A Primer: How Arizona’s Ambulance Licensing System Works

The Basics

Arizona uses a Certificate of Necessity (CON) system to regulate ground ambulance service.  The overall idea is to have a regulatory system that optimally allocates resources, makes sure every place in the State has adequate emergency medical services, and that reduces rates to the extent possible.  

Any entity that wants to run an ambulance service needs to get a CON from the ADHS. It’s basically a license to run an ambulance service. The CON describes the geographic service area, level of service (advanced life support or basic life support), hours of operation, response times, effective date, expiration date for emergency medical services in the specific geographic area.  

An ambulance service that gets a CON is supposed to stick with the criteria on their certificate and operate in accordance to the statutes and rules by which it's governed. 

A common misconception is that Arizona’s CON system is designed to limit the number of ambulance services in Arizona. That’s not the case.  Parts of the State (especially areas with high populations lots of transports) have multiple providers and overlapping service areas where more than one ambulance company can provide services. 

The Statutes and Rules require that people who want to start an ambulance service have to demonstrate that there's "a public necessity" for the proposed service. There are detailed statutes that define what the words “public necessity” mean for the purposes of providing direction to the ADHS Director when she or he decides whether to approve a CON application.  There’s also a guidance document that outlines what the words “other things as determined by the Director” means.

How it Works

When someone wants to get a CON they apply to the ADHS. There are usually competitors that don’t want the applicant to get it (because the new applicant will be taking some of their cheese).  When someone challenges an application (called an intervenor) a hearing is scheduled with the Office of Administrative Hearings (in the ADOA).

A new statute limits that hearing to 10 days of testimony (a big improvement because these hearings used to go on for weeks or even months). The Hearing Officer listens to the testimony and documents and issues an “Order” with their opinion whether the Director should issue the CON. 

The ADHS can take or not take the Hearing Officer’s opinion. She or he can approve the CON, deny it, or approve it with some modifications.  There's a lot of interest among the parties when these CON applications are being considered - mostly because there's a bunch of money at stake. CON applications are quite litigious.

Here's a couple of recent cases that illustrate recent urban and rural CON applications. 

The Case of Community Ambulance (Urban)

An outfit called Community Ambulance applied for a CON to be able to do inter-facility transports (no 911 service) in Maricopa County. The goal was to have a CON that would provide inter-facility service between the Dignity Health facilities in Central AZ.  Dignity Health was supportive of the application because they believe contracting with Community Ambulance would help them more efficiently transport their patients between facilities- improving patient care and reducing costs. 

While the current providers (AMR and a couple others) can and do provide inter-facility transports in Maricopa County, the applicant and their supporters believe that a specific service dedicated strictly to interfacility would improve efficiency (Dignity would have contracted with Community Ambulance for this specific service). 

After reviewing the application and documents, a Hearing Officer at the Office of Administrative Hearings recommended that the ADHS deny the application. Here’s that Opinion. Upon review of the Hearing Officer’s opinion, the ADHS Director agreed with the hearing officer opinion and denied the CON. 

There’s an opportunity to appeal, and Community Ambulance filed a Motion for Review with the Director. The ADHS Director can review the case and change her mind or stay with the initial decision. If the CON remains denied, Community Ambulance can appeal to Maricopa County Superior Court.

The Case of Timber Mesa (Rural)

Back in 2017, an outfit called the Timber Mesa Fire District applied to extend the boundaries of their CON to include the city of Show Low.  An existing CON was in place in Show Low (Show Low EMS- now called Arrowhead Mobile Healthcare).

After hearing the evidence- the Hearing Officer recommended that the ADHS deny the CON application because: 1) Timber Mesa didn’t show that more resources were needed in the service area; 2) the reduction in call volume for Show Low EMS would make Show Low EMS unable to meet their current obligations; and 3) Timber Mesa didn’t prove that Show Low EMS has engaged in substandard performance in either 911 or interfacility service.

The ADHS Director didn’t agree with the Hearing Officer’s recommendation and approved Timber Mesa's CON boundary expansion into Show Low. 

Show Low EMS (now Arrowhead Mobile Healthcare) appealed the ADHS Director’s decision in Superior Court.  Last week, the Superior Court judge in the case agreed with Arrowhead that “the Director exceeded her statutory authority when she "sua sponte" amended CON 111 to include the Expanded Service Area”.  It’s now the ADHS’ job to read the Judge’s decision and figure out what to do next.

Editorial Note: When I was in the Director position, I was reluctant to issue additional CONs in rural areas because adding too many providers in rural areas can jeopardize overall service and increase costs. That’s because when transports are spread “too thin”, one or both ambulance service providers may not be able cover their expenses - which can cause them to ask for rate increases or neglect underpopulated areas which jeopardizes response times.  

In urban and suburban urban areas, I was more inclined to approve CONs that met the basic statutory requirements because there are usually plenty of transports around to ensure that ambulance providers can meet their expenses...  and increasing the number of providers can safely increase competition. In urban and suburban areas there’s a lot less risk that adding additional resources will cause rate increases or result in providers neglecting the less populated parts of the service area.

This primer is just a short summary of the CON system and how it works in Arizona. One can spend an entire career on this subject and still learn something every day- so take this for what it’s intended- a small window into the complicated world of Ambulance service Certificates of Necessity in Arizona.

U of A Study Examines Emergency Department Use During the Recession

AzPHA member Patrick Wightman from the UA Center for Population Science and Discovery recently published an Issue Brief examining the impact that the freeze on “childless adult” enrollment in AHCCCS during the Great Recession had on the use of hospital and emergency department services. 

Because Arizona conducted a natural experiment by freezing Medicaid enrollment among childless adult, and the fact that data are available to measure the effect of those policy changes, Patrick was able to compare people’s behavior with health insurance to their behavior without it.  The fact that the freeze lasted years allowed him to examine any impact of pent-up demand following the lifting of enrollment freeze.

Here’s a link to the entire Issue Brief , which includes the entire results including several useful graphs, but here’s the Summary from the Issue Brief.

“While the trends presented here are descriptive, they occur in the framework of two significant “natural experiments”, the first drastically restricting low-income individuals’ access to public health insurance, and the second once again expanding that access.  Because these policy changes happen at the state and federal levels, beyond the control of beneficiaries, it can be inferred that, in large part, they are the cause of the beneficiaries’ behavior, in this case their health care utilization.

In this context, the patterns shown here provide strong evidence that health care utilization, at least in the form of ED visits and hospitalizations, follows the availability of health care, in the form of health insurance.  While this finding is not unanticipated in the case of hospital visits, in the case of ED visits it is perhaps somewhat surprising, at least to the extent that ED visits represent “legitimate” medical emergencies.”

Arizona Research will Change EMS Brain Injury Care

Traumatic brain injury is involved in about 1/3 of all injury-related deaths... it’s clearly a public health issue.  That’s why back in 2013 Arizona created the Excellence in Pre-hospital Injury Care (EPIC) project- which has been aimed at improving brain injury outcomes in AZ. 

Back in 2013 the National Institutes of Health chose AZ as the only state to evaluate the national standards for pre-hospital emergency care of brain injury (under a grant application led by AZPHA member Ben Bobrow, MD). 

EPIC has been a unique partnership between state government, the U of A and more than 130 fire departments and ground/air ambulance companies.  Together they implemented a series of pre-hospital traumatic brain injury treatment interventions and measured the effectiveness of the results.

The interventions included: 1) prevention of hypoxia by early oxygen administration; 2) airway interventions to optimize oxygenation; 3) prevention of hyperventilation; and 4) quickly treating low blood pressure by infusing fluids.

Participating EMS agencies sent treatment information to the ADHS and the UA College of Medicine for tracking and evaluation. An early donation from the Ramsey Justice Foundation made it possible for the agencies to receive special breathing devices to implement the new protocol and assist in the treatment patients at no cost.

More than 5 years of work by literally hundreds of Arizonans resulted in the publication of the results this week in JAMA Surgery entitled Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with Patient Survival Following Traumatic Brain Injury.

Remarkably, the team found that implementation of the protocol doubled the chances of survival among persons with a critical traumatic brain injury and improved neurological outcomes. Doubling the chances of survival is no small thing for a public health intervention, so this is really a landmark study.

This Arizona study will change the way EMS providers treat traumatic brain injury in the field around the globe. That shows the importance of publishing. When hard work like this with dramatic results is published in reputable journals- people take note. It won’t be long before the Arizona protocol becomes a global EMS standard for traumatic brain injury care. For more info go to www.epic.arizona.edu.

A huge public health thank you to the entire research team including Dan Spaite, MD; Ben Bobrow, MD; Sam Keim, MD, MS; Bruce Barnhart, RN, CEP; Vatsal Chikani, MPH; Joshua Gaither, MD; Duane Sherrill, PhD; Kurt Denninghoff, MD; Terry Mullins, MPH, MBA; P. David Adelson, MD; Amber Rice, MD, MS; Chad Viscusi, MD; and Chengcheng Hu, PhD.

Community Paramedicine Continues to Mature in AZ

Community paramedicine has been a paradigm shift for the use of paramedics in the US- and Arizona has been a national leader.  It’s a new model in which paramedics function outside their usual emergency response & transport roles- delving into the world of primary care.  As the health care world increasingly shifts toward prevention and well care- the system will increasingly demand more folks that can function in a community health (primary care and prevention) role.  Community paramedicine is increasingly being recognized as a promising solution to efficiently increase access to care (especially for underserved populations). 

For example- paramedics could shift from a sole focus on emergency response to things like: 1) providing follow-up care for folks recently discharged from the hospital to prevent unnecessary readmissions; 2) providing community-based support for people with diabetes, asthma, congestive heart failure, or multiple chronic conditions; and/or 3) partnering with community health workers and primary care providers in underserved areas to provide preventive care. 

One component of Community Paramedicine is known as “Treat and Refer” and it has really taken a step forward in the last couple of years in Arizona.  A couple of years ago the initiative was launched under the leadership of AzPHA Members David Harden, Terry Mullins, Dr. Ben Bobrow and others at the ADHS.

It’s called the Arizona Treat and Refer Recognition Program and was developed in partnership with the ADHS Bureau of EMS & Trauma Systems, AHCCCS, and the EMS community. Organizations that earn Treat and Refer recognition implement the program under the direction of their medical director and chief executive.  Once recognized, the EMS Agency can seek reimbursement from AHCCCS for the services they provide.  You can check out the AHCCCS website to learn more about provider registration.

Five EMS agencies have now been recognized as Treat & Refer EMS agencies. The T&R Program establishes a means for recognized EMS agencies demonstrating optimal patient safety and quality of care by matching treatment, transport, and care destination options to the needs of the 9-1-1 patient; and provide recognized EMS agencies the opportunity to seek reimbursement from AHCCCS.

The ADHS Bureau of EMS & Trauma Systems offers a pre-application technical review service to EMS agencies considering applying for recognition. The service includes a comprehensive review of EMS agencies’ education modules, standing orders, patient follow-up process, and performance improvement/quality assurance process.