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EMS in critical condition

A national survey reveals EMS economic and operations redesigns that would have been considered heresy just years ago


” EMS agency leaders and clinicians, EMS medical directors, and elected officials need to work together to transform how EMS is delivered,” writes Zavadsky.

Ask any EMS clinician or leader, and they will tell you – many EMS systems across the U.S., regardless of provider type, are on life support.

Workforce shortages, skyrocketing costs, supply chain disruptions and decreasing fee-for-service revenue have put EMS agencies in critical condition. Economic and human resource challenges, combined with clinical evidence regarding things like the impact of EMS response times and ALS care, have led to the implementation of numerous system redesigns that only a few years ago might have been considered heresy.

The National Association of Emergency Medical Technicians (NAEMT) conducted the first of its kind national survey of EMS agencies seeking information about the current state of EMS in the U.S. as part of NAEMT’s efforts to effectively communicate to state and national officials the impact of the EMS crisis.

The results from the survey were so compelling, NAEMT partnered with the International City/County Management Association, the Center for Public Safety Management and the Public Consulting Group to conduct a national webinar on the topic for EMS leaders, public officials and regulators. The webinar included panelists from every facet of EMS delivery; public and private EMS providers, billing agencies, physicians, and consultants assisting cities and counties who are experiencing EMS delivery challenges in their communities.

Here are the top five takeaways from the survey, from the panel of experts who shared their insights during the webinar.

1. Workforce challenges

According to data collected by EMS1 columnist Rob Lawrence, who is also the executive director for the California Ambulance Association, the director of strategic implementation for PRO EMS, and the chair of the Communications Committee for the American Ambulance Association, since January, 2021, 490 (58%) of 846 tracked local and national media stories about EMS have focused on the EMS workforce shortage.

Respondents to the NAEMT survey articulated the severity of the issue. Compared to FY19, responding agencies reported that applications for paramedic/EMT positions are down an average of 13%. Nearly two-thirds (65%) of agencies reported a decrease in applications, and over one-quarter (27%) of agencies reported a decline in applications of more than 25%.

Every panelist on the NAEMT webinar echoed this finding in their agencies. Panelist Tom Wieczorek, the director of the Center for Public Safety Management, shared that even fire departments are adding recruitment incentives, such as sign-on bonuses for paramedic-firefighters.

2. Skyrocketing expenses

Costs for personnel, vehicles, equipment and supplies are through the roof. Survey respondents reported an average of 11% increase in expenses for wages, and 12% increases in costs for equipment and supplies between 2019 and 2022. Respondents predicted these increases will continue or be even higher through 2026.

Webinar panelist Debbie Ailiff, the president and CEO of Procare Integrated Health and Transport in Maryland, agreed with these estimates. She indicated that she’s had to increase wages dramatically at her company to retain, let alone attract EMTs and paramedics to her service.

Staff shortages at hospitals and other healthcare systems are adding to the strain, as they often hire EMS personnel at higher wages than EMS agencies can afford to pay, given the current EMS economic model.

Panelist Amy Hanifan, the operations chief for the McMinnville, Oregon Fire Department, shared that even in fire agencies, personnel, equipment and supply costs are creating dramatic increases in fire department budgets.

3. Stagnant revenues

Panelist Regina Crawford, the advocacy liaison for EMS Management & Consultants, a premier EMS billing agency, shared her insights regarding the EMS revenue cycle. Insurance reimbursement for EMS have not kept pace with escalating costs. Even with recent increases in Medicare fee schedules, the increases are a fraction of the cost increases being experienced by EMS agencies. Adding to the challenge, commercial insurance reimbursement, typically one of the payer classifications EMS relies on the most, has generally decreased over the past 2-3 years. This is likely due to fewer patients having employer-based health insurance, and insurance companies ramping down their allowable fees for ambulance service. Survey respondents reported an average of 5% increase in fee for service revenue per transport, and for publicly funded agencies, a 10% increase in public subsidy. Obviously, if costs are increasing 10-15%, and revenue is increasing about 5%, EMS agencies will need additional funding to maintain current service delivery levels.

Webinar panelist Linda Frederiksen, the executive director of MEDIC EMS in Davenport, Iowa, shared that many communities are stepping up to provide additional funding for EMS. Iowa recently passed legislation allowing local communities to designate EMS as an essential service and authorize public tax support. During recent elections, many communities did vote favorably for essential service status and tax levies for EMS delivery. Frederiksen also highlighted that the State of Iowa approved a $15 million grant administered by Iowa Workforce Development called “Iowa Health Careers 2.0 Grant.” Previously limited to nursing and CNAs, EMS is included in this year’s grant opportunity. This is a registered apprenticeship program intended to improve the EMS employee candidate pipeline and is available for use at the high school or college level, in partnership with Iowa EMS training programs.

4. Service delivery changes

Survey participants were asked what service delivery changes they have implemented to mitigate the impact of staff shortages and economic challenges:

  • 49% reported that they have lengthened response time goals
  • 37% reported they implemented alternate response to low-acuity calls
  • 28% reported moving from all ALS to tiered (mix of ALS and BLS) deployment models
  • 23% reported transitioning from dual paramedic to single paramedic deployment

Other changes identified by survey respondents included alternate staff schedules, 24-hour shifts, discontinuation of interfacility transfers, reduced ambulance coverage, reduced backup coverage, and inability to answer calls.

Dr. Melissa Kroll, the medical director for Christian Hospital EMS in St. Louis, and member of the National Association of EMS Physicians. indicated that EMS medical directors have not reported any decreases in patient outcomes as a result of these changes. Dr. Kroll encouraged EMS medical directors and agency leaders to undertake deliberate and detailed clinical data analysis to determine appropriate EMS response plans for types of EMS calls and ensure comprehensive quality assurance reviews as changes in EMS delivery.

5. Communities in quandary

Webinar panelist Tom Wieczorek, the director of the Center for Public Safety Management, shared that the number of cities and counties seeking professional guidance about EMS delivery in their communities has increased dramatically over the past year. Some communities have volunteer systems that are failing, others have contracted providers who for the first time are requesting public funding to continue providing historic service levels. Still other cities and counties are requesting evaluations of fire department EMS providers in light of dramatic budget increases.

Wieczorek said he sees this as a unique opportunity for city and county leaders to re-evaluate how EMS is delivered in their communities to balance the clinical effectiveness with today’s economic realities. The prevalence of peer-reviewed study data related to things like the true impact of response time on most EMS calls, and the reality of EMS response types that truly need ALS care, has created the unique environment for fundamental system design changes.

The path forward

The EMS delivery crisis has the attention of community leaders across the country. State legislatures are providing additional funding for EMS through grants and increases in Medicaid reimbursement. Local communities are stepping up to fund EMS to maintain service levels, or redesigning (right-sizing) EMS response models based on clinical evidence. Congressional leaders are considering options to provide additional EMS funding by making pandemic-era waivers that reimburse ambulance agencies for treatment in place, transport to alternate destination and telehealth programs permanent.

But these initiatives barely scratch the surface of the fundamental changes that are needed in EMS operations and economics. EMS agency leaders and clinicians, EMS medical directors, and elected officials need to work together to transform how EMS is delivered. We encourage everyone to actively participate in EMS advocacy individually, and through membership in national organizations like NAEMT, IAFC, AAA, NAEMSP and other national associations.

Additional resources

Matt Zavadsky, MS-HSA, EMT, is the chief transformation officer at MedStar Mobile Healthcare, the exclusive emergency and non-emergency Public Utility Model EMS system for Fort Worth and 14 other cities in North Texas that provides service to 436 square miles and more than 1 million residents and responds to over 170,000 calls a year with a fleet of 65 ambulances. MedStar is a high-performance, high-value Emergency Medical Services system, providing advanced clinical care with high economic efficiency.

MedStar is one of the most well-known EMS agencies in the county, and operates a high-performance system with no tax subsidy, and the recipient of the EMS World/NAEMT Paid EMS system of the Year, and the only agency to be named an EMS10 Innovator by JEMS Magazine.

He is also the co-author of the book “Mobile Integrated Healthcare – Approach to Implementation” published by Jones and Bartlett Publishing.

He has 42 years’ experience in EMS and holds a master’s degree in Health Service Administration with a Graduate Certificate in Health Care Data Management. Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in high-performance EMS operations, finance, mobile integrated healthcare, public/media relations, public policy, transformative economic strategies, and EMS research.

Matt is also immediate past president of the National Association of EMTs, and chairs their EMS Economics Committee.