Many challenges impact rural EMS services, including in Orleans County

Editor:

Over the last several years I have been asked a number of questions and been presented with countless concerns regarding the emergency medical services (EMS) within our rural county.

Additionally, I have read lots of comments on social media from EMS providers, former EMS providers and the general public that are from folks that are misinformed or are just telling flat out lies.

What I have realized is there is a general lack of public knowledge about the EMS system, so here is the truth about the struggles we face as one of the smallest counties in New York trying to ensure that the public has an ambulance that responds during your time of need.  This will barely scratch the surface of the EMS issues we face, but it will give you a high-level overview.

First, I think it’s important for everyone to understand where we were 20 years ago, versus where we are now in regard to service. In 2004 there were 2,876 requests for ambulance service within Orleans County, despite a population decrease of around 3,000 people the requests for service in 2023 were 5,159, which is decline from the 5,600+ requests that took place in 2022 and 2021.

In 2004, including staffed career ambulances there were 13 ambulances in the county with 3-4 of them being staffed. Now we are down to 6 total and depending on the time of day between 3-5 are staffed. All of the fire department-based volunteer ambulance services stopped providing this service due to rising costs and the declining number of EMS providers.

The cost of operating an ambulance service is expensive, there is no way around it, especially if you want to attract good employees and provide competitive wages and benefits. To operate a single ALS ambulance 24 hours a day 7 days a week, it comes with a price tag of around $1 million per year. Although the ambulance bills for the services that it provides but in a rural county it’s just not enough, unfortunately.

I often see comments or get asked, why do we have to pay for ambulance service when other areas get the service for free. Ambulance agencies largely look at what is referred to as the payor mix. The payor mix is the percentage of patients that are covered by Medicare, Medicaid, private insurance or the patient has to pay for the transport themselves.

The Orleans County payor mix is generally around 50-60% Medicaid/Medicare, around 25% private insurance, 10% self-pay, and the remainder being correctional facility transports. In areas where the payor mix is much less lopsided towards Medicaid and Medicare and/or the ambulance service has a higher call volume, the ambulance service is able to generate more revenue. The ambulances have less down time between calls and have shorter transport times, allowing a greater return on investment per ambulance.

Medicaid and Medicare only pay a fraction of the bill, generally in the 20-35% range, and the transport agency does not receive any money for the remainder of the bill. The state correctional facilities pay at the Medicaid rates. Private insurance doesn’t always pay 100% of the bill either and it varies amongst insurance providers and what services were needed. The insurance will determine what they are willing to cover, and the provider is not able to bill for the remainder of that transport. Some ambulance agencies have standing agreements in place with the insurance companies that will guarantee them a certain payment on each transport. Some ambulance agencies choose not to enter into these agreements because they ultimately could lose money. If they don’t have an agreement, they could get paid between 20% and 100% of the invoiced transport cost, versus having the agreement where you know that you will always get a guaranteed percentage of each transport.

We regularly hear concerns over the billing rates. Most agencies set their prices based on the “Anonymous Ambulance Rates,” which is a report of the average rates being charged in an area. The rate charged varies depending on the level of care provided for the patient. There are various levels of billing for different advanced life support (ALS) or basic life support (BLS) services that are provided. For mileage, it doesn’t matter where the ambulance comes from you are only charged for transported miles. Because we live in a rural area, the first 17 miles of transport are charged at a higher rate.

Calls are dispatched based on the questions the Public Safety Communications Specialist asks the caller, known as Emergency Medical Dispatching (EMD). After asking a series of questions an EMD code and a priority level of the call are determined. Based on the priority, an ALS Ambulance or a BLS Ambulance is dispatched. ALS Ambulances are sent on the most severe calls – respiratory distress, chest pain, strokes, cardiac arrest, etc.  BLS Ambulances are sent on the less severe calls, such as general illnesses, falls, broken bones, etc.

Another comment we get often is in regard to responses with lights and sirens. People will ask “Why didn’t they respond with lights and sirens”? The answer is two-fold, its generally based on the priority system we discussed earlier as determined through the EMD process. The other part is based on crew discretion, as to whether or not a response with lights and sirens is going to make a difference in the patient outcome.

There are numerous studies that show that the time savings is minimal, and that the difference in patient outcomes are not impacted. In fact, it’s become more of an exception to transport with lights and sirens, rather than the norm that it used to be. It’s safer for the patient, the crew, and the public when lights and sirens aren’t used.

Largely, the EMS service dilemma comes down to people and money. In regard to the people aspect, we lack the volunteers to operate at the levels that we once used to.  Secondly, people largely abuse the EMS system and call for an ambulance when a simple car ride to their own doctor, the urgent care or ER would suffice. In a world where things are built safer and our county population has declined by 3,000 people, the number of requests for an ambulance should not have nearly doubled in 20 years’ time. People think that taking the ambulance is going to get them seen faster in the ER, but that doesn’t in fact work. The patient is transported in, triaged and then seen in the same order they would have been had they walked in the door on their own.

In regard to money, those who have it want to keep it, and those who need it are left begging for it. The money aspect is simple…insurance companies, Medicaid, and Medicare pay peanuts, and leave the ambulance services trying to figure out how to make their budgets whole. This then comes back to people, both elected officials and EMS agency leadership, to try and figure out where to get the funding and what levels of service are acceptable for the protection of a community.

What is the right balance to cover the call volume? How do you account for the surge? The other day there were 12 EMS calls in just over 3 hours. It’s not cost effective for the ambulance services, the municipalities or the taxpayers to staff at that level, especially when there are days where there are only 1-2 calls the whole day. The mutual aid system is there to assist with these times of surge, but there is such a demand on the system some days that even the mutual aid isn’t available.

The elected officials’ contract for a level of service they feel will adequately cover the community.  When we hear ambulances coming from another agency to cover a call, or from out of the county, the call volume at that moment is beyond what the contracted services were able to cover. This is not the fault of the provider or the elected officials.

This is a metric that needs to be monitored, and if this is beyond the acceptable level of risk to the elected officials and the public, the number of ambulances that are contracted for need to be adjusted. The money/public safety balance can become a real challenge for elected officials and ambulance service leadership, and these are responsibilities that I am not envious of.

The EMTs and Paramedics are also severely behind in both pay and benefits when compared to other first responders. The wages have come a long way since where they were pre-covid, but still fail in comparison to firefighters and law enforcement officers.  Law enforcement and fire retirements systems enable the employee to retire after 20-25 years of service. Some EMS agencies don’t even offer retirement, let alone pay wages where a provider could start saving on their own. Several providers work for 2-3 different agencies just to make ends meet for their family. Yet we wonder why we have issues with burnout, recruitment and retention.

There is a plethora of legislative issues in NY that aren’t helping the money or people problem. Slowly there have been a few changes, but not the sweeping changes that are needed to overhaul the EMS system.

Did you know that EMS is not an essential service required by law? Neither the town nor county are required by any statute to provide ambulance service. That’s just one of the many issues that we face, and that could be a whole other topic of conversation, but a quick Google search for NY EMS legislation will bring up a variety of the legislative battles that are currently ongoing.

We never hear the good news stories! For every 100 complaints that I hear about an EMS agency, I might hear one positive thing. This is a different world we live in now, people don’t always have the same morals, ethics, motivations, or drive, that they used to.

I have worked with some really good providers and some really bad ones. No matter where you go or what the name is on the side of the ambulance that pulls up, there will be good and there will be bad.

Unfortunately, with the challenges that EMS agencies face trying to hire staff some slip through the cracks for longer than they should. If you had a bad experience, I would encourage you to reach out to the ambulance service’s leadership. Complaining on social media isn’t going to resolve anything. However, I would also encourage you to share your positive experiences too. This is often times a thankless job. No one is doing it to get rich; they’re doing it to give back, to help others, and sometimes a little positive recognition goes a long way.

It’s a challenging time we live in on a variety of levels. The dollar we earn doesn’t go near the distance it used to at home, and it certainly doesn’t in the EMS services. These services we once took for granted have dwindled to a fraction of what they once were.

It’s going to take an understanding of what the EMS service once was, what it currently is, and where it needs to be to right the ship and finding sustainable financial solutions to make it all happen.

There is a lot of bashing of providers and agencies, but at the end of the day, the name or color of the ambulance doesn’t matter, the uniform of the provider that gets out doesn’t matter…the safety of the public is all that matter and needs to be the number one priority.

Justin Niederhofer

Orleans County Emergency Management Director