, that team responded to 30,000 patient encounters in nursing homes in South Dakota. But what I didn't realize, they actually track treatment in place as far as EMS transport avoidance. So of a potential of 1,600 of those 30,000 patient encounters, a third of them we were able to treat in place in the facility and keep that citizen, that resident in their home, in that place, which is, we would probably all agree, that's the best place for that patient when it's medically necessary. So just a little nugget. I'm actually, we're doing a body of work right now based on, you've motivated us to take a look at it. Have it ready for you, probably closer to session. But just a little food for thought when it comes to treatment in place in other care continuums. So thank you, Mr.

Chair. Thank you. So anything more on treatment in place? I think I think we're at the end of today. I think we should talk about maybe a little subcommittee there too to work the treatment in place before the next meeting. So just kind of take that idea. Okay, what we'll do, I think, Mr. Chair. Oh yeah, Senator Peterson, please go ahead. Thank you very much.

I didn't have time to raise my hand. We've heard a lot about the advanced life support and basic life support and the difference in what's reimbursed and what's not and what's administrative rule. And I'm just curious about why it's one way or another and how those decisions were made. And do we going forward need to be more specific in code about what's reimbursed and what's not at what levels?

And Senator, are you speaking to the treatment in place or is that more of a general—

Well, general. When we were talking about if a patient Maybe didn't make it and how it would be billed. And so I suppose that's sort of treatment in place because they weren't transported, but I think it's probably a slightly different category of that.

Okay. I think that we should— yeah, you're correct that we should gather some more information on that. So thank you for that question. Anything else in treatment in place? Representative Weems.

Thank you. I just, I just think treatment in place is kind of a broad terminology. And so when we talk about treatment in place reimbursement for— from Medicaid for ambulances, and then we also have treatment in place in nursing homes, and we talked at a conference not that long about go about reducing treatment in place by not even sending an ambulance. So I don't know, you know, I think this group needs to kind of hone in on what are we talking about treatment in place and how does that all— is it all-encompassing? Because I think there's multifacets that we could see benefit from for EMS overall.

And it may be something we write into the committee work that we've talked about before. Yeah, I agree. Oh yes, please, Secretary.

Melissa Magstadt, Secretary of Health. I think that's a really good point, Representative Weems, is that there is a piece that when you're thinking about your task force, Department of Public Safety as the 911 911 and the dispatchers. And so as you're having conversations about, you know, treatment in place or, you know, offloading the ambulance services from unnecessary runs, the dispatchers and that particular— may be on the list of the task force.

Definitely. Thank you, Secretary. So we have a couple more items to talk about, but we also have Mr. Rave here to talk about EMS and healthcare facilities. He's got a hard stop, and so I don't want to get going on the other two items and then take away time that we may need him for. So we'll go ahead and invite Tim Rave up from the South Dakota Association of Healthcare Organizations to talk about EMS and healthcare facilities.

Thank you, Mr. Chair, members of committee. Tim Rave from SDAHO. I appreciate you accommodating my ridiculous schedule. I have a noon meeting that I have to run for about an hour. I will come back, Mr. Chair, if we run out of time to answer any questions after that 1 o'clock meeting. I will. I do have a hard stop at 11:30. So I just, you know, appreciate Representative Hughes asking the question last meeting. And so I spent some time thinking about that, prepared some written testimony I want to talk about today. Then just maybe have some general discussion and stand by for any questions you might have on that particular topic about hospitals subsidizing ambulance services or any other topics. I do bring 23 years of being a paramedic in Sioux Falls experience. Haven't done it for 10 years, but happy to take off my badge and give you Tim Rave's personal opinion if you so desire. Mr. Chair, thanks for the opportunity to provide information as to why hospitals, whether large systems or independent critical access hospitals, should not be required to pay for, subsidize, or underwrite ground ambulance and emergency medical service, or EMS, operations in South Dakota. South Dakota faces a documented EMS sustainability crisis, thus you have this committee here, driven primarily by chronically inadequate reimbursement, rising operational expenses, workforce shortages, declining volunteerism, and I was going to add one more thing, can't remember what it was. I'll get back to it. There are systemic problems requiring systemic public solutions. Again, public. Shifting the burden onto hospitals is neither fair, sustainable, efficient, nor consistent with how other essential public safety services are funded. It would harm the very healthcare infrastructure that EMS exists to support. Hospitals already face significant financial strain. We have approximately 54 nonprofit hospitals in this state, including 38 critical access hospitals serving rural and frontier areas. Recent data shows a median hospital operating margin of approximately 0 to 3%, with 19— roughly 19 hospitals as of the last cost report operating at a negative margin. Heavy reliance on government payers further constrained resources. This is even more exacerbated today than it has been given the current disruption in the Medicaid expansion and the insured populations due to federal changes from the That's going to have further impact on hospitals. Heavy reliance on government payers further constrain resources. Many hospitals operate on thin or negative margins, as I had previously mentioned, while still fulfilling their community benefit obligations, maintaining emergency departments, supporting trauma systems, air med, absorbing unreimbursed cost— or I'm sorry, unreimbursed care. Requiring hospitals to subsidize independent or county-run ambulance services would Deibert scarce dollars from core core hospital functions— staffing, equipment, facility maintenance, and retention of physicians and nurses— potentially accelerating closures or service reductions in areas already facing challenges in accessing healthcare. Hospitals are not an unlimited piggy bank. Forcing this subsidy destabilizes the destinations to which the ambulances transport patients. Unlike hospital care, EMS response is a community-wide public good available 24/7 regardless of ability to pay, similar to police and fire. South Dakota law does not currently classify EMS as an essential service that must be provided or funded by any particular entity. Ambulance services are operated by a mix of local governments, volunteer organizations, nonprofits, for-profits, that's important, and in some cases hospitals themselves. Public safety services are appropriately funded through taxation, local government budgets, dedicated districts. We already have ambulance districts under SDCL Chapter 34.1 that can levy limited property taxes. User fees where feasible and state-federal support. Shifting costs to nonprofit hospitals, even large systems, privatizes a public obligation without corresponding authority or accountability. Hospitals already contribute through collaborations, inter-facility transfer coordination grants, training support, and in some communities direct operation of the ambulance service themselves. Voluntary partnerships should be encouraged. Financial mandates should not. Cost shifting and higher patient costs. Hospitals would never recover these added expenses through higher charges. There is no guarantee that government or commercial payers will increase their rates to cover these additional costs. I think an important note here is what happens in the case that the patient doesn't pay? Does that mean the ambulance does not get paid either? These decreased revenues and increased costs will lead to reduced services elsewhere. It should also be noted that hospitals subsidize emergency rooms as not-for-profit hospitals. The reason we have the emergency rooms in this state is because of our community benefits. Large systems and independent rural hospitals have vastly different capabilities. A mandate would hit independent critical access hospitals, or CAHs, hardest while potentially favoring system-affiliated transport preferences. I'm going to pivot here for just a second and talk about the anti-kickback Kickback statute. That's a federal statute. It's 42 U.S.C. and a bunch of numbers that I can give you later if you want them. But I really think the thing that jumps out there is, and especially because I'm sure in rebuttal out here we'll know just the large systems should pay. I'll talk a little bit more about that in a second. If you— and I think it really falls under anti-kickback if you then limit who would subsidize these ambulance services. And I'll tell you why. Thank you. Subsidies that cover EMS operating deficits, subsidize staffing, or pay above fair market value are in the highest risk structure under the anti-kickback statute. They also— they look like value flowing in a referral service when no clear service is returned. And so I'm not a lawyer, not an expert, but reading the anti-kickback, I think You certainly could run into trouble there. And subsidies could create real or perceived pressure for ambulances— again, a little bit more on the anti-kickback— to preferentially transport to subsidizing hospitals, undermining patient choice, competition, and clinical independence. Lastly in this area, public funding streams can include performance standards, as the Secretary, I believe, or someone on the committee noted earlier. Maybe it was Senator Peterson, I think.

Yes.

Regionalization and transparency. Private subsidies lack equivalent public oversight. The core shortfall is inadequate reimbursement relative to the true cost of readiness and response, especially in low-volume rural areas where transport volume cannot cover fixed costs. And I think you cannot overlook that, that in— like my good friend from Kimball, they're never going to have enough volume to subsidize their ambulance service. And in fact, I only know of one I could be wrong. Service that's not subsidized in some other way other than the service in Sioux Falls, which is running, I think, now on the average 90-plus calls a day. That service is not subsidized by any municipal or state tax dollars. Other than that, I don't know of another service that doesn't get subsidized another way unless they're purely volunteer, like my good friend from Kimball, and they don't get tax dollars that I'm aware of unless it's changed in the last decade, which it could have. So I would say some possible solutions include improving Medicare and Medicaid reimbursement rates, which you're talking about today. You know, looking at that treat-in-place or non-transport response. And, you know, Representative Weems, you kind of asked about that a little bit, and you're right, it is a broad category. And back— we've been, you know, billing for treat-no-transport for many years, and I knew— I was aware of the Medicaid change a few years ago, even though I was out of EMS. But I really think the simple one is, a very common one, is diabetic, a known diabetic that, you know, their blood sugar gets low. You get called because they're unresponsive or incoherent. You give them, start an IV, give them an Apid D50, they wake up and go, I'm not going to the hospital. This happens, you know, 2 times a month and I'm used to this and I'm not going. And as the fire chief noted too, you know, there is added expense then in supplies and that cost has only exponentially gone up since I've gotten out of it. So I think there should be some reimbursement for some of those things. I think Representative Peterson brought up the, y'know, the fall, the, y'know, you go help an elderly lady up, she fell down in her home, she physically couldn't get back up again, but you pick her up, she's otherwise fine. That's something you guys all have to figure out, what is reimbursable and what is not. That's not my job, and God bless you for trying to figure it out. But I do think there's some model there. But again, that goes to really subsidizing, right? I mean, you're not— didn't really cost you anything. Cost you a little gas to drive over there. You're not losing any— using any supplies. But, you know, it does take time, takes you away from another call. And so anything you pay for there is air quote subsidy, right? I mean, that's just a different word for what you're doing. But, you know, certainly could look at EMS as an essential service. I know you guys are talking at length about that. You could look at expanding the use of the ambulance districts, generating some local support there. And I, you know, you guys talked about the state, and Senator Otten and I have talked about this, you know, is it solely a state burden? Is it a local effort as well? And I think the solution maybe lies somewhere in the middle there. I'm not sure. That's my opinion. Taking my badge off on that one. Regionalization, you guys have been talking about shared services, workforce development, technology. Mr. Johnson talked about telemedicine support. You know, that improves efficiencies without shifting costs to anyone else. Encouraging voluntary hospital-EMS partnerships for billing support, training, equipment, et cetera. Hospitals benefit when EMS is strong and reliable. They have every incentive to collaborate voluntarily. They should not be compelled to fund a public safety service that local and state governments have the primary responsibility And taxing authority to support. I think also a key piece, you know, it's not just, oh, these money-making patients come in, and I already addressed that, that they're not money-making patients. That, you know, on the flip side, where is the responsibility for getting patients out of hospitals back to a place that would be more appropriate for them to be cared for when the local service can't or is not able to take that patient to a different facility that's more appropriate for that patient at that time. I understand they're strained. They don't have the time to leave, be gone, do a 3-hour turn. I understand that. But that doesn't get back to the root cause of the patient is the one we should be talking about. They need to be in the most appropriate place for their care and to Representative Peterson's point, efficient cost. It's better for them to be in a long-term rehab or wherever that is Instead of a hospital. So I think, you know, you got to look at the whole pie. If you're just— if you just— you can't just look at slices on any given day. It's— let's see, I already talked about that. Concluding, referring hospitals or requiring hospitals to pay for subsidized ambulance services would paper over the real problem of underreimbursement and the lack of essential service status while imposing new risks on already strained rural health healthcare providers. It is inequitable, inefficient, and counterproductive. South Dakotans deserve a sustainable EMS system funded as public safety and healthcare readiness function through transparent public mechanisms, improved payer rates, and local choice, not by exacerbating subsidies from hospitals. I urge you to reject this idea, and I stand down and stand by for questions, Mr. Chair.

Thank you, Mr. Rave. Questions, Mr. Chair. Representative Hughes, go ahead. Thank you, Mr.

Chair. Mr. Rave, thank you for your forceful opposition to even discussing the idea of voluntary contributions from the healthcare systems. I do have a metric question for you, and that is I'm wondering. If the if there is a metric, and maybe Mr. Chair, this is something that could be pursued. I'd like to know what the conversion ratio is. For example, based on the type of emergency care provided and the subsequent outcome of the patient destination, because it seems to me that you know I don't know of any sector of our economy. That is better at cost accounting than our healthcare people. And so that's— perhaps you could comment on that, Mr. Rave. And then I do have a comment that I would like to offer, but I would like you to let us know if you are aware of a conversion ratio metric, if you want to call it that. You know, it's sort of like reaching out for digital advertising, which of course is something The major healthcare systems have enormous advertising budgets. I'm just wondering how you would bring to bear a conversion metric on EMS visits to hospitalizations.

Well, thank you for the question, Representative. I don't know that I have the perfect answer, but as you were asking the question, the scenario occurred to me. So maybe I'll state this scenario and then you tell me if I'm on the right track. You have a car accident victim that has multi-system trauma. They come into the hospital via ambulance to the emergency room, get stabilized to the point where they can go have surgery. Let's say they have many internal injuries, obviously some long bone fractures, et cetera. They require a subsequent long-term stay I think of some of the patients I took care of over the years, weeks, a month, much of that in ICU. Maybe, you know, racking up just— I'm just pulling this number out of the air theoretically, and I'm probably low. Let's say they rack up a quarter million dollar bill and they don't have insurance, but they're also not eligible for Medicaid because maybe they're making that 50 grand a year, can't afford insurance. But can't be on Medicaid. And so the hospital, that goes into, you know, uncompensated care. And the last data we had was $170 million of uncompensated care that hospitals across this state provide. That was 2 years ago. And so I guess, you know, on that, if you're looking at metrics, I'd say the hospital comes up really upside down pretty bad on that. You know, if you look at, you know, maybe then that person has Commercial insurance, you know, you're probably looking in that somewhere to— again, I'm not an insurance expert. I know a little bit about it, enough to be dangerous. Probably in that, you know, 85-90% of a contracted rate that in a contractual agreement they have with that person— or I'm sorry, with that insurance provider. Then you go to Medicare and that's somewhere, you know, 75% of that, and Medicaid's below that. So I, you know, I— I think I can ask. I know my coworker has written it down, I'm sure, behind me, and we'll look into it. But I think it's a really tough metric to measure because you'd have to get down to the detail of, well, that one came in in an ambulance and, you know, it didn't have insurance. There's no way for the hospital to recoup anything. You know, they'll pay $25 a month on a $250,000 bill forever. And that's, you know, that's the charity care that hospitals provide And I think if I could just talk a little bit about, you know, the— I failed to mention it earlier, the— you know, you brought up several hundred million dollars or whatever of money from the hospitals made. So I think, again, without knowing the details of what you're talking about, it's important for people, one, to understand any money that's made above margin is not profit in a nonprofit hospital. That goes to 3 buckets. Right. It goes back to their community. It goes back to their employees in the form of salaries. And it goes back to the form of infrastructure, making sure the facilities are up to date and safe for patients. And so, and the last piece of that is, even if one of the 3 systems which have footprints, and this is important to note, in multiple states, that is not a South Dakota bucket of money to play with. That is money that has to go back to all of the infrastructure in all of the footprint of the entire health systems. And so I think it's more complex than just saying, oh, there's a couple hundred million dollars there, so you should just pay for it. That is, that is really— it's a, it's a lot bigger. It's a lot bigger issue than just that. So I hope I answered your question, Representative.

Well, Mr. Chair, go ahead. I used to have 6 physician-owned medical practices. One of them was a A highly trained subspecialty group. And in 1996, I believe, South Dakota repealed its ban on the corporate practice of medicine, which allowed healthcare systems, which are corporations, to employ physicians in employment contracts. Until 1996 or '97, that was banned, that was outlawed. And that's still the law in California. So I want to go back. I want to roll back the tape a little bit and explain how we came to have the healthcare systems that we have. They were allowed to be created legislatively, and I want to clarify: they are not nonprofit; they are tax-exempt entity. And I'm not sitting here saying that there should be a statute that mandates subsidies. From healthcare systems, I'm calling for a recognition of the humanity of providing an essential service, which I certainly view EMS services as an essential service by collaborating as partners with a group of highly trained people that are experts in emergency care, emergency trauma care. Each of the major hospital systems has an ambulance system, both ground and air. This isn't anything that is unreasonable or unfair to ask. This is an ask. This isn't a mandate, and the word compelled was used. Far from me to mention compulsion. That's not what it is at all. I would never want to burden a community hospital Or a small hospital that is struggling to survive. What I'm talking about is extending philanthropy to truly benefit the least of these, really, and frankly, our own friends, family, and relatives when we have an incident. I mean, I can't— I don't know how we have a hard no on asking the healthcare systems. To become involved and to contribute. That—that's all this is—is an invitation to discuss. South Dakota changed its landscape. We completely abrogated our public policy going back to the Bartron case from Watertown in the 1940s that said that corporations should never be allowed to practice medicine. In fact, it used to be a criminal statute. for a corporation to practice medicine. And that was the law of South Dakota, basically from statehood up until 1996 or 1997. That's when the Sioux Valley Physician Alliance was formed. And it was formed amidst a lot of great controversy over whether any incorporated entity that is not physician-owned and physician-managed should ever be allowed to employ a physician. And South Dakota did like we did on usury. We repealed our usury laws to allow unlimited charges in the bank card issuance industry. So I'm trying to take a balanced view of this. South Dakota has bent In fact, some people might say that it's bent too far to accommodate corporate interests. And when you have a tax-exempt enterprise that owes its very existence to a fundamental change in South Dakota public policy, it is certainly nothing to be shy about or embarrassed about or to be talked down to. When we are simply asking our three major healthcare systems to join us in this conversation and even contribute staff, what would be wrong with having a committee of medical directors appointed from each of the major hospital systems that are board certified in emergency care to? Join us in this. I'm talking about having a conversation. People are living and dying in certain parts of our state based upon the geography of where their situation, their crisis, their healthcare event occurred. And I think that as an enlightened society, and especially when we're dealing with such an essential profession as medicine that we can have a better conversation about this issue. And we know South Dakota is so shy, and I am a lifelong South Dakotan. I love this state, and its people are so compliant and so trusting. And I think it's time that we reflect on the history of how we've changed our laws To accommodate things that we were told were going to be good for all of us. And this is an area, I think, which is so critical, and it's so obvious. And that's why all of us are so energized by the prospect of actually sitting down as a group and proposing measures that may well make a life-and-death difference for our people, if not our constituents, our people. And so I'm not trying to force anybody. I'm trying to have a rational conversation which is based on mutual respect and say, why not?

Thank you. Go ahead, Rep. I was going to say thank you, Representative Hughes.

This requires my name tag off just a sec.

I hate to tell you this, but you're kind of— I thought you shouldn't. Yeah, once you're here, you're here.

All right, I'll be up here with my name I'm aware of a rural hospital that's not— I'm not systems-based, but I'm aware of a rural hospital in my district that actually subsidizes the nurse's hourly rate times 2 to do ride-alongs for ALS because BLS is not enough for a lot of patient transports. That rural hospital with less than a 2% operating margin pays those rates, also does the laundry for the local EMS, does the training.

Okay.

And is there to help recruit, facilitate, and communicate because we need to, out of just necessity to provide EMS services and to help our county ambulance to meet those needs of patients. And so there are certain hospitals, you know, and I think that exists actually. It's not a system thing. It's a practical thing to keep the service and to keep patient safety number one. And that's what we all are doing across this great state is trying to keep patient safety To move the right patient with the right services, and sometimes it's just not even available. And that may be the case too in more of our metro areas as well, maybe less than it is in rural. And I guess I just wanted to make that point. I don't think this is even a system thing, and philanthropy could be philanthropy that would exist in all areas, but including receiving hospitals that also have charity care and a lot of times eat those same costs. Just as EMS does.

Other comments? Mr. Chair, hold on, Representative Hughes. We have more other people here that I want to get to. So any other comments here on the dais? Um, sorry, Senator Peterson. Senator Peterson, you had your hand up.

Thank you, Mr. Chair. Just a logistical, um, request, please. If, uh, For those of us online, if speakers would announce themselves before they speak, that would be really helpful. I just didn't know who the last speaker was.

Thank you. Yeah, thank you, Senator Pearson. I've been trying to call off names as they speak, and I may have missed it that time, so I appreciate that. Okay, Representative Hughes, we got a few minutes here if you want to go ahead. I mean, you want the last word on it.

In the most respectful And hopefully dignified way. What I want to say is, in South Dakota, we can't let the exception drive the rule. I've practiced law for 44 years, and I've dealt with expert witnesses who want the exception to drive the rule. They want the exception to eat up the rule. I just said, and I don't know how I can more clearly state it: I am. I understand health. Look, I have two family members that are subspecialty physicians. I love them to pieces. They're terrific people and terrific physicians. And so my heart is in healthcare. I had many— my goodness, I, like I said, I had 6 medical practice groups, all of whom were purchased. They were all acquired. And I have to ask myself, we've lost something. We've lost a connection to community that we used to have. And I live in a town that is awash with healthcare presence that is awash with advertising budgets. I'd like to see a voluntary contribution of a small percentage of each of the advertising budgets of the healthcare system, or perhaps to do public service announcements that are saying we are part of the EMS solution. And as, as the speaker here knows, I was part-time city attorney in Baltic for 25 years. And Mr. Rave is very familiar with that community, and it galled me every year as that community struggled to provide funding for EMS services. And this is a song I have been singing or humming for 30 years, which is, why can't we get a community conversation going in our state and say, We have these brilliant people that, including Mr. Rave, Representative Fosness, who I have deep respect for, Representative Emery is involved in this industry and many others. Why can't we sit down and say what would be a reasonable ask to give back? The percentage of charity care is nothing to brag about in this state. I mean, not on a system By system basis, it's not. It's small percentages. And so I just think I'm not afraid to ask, and I guess that's the point I'm trying to make. And people can say no, and I will respect that. And if that's the position of Mr. Rave and his organization, hard no. Okay, I've been told hard no on many things that I've tried to accomplish in my legal career. And so I appreciate this, and I hope there will be some Oh, what should I say? Some acting upon what the points are that I'm trying to respectfully and politely get across. And then I thank you for your time and for listening.

Thank you, Representative Hughes. Last, any other comments on this? Okay, Representative Weems, and then we'll go ahead and move on.

Thank you, Mr. Chair. I know that some of the 3 major healthcare systems in our state own ambulance services in different communities in our state. And so I think they are interested in EMS, and I think it's really hard for a committee to say, You have to do this as a philanthropy, I think that is all up to the individual company to determine. But don't think for a minute, I don't think for a minute that they're not vested in EMS. They realize that EMS is an essential service in our state. And I would guess that in any of the communities Where there is a presence, they're probably active with the EMS in some way, shape, or form. I also think there's a distinct difference between asking for money and asking for advisory services. And I think having advisory services might be a benefit for everybody. But the other thing that I think, you know, when we're talking about EMS and we're talking about healthcare in general, this is all about the patient. We need to get back to what's best for the patient and not— and that's what EMS does, is they go, they show up, they are there for the patient. And that's what the hospitals hospitals do in every little town across South Dakota, in the independent ones, in the, um, in all of them. And so I just, I just want us to know that we appreciate what all of our hospitals are doing, independent. We appreciate what the EMS are doing, whether they're large-owned, whether they're volunteer Whatever, I think our eyes have been opened, and I think I'm speaking for the whole committee here when I say our eyes are opened to how large the problem is, and that we all care about this too, and that but we have to think about ways to solve this the problem that are innovative and move us forward. and not demanding a certain entity add into the mix. So I'm not speaking for the whole committee on that last statement, but yeah, I'm speaking for myself.

Thank you, Representative Weems. We'll go ahead now, I think, and move on. We've, we've worked on this or had good discussion about this on our agenda. Sorry, I'm trying to get it pulled up here. We've got 2 different things that still were in the morning. I'm afraid we're going to have to move to the aft— well, at least one of them to the afternoon. I think the easiest one to tackle right now is the interstate and transit calls. We want to make sure we're back at 1 o'clock because we do have Indian Health Service representative here to kind of talk through those issues with us. So let's talk about interstate and transit calls, if that's okay, and then we'll We'll go ahead and break for lunch. There was a document that was—it's it's a it's on the public side of our our website, and trying to pull the document up here. I can find it, and it was put together from the Department of Health for us, and it's I ninety and I twenty nine ground ambulance nine one one calls. And that just gives us a little more data on what's going on with the ambulance calls that we do on I-29 and I-90. Some good work that they've done for us. And as you guys are calling it up— I'm trying to summarize it a little bit here. And in here it says that there's 585 patient records from I-90 and I-29, which is 6% of the roadway patient records that they've found. So otherwise, I-20, you know, our interstate versus highways. So our interstate is 6%, and then 37 different agencies respond to those, I-90 and I-29. And out of that, 390 patients were transported, 276 were not transported. And then they talked about that 26 of the 37 responding agencies use volunteers. I think that's one of the more critical aspects of this, that it's very volunteer-based when you're on the interstates. And then it did a good job of showing what— when do those responses occur. And as you can see, the busiest times, of course, are during tourist season. So thank you for providing this information. The Department of Health. I think it was really helpful. Questions or discussion on it?

Mr. Chair, just a question for clarity. In establishing the interstates, is this a request for additional reimbursement or attention, or is it— what would be the goal of that?

Yeah, thank you, Representative Fosness. We had just had discussion about how— what's the impact, what's going on, you know, with our I-29, I-90, because it's always been a discussion. We've had people here talk about it. So this gives us an idea of kind of the how many. Right, and how many of them are you know due to accidents and such. And then I think the most important. I think the two things I took from it was how many of the agencies use volunteers. So this is a volunteer issue when we talk about the interstates, which links back to Senator Otten's you know concept of the hotels and such to help help with this situation, and seeing that it's you know it's in the summer months. I think that's. That's the point of what we wanted to have. Is that fair, Marty? Kind of what the—

Yes.

And of course we can talk about it at the end too, but that's just what this information is about. Okay. I guess with that, we're a few minutes early before 11:30, but it probably still is a good time for a break. We will get started right away at 1:00 because we do have a presentation from Indian Health Services. Thank you, everybody, for a good morning, and we'll go ahead and gavel back in at 1:00 p.m. Good afternoon, everyone. We'll go ahead and get started, and we're going to go ahead and do the 1:00 agenda item, and that we have Jared Sampson, who is EMS supervisor for the Cheyenne River Health Center. Last meeting we had some questions about Indian Health Services and the arrangements and agreements that they had kind of inside and outside of the reservation. And so, Jared, if you go ahead and introduce yourself, please, and if you had any kind of opening comments. Oh, sorry, we're not hearing you, Mr. Sampson. And you are— we see you are unmuted. Representative Hughes, could you just make sure we can hear you, make sure we have everything on our end?

Yes, Mr. Chair, loud and clear.

Okay, thank you. Mr. Sampson, we're— oh, it looks like you're— that's somebody else. We're going to go ahead and send you a phone in. I know if you could check your, you know, your mic, if you have the correct mic chosen. All right, Mr. Sampson, can you, can you hear us? Can you give me a thumbs up if you can hear us? Okay, we just can't hear you. Okay, I will send him the phone number. Mr. Sampson, we have sent you a phone number if that'll work easier for you.

Okay.

Good morning. Can you hear me now? Morning. Can you hear me now? Morning.

Can you hear me now, please? We can.

Now we're getting— am I still getting the feedback?

No, we're not getting the feedback anymore. Okay. So sorry, let me get everybody back to order here. So we've got you on the phone. Thank you. Sorry about the the issues with that. But if you want to go ahead and make an initial statement, if you had any kind of information you wanted to provide us, I know we did provide you with the questions, the video of the questions from the last time that we were together. So if you want to go ahead and talk about that, otherwise we do have the questions too. And then Senator Peterson was active in asking those questions, so then we'll check in with her too. So go ahead, Mr. Sampson, just introduce yourself.

Please. Okay, my name is Jared Sampson. I'm the ambulance director here. I was formerly the EMS coordinator for Great Plains Area IHS. I've been the EMS director here for 5 years. I've done some assistance with Pine Ridge as well, and I believe the purpose of the meeting was asking about IHS covering EMS costs for tribal members off the reservation. Kind of, there's no easy yes or no answer. It's going to— you start with the eligibility. Not every tribal member is eligible off the reservation.

Okay.

For their healthcare being— there's certain steps that need to be taken in order for IHS to cover that healthcare. Eligibility is one. Looking at their purchase-referred care is how IHS covers it, defines it. Making sure that they're— are they in their designated area? For example, I'm a tribal member here in Eagle Butte for the Cheyenne River Sioux Tribe. So some of our surrounding counties are our coverage area. And then you— there's other steps to take to— if I was to be off, say, in Rapid City for training, business, shopping, and I needed an ambulance, the first couple steps would be for an ambulance. Service to bill for that would be to determine if I was eligible. Just because I'm outside of the coverage area that my tribe covers doesn't mean that they wouldn't get payment. It would just take a few more steps. There's a 72-hour notification in most cases that ambulance service or healthcare provider or the individual would have to Make sometimes that gets extended based on circumstances, and then you start getting into was it medically needed? Was the services could the services been offered by IHS-funded resources? And it would just be case by case. To find out if IHS would cover the cost. And I, I can take questions on different situations if you would like.

Sure, thank you. So I guess the first question is, are there agreements between IHS and providers or in the state on the reimbursement amounts?

IHS typically does payer of last resort, and I don't know if there's a set of agreements on rates that IHS would pay. I do know there's some— if we refer back to the IHS website, they have some PRC rates that they publish that would cover ER visits and outside hospital Services, but as far as I know, I would have to double check that if IHS has a specific agreement with the state.

Okay, thank you, Senator Peterson. I know you had some questions at our last meeting. Would you like to go ahead and and ask those questions at this time?

Sure, thank you, Mr. Chair. And the questions may be, it might have to be a combination of people who help answer those. Maybe there's someone on the state side that can help as well. But really, you sort of asked it when you said, are there agreements? And I think the key is, you know, we made agreements as the state with IHS several years ago for Reimbursement for other types of healthcare. And, you know, so my question is, are those same agreements and conditions and eligibility requirements in place for EMS services, or does that run on total separate track? And do we need to try to get them on the same track with the same agreement so that if those are actually legitimately IHS expenses, that the state or the county Or the city, whoever's running the ambulance service, or private entity, is compensated for that by IHS?

I would have to look under the agreement itself to see if— but I would imagine the same eligibility for IHS to receive or to cover those expenses would fall in place.

Mr. Chair, follow-up?

Yes, you go ahead and continue on, Senator.

Okay, thank you. So then I guess my question would be, is there the follow-up happening in terms of the billing and the reimbursement? And I mean, I know it's complicated for these small ambulance services just to get the billing done. But then for them to be able to interact with IHS, make sure all those criteria are met, and then actually follow up and stay on it to make sure that they get the reimbursement. I'm just wondering if we need to look at some improvements in that process, or can that process be, you know, tagged along with some other process that's already happening with healthcare? And again, I think we might have to get Maybe somebody from the state involved. I'm trying to remember who the key people were in negotiating that agreement, but maybe there are some folks who were involved in that in appropriations at the time that could help point us in the right direction.

I don't know if we have anybody here that was part of it. I remember it happening. I don't think we have anybody here that was part of that, but I think—

I don't think there's anybody currently, right? But there's a few people that I might be able to check with to see if they could. I didn't wanna call 'em out by name.

Sure, sure, I understood.

But I think that there are a few of us long timers still around that might be able to And I think the regionalization aspect of it too could create the, you know, having the communications to make sure those kind of things get done for each. Because what I'm hearing from this conversation is that it's really like you said, what's the follow-up, you know, and who's working with that? And I'm sure that gets more difficult for these ambulance services that may not have the time or resources to be able to follow up and figure out how to do all that. So I think that's what we're hearing.

I agree.

Okay.

Because I think it was in the beginning a paperwork nightmare for even some of the larger healthcare systems when it started to try to get that process in place. But I think it's been there now for a while, so hopefully they've been able to streamline it and maybe we could tag team with that somehow.

Yes, I think that is point well taken, Senator. Any other questions for Mr. Sampson from the committee members? Well, thank you for being here. We appreciate it. Taking a little time out of your afternoon here. And then now we've got the contact information. We do need to have some question and answer that you might be able to answer. We'll go ahead and—

Mr. Chair?

Oh yes. Is that— yeah, Mr. Hughes or Representative Hughes.

Thank you. Thank you. Yes, John Hughes, District 13. Mr. Sampson, are you familiar with instances on the Cheyenne River Sioux Reservation where death has occurred In your view, that could have been prevented by more timely EMS response.

We cover a very large area, so yes, you can probably go back and. See that if we had more ambulances to cover, like some of our outlining communities are— it takes us an hour and a half to get there just because of dirt roads, some that aren't even graveled we have to take. So, yeah, there's been a few calls that probably if we had something closer would have better suited the patient.

Follow-up, Mr. Chair?

Yeah, please go ahead.

On the Shimer Reservation, do you know the average response time from emergency contact until arrival of EMS?

So we have 2 ambulance services that operate on the reservation right now. You have one in Timber Lake, then you have us here. We're kind of centrally located. Obviously, the 911s in town get answered pretty quickly. I would say probably outside, you're going to average 30 to 45 minutes when you get into those rural areas.

Follow-up, one follow-up question, Mr. Chair.

Go ahead.

Mr. Sampson, are you aware of any Indian Health Services standards On that, for example, I know that in the case of a cesarean section for a child, for a baby being born, a hospital is required to have a team that is able to respond within a certain time window of being notified that they have an emergency birth coming up. Is there something equivalent in Indian Health Services or even in—

Yes.

Standards of care for EMS in general that you're aware of as to response time?

Yeah, we— so we still require responding. We have 5 minutes to respond. If your question is more towards trying to set up other areas so that our response time from the patient is cut down, that I am not Okay, Mr.

Chair, one clarification. So I probably wasn't as clear as I should have been. This would be, is there a response time from first contact to arrival of emergency personnel at the point of the patient, the potential patient, that is required by any IHS standards or national standards of care that you're aware of?

No, not at this time.

Okay, thank you.

Anything else? Okay, sounds good. Well, thank you again, Mr. Sampson, for being here. If we have any follow-up, we'll go ahead and contact you. Great, thank you for giving me your time. Thank you. We're now going to return back to I can find my agenda. The last thing we have from the 9 o'clock session is reimbursement rates for EMS by Medicaid and private insurers. And in the— in our information that was provided to us, we were given the The Medicaid— there's a sheet called Medicaid versus Medicare Ambulance One-Pager that kind of compares the rates. And what you'll find in this report is that Medicaid versus Medicare are pretty close, except for, as it's called, the super rule areas. And there you can actually have a 22% below in the super rural areas. And of course, those are the areas that we hear, you know, that some of the toughest areas to keep our EMS system going. And so the question there is, is there something that we should be looking at for the super rural areas? And I think, Mr. Butler, if you have anything you'd like to come up, Just let us know if you'd like to come up and talk about this. But this has been shared with you, correct?

Yeah.

So is there anything that we want to take a look at because of these super, super rural areas for reimbursement rates? Everybody got it up to kind of take a look at it?

Yes.

Maynard, come on up here while everybody's taking a look at it.

Maynard Konechne from Kimball with the South Dakota EMS Association. Just to let you know on that super rule, that's actually every year they have to renew that. They've been trying to get away from even paying that. The National EMT Association would like to see that put in there forever. A year ago, they got it to go for 2 years, so it is good till next year, but we'll be back fighting that again. But that's not guaranteed. It's a yearly thing up there in Washington. They've been trying to get it permanent, but it hasn't. So just so you know that that's something that— Thank you. Could change very quickly.

Sure. Thank you. Comments on what you guys think with that? Mr. Chair, is Mr. Hughes representing Hughes? Yes. Yes, Your Honor. John Hughes, District 13.

You know, back in my healthcare days, I know that healthcare providers that took Medicare assignment. were greatly welcomed in the area, especially of interventional cardiovascular services. And I worked with a group that did offer assignment. Do we have something similar with EMS providers where they accept assignment of Medicare or Medicaid or private third-party insurance? Is that something that— That this gentleman is able to address, or someone else?

Would you restate your question, Representative?

Certainly. My question is, is there any customary practice in the world of EMS where EMS providers take assignment of benefits as payment in full? For example, ground transportation, you know, whatever Medicare provides, whatever Medicaid, whatever private insurance provides. Do we have anything like that? That is a— I know back in the day, I don't know how it is now, but back in the day, going back about 30 years when interventional cardiovascular services, stents, angioplasties was emerging as an alternative to bypass surgery, The healthcare providers that took assignment, for example, of Medicare benefits, that was of great benefit to the patients. And there were other providers that didn't. And so they only took Medicare payments as a partial payment, and then the patient remained responsible for the balance, which could be huge. So I'm just wondering, in the world of EMS, Is there any consensus, or is there— because obviously what we're talking about here is third-party payment, but we're also talking about perhaps trying to address the medical bill fallout that occurs when individuals— at least I am interested in that issue— when uninsured or uncovered medical expenses are Are the responsibility of the patient. And so this would be really someone familiar with the billing collection system for EMS services in South Dakota. Do EMS providers take assignment of benefits, I guess, is really the simplest way I can state that, Mr. Chair.

I think you're talking about balanced billing.

Thank you.

Balanced billing. And we're actually going to talk about that in just a moment.

Oh, excellent. Thank you so much.

Okay, Mr. Chair. Yeah, go ahead, Representative Fosness.

Thank you, Mr. Chair. I just, I guess I would, I would like to know more about the list. You know, in South Dakota examples here, it lists Philip, Kadoga, Faith, Buffalo, Lemmon. Those are just examples of commonly super rural status communities, and they have to apply. Appreciate the clarification on how often they have to apply annually. Sounds, or biannually now, biannually, apply every year. I just want to make sure I heard that right.

I don't think they had to apply every year. It's just that the federal government requires the community—

No, it's, it's based on their zip codes.

On zip codes?

Yeah.

Okay.

So if that zip code is designated a super rural, it stays that.

Okay. Along those lines, the question I believe you asked, is there anything within Can this task force look at Medicaid rates to possibly mimic the super rural Medicare allowance? Is that your question to the group?

Yes.

Within the capacity that we could make a recommendation, I would think yes, because Medicare did it. Maybe we should look at that as a state Medicaid as well. But just wanted to make it— someone to address your question.

Go ahead, Maynard.

Maynard Konechne from Kimball with the EMS Association. To answer your call, it's the federal government that makes that determination. You don't have to apply because in South Dakota every ambulance service in this state except Sioux Falls and Rapid are super rural and get that increase in mileage. Other than those two services, I believe. There are some that are on the verge of that, but most of us all get that. So it pertains to the whole state of South Dakota. And as Representative Emery said, it's based on zip code. So that's where that comes from. But it's the federal government controls that, and they. They have tried to get away with that without paying that, and the National EMT Association has fought that, and hopefully we can— like to see that become permanent.

Thank you, Maynard. I think we would want to take a look at this, not necessarily like it's defined for everybody except for Sioux Falls, but I do think it's Something we might want to look at for what we would consider super rural areas.

Right.

Yes. Okay. That's something that we can figure out what's the appropriate method to move it forward and then have a vote at the next meeting if it's something we want to do. Any other comments? Okay. Now we'll move on to the second half of that part. And as you know, last year Last year. Or last session, I should say, we proposed Senate Bill 211 as kind of a start of the discussion on reimbursement rates when there is not an agreement in place, you know, contracted rate. And it kind of is two-sided as well. Then how much should be paid? And then the other side of that is then, but you would not have any balance billing. So in other words, the ambulance service itself would get paid, and then you could not send more of a bill to the patient. And so it's something that I just wanted to start the discussion with, with the committee, if it's something else that we want to propose, or if it is a bill we want to propose for the next session. If we want to, we can have the— at any time we're discussing this, if the insurance industry wants to kind of speak up about it, just please stand up and come on up here if you want to make a comment. So that's what I'm wondering on that bill. Is it something that we want to do again? North Dakota has theirs set at $250 of MediCare, um, and then the balance billing is part of that. That's something that has happened up in North Dakota and is working now. We had Senate Bill 11 we proposed at 350, and I think it was more of a starting point as a necessary where we had to be. Go ahead, Representative Weems.

Well, Mr. Chair, I think you mean Senate Bill 211.

Yeah, I guess I thought I said 211, but yeah, so 211. Sorry about that. It was my bill. You think I'd know what the number was?

I'll keep talking then.

Okay.

I don't think this is— I think this is a good idea because I think otherwise it's all being balance billed. Well, it's not consistent, is it, if it's balance billing to the patient or not? Yeah, I think this is a good idea. Some might not like me saying that, but Mr.

Chair, go ahead, Representative Hughes.

You know, pardon me if I'm behind the group here, but Do we have a definition of balance billing to work with?

Balance billing is where you can't— once this amount's paid, the ambulance service cannot then go— cannot— the balance of what they thought they should get, they cannot bill the patient.

Okay. And that's what— During my tenure in healthcare would have been referred to as an assignment, taking assignment. So I appreciate that, Mr. Chair. Thank you.

Now the House didn't see this bill last year. It failed in the Senate. So that's a little bit— puts you a little bit behind the 8-ball on it.

Thank you. Thank you, Mr.

Chair. Thank you, Representative. Mr.

Chair, I have a question. Okay, go ahead. Very basic definition question. I have a question. In Section 4 on the second page, right at the beginning, out-of-network ambulance service, are pretty much all ambulance services out of network unless it's an Avera ambulance taking a patient, you know, getting paid by Avera insurance? Is that correct? I just, if anybody wants to put that on record, because sometimes in certain plans, it seems like, you know, it's not out of network unless you're paying extra. So sometimes it becomes an in-network thing because there's not an otherwise in-network hospital.

Thank you for coming up. Please go ahead and introduce yourself.

Melissa Clayman, Wellmark Blue Cross and Blue Shield. Thanks for allowing me to geek out over insurance, I guess is probably the answer here. So I'll go back. So insurance law today says that if any provider has a contract with me, they can't balance bill. So they're in-network. If they are out-of-network, then they can bill the remaining amount that the insurance company doesn't pay. So to answer your question about the in-network, out-of-network, I can tell you for Wellmark and Wellmark alone, because I think we're talking about So, for EMS services, 15% were private insurance. I think there's a question of exactly what that private insurance is. Wellmark is in a subset of that 15%, but of the ambulance claims that we see today, we have 93% of those claims that we see today are in-network providers. So it's a small portion that is out-of-network but is— has the potential to balance bill consumers. Does that help?

Yep, go ahead. Go ahead, Representative Fosness.

Okay, let's, let's go another layer with that. I get in an accident in Pierre, and if AMR here in town is not in that network, they would have the ability then to bill me above and beyond what Wellmark would pay out-of-network.

Correct. So if we have an insured in the Pierre area for Wellmark, we're going to pay it what our average cost is. And so we pay that, and I'm just going to use straight numbers here. And so if that's $1,000 that we pay as a negotiated rate for our in-network, and that bill from AMR is $4,000, they can bill that patient the remaining $3,000.

And to follow up to that then, in the same So in this scenario, if AMR were in-network, they are to take the negotiated rate with Wellmark, right? And then they cannot bill the patient beyond that, correct? I want to make sure our whole committee is clear on that difference. Okay, thank you.

So I'll continue on something we've talked about before. If it's out-of-network though, you actually pay the patient. Is that correct?

Yes. Yep, we're gonna pay who we have the contract with, and that would be our insured, the patient.

The insured, the patient. So that's also important to know that this would flip that also. You could charge a certain amount, pay, and then the patient, they would go directly to the ambulance provider, which obviously can, you know, be beneficial to the providers.

Yep, but we pay who we have the contract with.

Right. And go ahead.

Do you have a notion of how many in-network providers, ground ambulance providers, that you have here in South Dakota?

So 93% of the claims that we see are in-network providers. So we have a majority of the providers are in our network.

Representative Peterson.

Yeah, thank you. Thanks for that first answer. Is that kind of an industry standard? Up in that high range. Do you know if anybody else wants to speak to it? They're nodding their head yes. So one of them are.

Yeah, I think it's pretty consistent.

Any other questions for Melissa? Representative Weems. Thank you.

So my question is, if somebody's traveling inside the state and has a No, it's traveling from outside the state into the state. And let's say they have Wellmark from another location, okay? What— Blue Cross Blue Shield Minnesota, okay? Then how would this— did you look at the bill?

I've looked at the bill from last year, but if it's any different from last year, then no.

How would this impact that? If it's an out-of-state person traveling through the state getting EMS services and their insurance company is from out of state and doesn't have any contracts with our providers.

So how insurance law works— and Dylan, you can help me out on this— how insurance law works where that policy is cited, so if it's Minnesota consumer with a Minnesota policy, it's typically going to be Minnesota laws that control that policy.

Okay, anything else?

Representative Peterson. If I may, can we go back up just a touch? So in-network negotiating rates, is there a parameter you're Whereabouts are those rates at generally, and do you base them off of Medicare like this bill would, or Medicaid, or is it more of defined numbers on a contract, not pegged off of another rate?

So rates are all negotiated individually, and I know the issue and the concern with smaller ambulance services negotiated. Average Wellmark is around 125% of Medicare. So we are higher than Medicare, Medicaid.

Good question. Nothing else here? Okay. Thank you. You have to sign in too if you want to do this.

Oh yeah, I have not.

Thank you for coming up here. Further discussion? And this is one where we have a model bill that we can put together pretty quickly. You know, it can be thought about a little bit, but wanted to make sure it got in front of everybody. Representative Weems.

Can I ask some of the EMS people?

Sure.

Thank you. Okay, so for any of the EMS providers in the room, um, do you— when you're balance billing the patient, if you balance bill the patient, do you Do you usually recover those dollars or are they uncollected dollars?

Yeah, thank you for coming up, and if you'd go ahead and state your name again. Gary Langerock, Watertown Fire Rescue. So when we do our balance billing, balance billing the patient, Sometimes they're collected, sometimes it's not.

If the patient— the patient will get the invoice for the remaining amount due. If they don't pay it, they'll get repeat notifications, repeat invoices. At some point, if no payment is made, they will go off to a collections agency. So some of them pay it, some of them don't.

I guess I'll follow up. Do you have any idea of how much you write off on an annual basis with nonpayment?

It's a considerable amount. To get actual numbers, I could certainly get you actual numbers, but yeah, I would have to get you some better numbers.

But it is—

yes, it does end up being a considerable amount.

Okay, thank you. Anybody else have another anything else or discussion on this item? Dylan, if you'd like to come up, that'd be great. And if you'd go ahead and introduce yourself, and then if you'd sign in too when when you're done.

Thank you, Mr. Chairman, members of the committee, Dylan Wheeler, Sanford Health Plan, Representative. Representative Weems, just in response to your question, I agree with my colleague from Wellmark, but I think it's important to note, too, the scope of state legislation as it relates to health insurance benefits. So in addition to a jurisdictional question of where the plan is cited from, it's important to note, too, what type of plan it is. So conceptually, state legislatures can only regulate fully insured lines of health insurance businesses. So that's your products that you buy purchased through the Affordable Care Act or you may get from an employer. But what's important to note here is what is excluded. Your self-insured health insurance products. So those products that are purchased by large employers across the state, states cannot essentially set coverage requirements for those types of plans. So when we're talking about even the bill draft previous this morning about the treat-in-place, the mandated or excuse me, the Medicare rate from this bill would only impact probably less than 25% of the health insured lives here in South Dakota. So as we try to scope and understand Senate Bill 83 and potentially this draft moving ahead, just wanted to, in addition to the jurisdictional question, understand the scope of and who this would impact across the state.

So thank you, Dylan. Yeah, of course. So, and if you just stay up for a minute, does everybody kind of follow that? Okay. Because it took me a while when I— that was explained to me. But basically, well, in the state, the state would be— they're self-insured, correct? I believe, Mr.

Chair, I do believe the state plan—

and then the major companies, and then this would not have applied to them is what you're telling us?

Mr. Chairman, if the state were to pass a law, they could voluntarily adopt that for their plan, but traditionally the plan sponsor, i.e., the employer, would direct your TPA or third-party administrator how to create a plan. So they could say, hey, Sanford Health Plan, we— they passed this law, we want to do the same with our products, please do so. But in the absence of that direction, no, we couldn't without their authorization to do so.

And we as a state would not force them— if we pass this, that would not force them to pay that amount, or they would not have to follow any of those rules? Rules is what you're telling us? Mr.

Chairman, I think in the absence of specific legislative text directing the state health plan to do so, no, I don't think it would necessarily apply. Same with Medicaid, Medicaid expansion, etc.

And any company that has a group plan? Correct. Okay, thank you. Just want to be real clear with that. Okay, thank you very much. You're welcome. Mr. Chair? Yes, go ahead, Representative Hughes. I appreciate that.

From the gentleman from— that's a huge clarification for me. So thank you for that. Thank you for that clarification. So really, the heart of volunteerism is at the heart of a lot of this, the way I'm looking at this. So just because the minimum requirement of the law is such and such doesn't mean that we can't do more voluntarily again. Thank you.

Thank you. Further comments? Like I say, this is something we can decide at the next meeting. The draft is there. You guys can give it some thought. It's a small amount that it— go ahead and come up, Ms. Rowland. It's a small amount, although as we talked about, it might kind of set a pattern saying this is what really should happen. I have a feeling that most of our— it's just a feeling, there's no data to back it up, but I wonder if a lot of our group plans don't make sure that this is done anyway at a reasonable rate. So go ahead.

Mr. Chair, Fire Chief Rowland and Watertown Fire Rescue. I know you asked the question to my EMS chief in regards to numbers. Last year we billed $3.7 million in collections last year, and we took in roughly $1.4 million in revenue. We had $500,000 in ambulance collections and And $1.8 million in contractual write-offs through Medicare, Medicaid insurance and such, IHS.

So you're saying that $2.3 million was what you wrote off?

We wrote off $2.3 million, yes.

Okay, and then just say that again, just a little bit slower. What, what areas is that through $2.3 million? Medicaid?

So $1.8 million was contractual write-offs, Medicare, Medicare, Medicaid insurance. $500,000 was ambulance collections that went to the patients. That was unpaid, of course. $1.4 million was ambulance collection revenue.

Yes, that's the revenue. Okay, thank you. I think that helps put it in context. Appreciate that. Uh, Senator Otten, is it for Mr. Rowland?

Um, do you know how many runs That you did to accumulate this?

We had 3,000, uh, I believe 84 ambulance calls— I'm sorry, 3,184 ambulance calls last year. We did transports for just around 2,200. That's in 2025.

Good. Senator Otten? Okay, great. Thank you. We'll let everybody kind of let that sink in. Any comments? I mean, like I said, this is something we can discuss more, but I wanted to make sure we had it in front of us because then we could vote on a draft if we wanted to go forward. It doesn't— it seems like kind of discussing it, the juice, you know, isn't worth the squeeze on it. I think it's worth discussing. But then when you start seeing that, you know, that there was $2.3 million in write-offs— Yes, you may.

Okay, thank you, Mr. Chair. Can I ask one more question on that, on Watertown's data? Of the $1.4 million ambulance collection revenue, how much was straight self-pay and how much was balance billing? Do you know that?

Mr. Chair, Chief Rowland, Watertown Fire Rescue. Representative, I can tell you the payer mix was a collection of Medicare patients, Medicaid insurance mix, IHS, VA insurance, and self-pay. So that would be our payer mix.

Thank you. Thanks for coming back up. Yeah. Okay. Okay, good on this subject. Like I said, do you want me to keep it on for an agenda item that on the next? You don't think? Okay. Okay. Well, I'm gonna. Unless I get an overwhelming response from you guys to, you know, have it on the next agenda, we'll— it can be brought up at that meeting too. So, um, Representative Hughes.

I— yeah, Mr., uh, Mr. Chair, John Hughes, District 13. Yeah, I would appreciate it staying on the agenda.

Thank you. Okay, I think we will probably just let it sink in with everybody and Have some discussions and then we can talk about it. So, okay, thank you. Okay, we are a little early, but now we're at the open public input. And let's— I want to make sure I see that we're up. Yes, so we're at general comments. I think you've heard a lot that we're talking about here. If you remember those items, it's in the 9-10 portion, all those that we talked about. This would be a good spot, you know, to hear from people. I think we're going to have a few, at least one person online. I'm going to check that, but general comments on where we're heading with this. It's a good time because we're going to start looking at the legislation, so that would actually write. So it's a good time for input. Okay, well, I'll go, um, Gavin, we see that you're online. Would you like to speak to this?

Sure, I have, uh, something I would like to say here. It's a little bit different of a topic.

Um, okay, so go ahead and introduce yourself first.

All right, so My name is Gavin Sanas. I grew up in Webster in Day County, and I've been an EMT for both Day County Ambulance and Brookings Ambulance.

Hey, go ahead and let us know what you'd like to talk about.

All right. So today I'm here to talk about my experience in EMS and hopefully offer some insight into the rural workforce funding, and then also the sustainability of it. When I started volunteering in Webster, I was the only active volunteer under the age of about 35, with volunteers pushing into their mid and late 70s. I saw this as an opportunity to combine my youth and experience in EMS. So then in January of 2026, I started a cadet program in Webster High School, Day County Next Gen EMS, that allows juniors and seniors to job shadow the ambulance on 911 calls. 9 students participated in the first semester, with 2 pursuing EMT training. To my knowledge, only 1 high schooler had pursued EMT training before this program. We had 2 in the first semester. I received very positive feedback about the program, and this year we already have 14 cadets, indicating over 50% growth. This is evidence that there is still desire to volunteer within EMS. Whether these cadets stay in Webster or move to another town within South Dakota, we are supporting rural EMS in South Dakota. I am not an expert on reimbursement or treatment policies that we talked about today, but I have seen an aging workforce and believe that South Dakota is in desperate need for youth within EMS, especially in rural areas. As you guys consider EMS funding, I would encourage you to consider investing in rural workforce development, including youth recruitment such as cadet programs. These programs require many hours to organize and would benefit greatly through funding such as training supplies and resource sharing between towns. These programs may even eventually serve as a long-term remedy to help workforce shortages in volunteer ambulances. Many discussions have understandably been focused on reimbursement and affording the supplies that allow care to continue. I would challenge the task force to consider— continue considering this: who will be driving those ambulances and using those supplies in 10 or 20 years? The answer to this question will rely on funding programs developed now for the future workforce, giving the ambulance and supplies they need to retain these workers. Thanks for your time.

Thank you. That's really great. Can I ask a little question of you?

Yeah.

So what got you interested then at a young age of being an EMS provider?

Yeah, I was on scene when my great uncle had a bilateral stroke, and that was up in Day County, and I saw the EMTs work, and that got me really interested. I've always had an interest in something that's high energy. And I think a lot of high schoolers do. Like I said, when I gave this presentation to a lot of high schoolers, our graduating class in Webster is about 35 each year. So to have 14 cadets within 2 classes is a really high participation rate. I think there's kind of a myth that people don't want to volunteer within EMS anymore. I just think that they're not getting the opportunity to do so as much.

Great.

Thank you. Any other questions for— go ahead, Representative Fosness.

Hey, Gavin. I don't know if you can see me. This is Nick Fosness here. But you have led a charge in that in Webster that should be commended and replicated statewide. And I appreciate your comments as well on volunteerism isn't dead. We do have an aging workforce in EMS statewide. But it doesn't mean that it can't be newly seeded. So hats off to you, young man, for what you've done with ownership changes in Day County Ambulance. This was a huge deal that this young man, for our whole legislative task force to know, started something that I think goes right into the Department of Health presentation we heard about what does success look like for EMS regionalization. Let me quote, a stronger, more sustainable workforce statewide. That's right from Secretary Magstadt's presentation. And so I just want you to know, as you presented to us, that that coincides with the work that this task force is doing. Thank you.

Yes, thank you. And I do think as we talk about the regionalization bill, maybe there's something we need to get in there You know, when we talk about some— what we expect out of, you know, the advisory council, as we may start calling it, you know, what— you know, what— let's put something in that, that whole regionalization aspect also has to do with making sure that we're, you know, getting into the high schools. So this was very good conversation, Gavin. Thank you so much for being here. So thank you.

Thank you.

Any other public input?

Maynard Konechne from the Kimball Ambulance. We've talked a lot. You heard about the large services of the calls they have, the money they write off. In Kimball in 2025, we had 50,000 calls.

Okay.

53 calls that were billable, we wrote off $26,000 out of $85,000. So it's not just the big services that are taking a hit, it's the little services. And for the little services to take that kind of hit, that's a lot of money to put back in there. So—

Okay.

And I've got the breakdown of where the write-offs were. Of course, it was Medicare was the biggest one, but there was also Medicare replace— Aetna Medicare replacement, Blue Cross Blue Shield, Medicaid, and Medicare were our write-offs.

Okay.

So, Maynard, would you talk about just your initial numbers?

Yeah.

Again, your first 3 numbers or so.

53 calls that were billable. We had 85, I think, but those other ones were treat-in-place or refused when we got there or DOA. And, uh, We we wrote off $26,616, and that was for annual. That was your 2025 for 2025. Okay, and there was $85,650 bill that we billed for.

Okay, okay, that helps put it in perspective. Thank you. Yeah, go ahead. Sorry, Mayor. Yes, sorry, Mayor. Drew Peterson, Representative.

Question on your in-network negotiation. How do you do that? Do you negotiate that right now? Do you negotiate that independently and with each insurer? How do you go about that?

I really can't answer that, Representative, because I don't do the billing. I've just got the numbers from our gal that does our billing. I guess I'm— I'm not 100% if we're one of those that are in network like that or not for sure.

So thank you, Maynard.

The best we actually got is car accidents. 100% we get paid.

Representative Emery has a question. Do you have a kind of accounting of how many services have a billing company on retainer, whether it's BCC or somebody else? I can't answer that.

I don't know if Marty or Lance can answer that through the image trend or not. I can't answer that for sure.

Go ahead, Representative Fosness.

Thank you, Chair. So is the Is the amount you bill the same amount that is being paid in the negotiated, you know, say Medicare payment? Is that the exact amount that's billed and then there's still a deficiency with that? Or are you billing more and it's a contractual allowance?

We have our set rate of so much a mile out, of so much to pick up the patient and then so much a mile. And this is what's So that's what we're billing for, and this is what we're getting left after we get reimbursed from those insurance companies or Medicare and Medicaid.

Okay. Follow-up with that.

Go ahead.

It's very helpful, and thank you. It appears to be almost a quarter of your billed miles loaded then that come back in true revenue. It's hard for me to understand it from apples and apples though, because Medicare has a rate, Medicaid has a rate plus mileage. I'm just trying to look for the delta in what's billed and then what's actually paid to make—

Well, I can give you with Medicare, we'd billed $33,339 and we wrote off $14,748. That was on Medicare alone.

So to understand that, and you know this from your healthcare background, when you say, and maybe Maine or 2, what you bill, are you billing what the Medicare rate is or are you billing higher?

We're billing higher than that because otherwise Otherwise, you know, it's like everything. You bill what you think you should be getting, and then you take what they give you, basically.

And is what they give you usually the rate that's published?

No, it's usually lower than what we're billing. Otherwise, we wouldn't have—

No, I mean, you have what you billed, and then you receive a certain amount.

Yeah.

The amount usually that—

That they're offering to pay, yes.

Okay, okay, just wanted to make sure of that.

Yep. But we keep it higher because of the insurances and stuff that we'll pay a little more than that.

Sure, so you're billing your rate.

Yep.

And then—

And I'm not sure where everybody's at, but I think we're about $1,000 to pick somebody up, and then $18 a mile, I think, Okay, okay, thank you.

Yeah, I think just for more of a follow-up comment to that, that makes sense, right? I just— it also could be misleading to us that all the payers are falling short except commercials, you know, and if it's only by the billed mile. Um, yeah, we know these are set rates with Medicare, Medicaid, and so there's going to be a Contractual allowance there if you're billing higher than that. I just, I don't know that that's necessarily uncompensated care, but it is, it's notable.

Actually, with Medicare, the mileage is where you make up the money on it because you get that 22.5% extra.

Which is that super rule.

That super rule, which is in everybody in South Dakota but Sioux Falls and Rapid.

Gotcha. Thank you. Representative Emery.

Yeah, just to kind of Elaborate and somewhat answer your question, Representative Fosness. So I think what happens is a lot of the service across the state will just stick with one rate, and then they bill that for everybody. And they don't really—I mean, I guess the best way to put this is I don't think they really do do the deep research into what they could be getting versus just setting a standard rate, and then that's what they send out. So that that does kind of affect the delta because. Because they're always gonna probably be over that no matter what they do. So that could fix some of the problems. But again, that just comes into education. I think educating our EMS providers, especially from an administrative level, of what this hard work is. I mean, 'cause it is hard work. It is hard work year after year to look at the rates and then change your rates to that. What that might have to do if you have to go to your city council, your county commissioners, whoever that might be. And then people start asking, you know, why are these rates changing every year? And then you have to do education. So it is a timely, timely thing that happens. And I think I get where some, some of our smaller volunteer services that like, I'm doing 30 calls a year, like, am I going to go through all that work? You know, so I get some of where that pushback comes from. But I think ultimately it comes down to just the education of our administration— administrators within the EMS, because it just really isn't there. And I think— and that's not really any fault of anybody. I think it's just how our system has been set up for so long here in South Dakota that a lot of that higher-level work just doesn't get done, and people aren't trained how to do it.

Yeah.

Well, and I think also a few years back there were services that weren't billing yet, and that was hurting all of us because they take an average of everybody that bills and then they set their rates. When you had those services that weren't billing, that took that average down. Now that we've got everybody billing, it's more up there where, where it's closer, but it still doesn't get there, so.

Thank you, Maynard. Thank you. Um, Matt Helling, we have you online. I think you wanted to testify. If you'd go ahead and introduce yourself, please.

Yeah, hi there. Can you guys—

Yep, I can hear you.

Can you guys hear me okay? Sure. Uh, my name is Matt Helling. I have been a paramedic in South Dakota for 15 and a half years, and I have been teaching EMT, advanced EMT, and now I'm the paramedic instructor at Western Dakota Technical College out in Rapid City. And I guess I wanted to speak about education and training new EMTs. I think the— so a couple things just to make sure everyone's on the same page. In South Dakota right now, That basically is an EMT can teach EMT classes. Anyone that's an advanced EMT can teach advanced EMT. At the paramedic level, you have to be part of an accredited program, which I think limits it in South Dakota to WDT, the community college in Watertown, whose name escapes me right now. I apologize to Watertown. And then in Sioux Falls, they've got— Southeast has a program, University of South Dakota, and I believe the other, the ambulance service there, was it Patient Care, has their own program. So the dilemma is I have been teaching classes in rural South Dakota for 12 years now, and it is extraordinarily burdensome to the average adult. So we're not usually getting in rural South Dakota 19-year-olds that say, hey, I want to be a professional firefighter, or I want to be a professional EMT or paramedic. And they dedicate their time and energy to the program. And generally speaking, they live close to Sioux Falls or Rapid City or Watertown. What we're dealing with in rural South Dakota is people who this is The thing that they're going to do to volunteer for their local community. And this is a huge time and money burden for these people. So EMT education runs around 160 hours. If you just do all 160 hours, and that's something that you're not making money at a part-time job, And then most people are going to spend about another, every hour they're in class, an hour reading, doing homework, et cetera. 320 hours at, let's say, $20 an hour is $6,400 that that person could have earned at a part-time job. And then we've got distance because if you're not lucky enough to have someone teach you the EMT class right where you live, A lot of rural stuff has got a 30 to 60-minute drive to the nearest decent-sized town that's putting on the EMT program. Multiply that across, well, especially with gas prices today, and 30-minute drive to class, 30-minute drive back. Maybe the person's got to arrange for a sitter, someone to take care of the kids, et cetera, et cetera. And then you add the cost of the class. And so even when there are grants making the class quote unquote free to the student, this is probably still a $6,000 to $8,000, $9,000 commitment. And this is all for the privilege of being, for the most people, a volunteer or a barely paid volunteer at their local ambulance service. And so I just kind of wanted to highlight what I feel the True costs of asking someone to get their EMT. And when I've talked to ambulance directors, county commissioners, that sort of thing, I get a lot of pushback where the county commissioner, the ambulance director, someone says something to the effect of, you know, people just don't want to volunteer and help out their community like they used to. And I don't think everybody really recognizes how much this actually costs that person. to get their EMT certificate, because it's not just a weekend course and it's not a once a month for a couple of hours. It's a huge commitment. And when I— I don't know what everyone else is like. I'm 49 years old, right? When I grew up in the '70s and '80s, my dad worked. My mom didn't work when us kids were little. And then once we were all in school, she worked at the fast food restaurant during the middle of the day, right? From 9 until 2 or 3 o'clock in the afternoon. So then she was home when we got home from school, helped us with homework, cooked supper, et cetera, et cetera. Nowadays, I think that's a luxury that most families don't have. So you're asking a family that has 2, if not 2.5 or 3 jobs between the 2 parents, to then spend $8,000 to $10,000 to become a volunteer EMT. to get another job that almost doesn't pay anything. And I think this is a thing that probably, I guess, needs to be addressed and we need a better system. Maybe it includes stipends, maybe it includes just straight up pay that we know this is going to cost a lot of your time and money and we, the state, want volunteer EMTs. And you get your volunteer EMT and we'll write you a check every year you stay at the ambulance service, right? You get $2,000, something like that. That way there's a benefit, or at least not a benefit, but at least it pays back what the person put into getting their volunteer to get their EMT certificate so that they could volunteer for their local community. I don't know if anyone has any questions.

Great. Thank you, Mr. Helling. Any questions for Mr. Helling? I'm not seeing any, but thank you very much for coming on and letting us know about that. It is— we are looking at volunteerism, and you brought up a lot of good points, especially the kind of the extra costs there are in training volunteers. So I really appreciate your testimony. Thank you.

Thank you, sir.

Mr.

Chair, Representative Hughes, just is a very brief comment in order. The South Dakota Supreme Court years ago determined that legal services in rural areas was a critical need. So what the Supreme Court did is develop a plan. To get lawyers volunteer to move to rural communities, and I will tell you, people people lean on bar a lot, and they make lawyer jokes and other things. But let me tell you, when it comes to pro bono services, that's part of our creed. And I salute Mr. Helen. What he's really calling upon is for us to realize that we need to encourage our culture. We need to engage the culture to provide critical care, emergency care to our rural communities. You know, in a clinical world, time is heart, time is brain, and time is blood. And I think we— I mean, I appreciate all the clinical, you know, the sort of the statistical approach to all of this. But, for example, if an EMS provider loses money, My thought is, yeah, but we're lives saved. How do you put a price on, you know, Mrs. Jones who had a stroke and gets to the hospital on time even though she can't pay her bill? I mean, somehow I just think we need to be less statistical-driven and more volunteerism and service-driven and to not be shy about engaging our stakeholders in this process. And we have this gentleman, Mr. Hulling, who's basically telling us, help us. Well, that's helping. And everyone calls on the legal profession to bend over backwards at personal sacrifice. And I will say healthcare contracts with physicians ban the physicians from writing off care because they assign their revenue stream to the corporation. And that's at the heart of a lot of problems that we have here. And I'd like us to recognize that. And I intend to not remain silent about that. So thank you, Mr. Chair.

Thank you, Representative Hughes. We're at the point of task force discussion and directives. And just to get the conversation going, I think the first part we talked about— oh, go ahead. Sorry, Senator Peterson, go ahead.

Thank you. So I'd just like to tag team a little bit off what Representative Hughes has said throughout the morning. And I think one way for some of us to put this in perspective is, you know, there are a number of us from Sioux Falls on the task force, and we're fortunate, you know, that if we need emergency medical response, we can get it almost within minutes. And, and that's just norm to us. But think about what if we were somewhere in rural South Dakota on a trip for whatever reason? We'd be facing the same thing. So I think some of us in Sioux Falls have to sort of put ourselves in that situation and remember that. I'm from rural Montana, and you know those folks face that all the time. So I think we need to keep in mind the human factor here, and and I do think it's a community issue, and government is involved to an extent, but it doesn't have to be totally government. I think everybody needs to be invested. Thank you, Mr.

Chair. Thank you, Senator. So the items we've talked about, we had a good discussion early on about the concept behind regionalization. And, you know, we asked some, got some good questions or had some good answers to maybe how we could put a bill together. We also talked about the concept of funding, that there may have to be some backfill from a state level to make sure that, you know, especially, and I think to Representative— I'm sorry, Senator Peterson's comments that we got to be thinking more, you know, we got to think about these rural areas too. And we got to think about them differently than we'd think about Sioux Falls or Brookings or Watertown or Rapid City. Although everybody's still struggling. And we've got our issues also in Brookings. But we do— we are going to have to look at some sort of kind of a backfilling, you know, the state being the backstop. We also have to make sure that we continue to have local effort. I think we can't just, you know, kind of abandon that. We got to make sure that communities have their in on it also, their skin in the game, as Senator Otten says. So I think that's one bill that we're going to have to package. We may, maybe 2 portions to it, one or 2 portions to it. But as I said before, the governor's office is interested in partnering with us. on this. And so I think as we put all this together over the next month, we may need to, you know, have a— maybe a subcommittee put together on that aspect of working with the governor's office and putting together a bill that we think would be palatable for us to vote on, you know, in the end of October. So thoughts on that whole— what I was saying there?

Representative Well, I absolutely think we're probably going to need to have some kind of subcommittee because between now and when we meet again, we need to have bills in ready to go for all of us to vote on. And I think we're going to have to have some subcommittees to get those hashed out.

And I think they'd be a little ad hoc. I think we'd just be— yeah, it's not like we'd have to come here, but just to be reviewing where we're at and such. So any other concerns with that? So as far as putting together who that would be, I would want 2 from the Senate and then 2 from the House. And so I do think myself leading that portion and then Senator Otten, because I think we better have somebody from Appropriations, and then I'd like a couple House members to also be a part of that. Mr.

Chair, Representative Hughes, I mean, you may be reaching out, but, uh, just so you know, I'd be willing to offer my services.

Okay. And then should I have the co-chair? Does that sound good to the House members? Okay. Okay. So those will be that 4. Okay. And then we also have the how we figure treatment in place. I think we had a little bit of a shocker there on how we how we work through that. So we're going to need a committee to kind of work through should we have a bill on that or not, and kind of what's what's happening with maybe the ambulance services, you know, not knowing the agencies not knowing that they can bill on that, and are I think it's a good bill, but where there is, there's some tweaks we need with it. So I'm looking for volunteers to be on that.

I'll volunteer for that.

Okay, so Weems, Representative Weems. Anybody else? And then we'll have Senator Jensen. So we need another House member and another, um, another senator. Anybody else before I start calling on people between you two? I think it'd be good for Representative Fosness. I think with your background on it, and then I'll also—I guess if we want to have two senators, Jensen's on it. I'll go ahead and sit on that one too. So I think those are our two major things that we need to have done before the next. Meeting. Anything else from the committee that we need to give directives to LRC and/or something that we need to have prepared for the next meeting or anything else you think we need legislative-wise? I'll go with Representative Fosness.

Just a quick comment. How do you envision the governor's office being involved? They're going to be involved in the creation of this legislation. Can you expand on that a little bit for us?

Sure. I think we've got a good idea earlier on. I think the committee did a great job of kind of, you know, the term guardrails have been used that we need to put in. So I think we'll have LRC work on that quite quickly and then put that in front of the governor's office with that group and see where they think we're at. So that's how I see that progressing. Representative Jensen.

Okay. Thank you, Mr. Chair. We do have a ballot amendment on the table too about Medicaid expansion. If Amendment I passes, nothing happens. If the federal government rolls back the FMAP, then we go back to what the original intent of Medicaid was. So my kind of my concern and my question is something for us to all think about is I know that we can get Medicaid We can we can manage the Medicaid working with within administrative rules the way we are now. But what we need to think about is if Amendment I passes and the federal government rolls back FMAP, how much money do we have to work with? And where I guess in the administrative rules process, how are we going to put that together? You know, I know that's kind of a mouthful, and I'll.

Thoughtful.

But it's a very real possibility that amendment passes. And I think we've heard often from the administration in D.C. that they would like to roll the FMAP back from 90%. Right now, this year we're going to spend $340 million in Medicaid, but $306 million of that is federal money and $34 million is budgeted from ours. If that $300 million goes away, we have to be mindful of where we set ourselves as far as Medicaid assistance from the state. And those are real dollars. I mean, we're going to, you know, if we get ourselves out there too far, we're going to have to find a way to pay for that. And a lot of that has to do with the treatment in place. I think that's the treatment in place and real cost reimbursement is where the Medicaid could kind of help us play into that. But I think we do have to keep that in mind as we move forward. Thank you.

Thank you, Senator. Other comments? How are we doing? Anything else?

Just could you go over that first committee one more time? It was pretty broad. I just want to make sure we're covering everything.

What will it be about?

Okay.

It's a lot of things. It is, it is. Yep. It's really the regionalization concept, setting up an advisory council that would help with that process. And of course, work with DOH and the administration on how we would do that. And then the concept behind that is we need to understand what the costs are in those regions and then local effort and Then, you know, the whole backstop funding from the state. The second part of that would be, as we talked about the finances of it, and, you know, Senator Otten brought up the concept of an occupancy fee on hotels. I think as we've been discussing this also, it could be something that we could appropriate and not have to increase anything, you know, over time to figure out what that backstop would be. But I think it has to So those are the two portions of that one. I think they have to be tied together. It's important that we have a funding discussion, you know, instead of waiting until the end and saying, well, now how are we going to fund this? I think we've got to do it up front.

Thank you. And that's kind of what I thought. So, and then as far as reimbursement rates from the various payers, Medicaid or private or whatever, We'll continue to work on that as well, just without the workgroup.

Right. I think those information we'll have coming to us for the, for the last meeting. But these, these pieces of legislation, whether it be the regionalization and funding and treatment in place, I think we need to work through. Okay. Everybody good? Just want to make sure. You have a little extra time for thoughts. Okay, so our next— our last meeting— Mr. Chairman.

Oh, was that—

Sorry, Mr. Chair.

Go ahead.

Could you repeat the individuals that will serve in those capacities, please, just so I can make sure I write them down?

Sure. Yourself and Representative Emery, Senator Otten, and myself on the subcommittee that has to do with the With the regionalization and possible funding, and then Representative Weems and Fosness and Senator Jensen and Reed talking about treatment in place.

Thank you.

Okay, great. Well, thank you everyone. We kind of really have a working session, which is a little bit different, but I think we really did. We're going to get ourselves in a place that we'll be in good shape at the end of October to have some legislation. Representative Weems.

I have, I have one question for our next agenda. Is there any way we could have the Department of Public Service or Public Safety give us an update on 911 and how that all functions?

Dispatching ambulances.

Yes.

Yeah, yeah. And I do— I don't know if we had this discussion, it might have been more in side conversations, but I think DPS is important to be part of.

Yeah, yeah.

That overall committee that we talked about.

Yeah, that would be great.

Okay, okay, we'll work on that.

Okay, thank you.

Okay, so I will entertain a motion to adjourn.

So moved.

Second.

So we have a motion by Representative Peterson, a second by Representative Weems. All those in favor will say aye.

Aye.

We are adjourned. Thank you.