Preparedness

Air and Ground Emergency Medical Services Face Special Challenges in Rural Areas

The protocol for when a certain EMS base is unable to respond to a call for dispatch to reach out to the second-closest ambulance. On a non-emergent call, dispatch’s policy is to wait four minutes before calling the second-closest ambulance.

by Olivia Belanger, Watertown Daily Times, N.Y. / February 3, 2019

(TNS) - Emergency medical services across the nation have been struggling for decades, especially in rural areas. Built on the backs of hardworking, dedicated volunteers, rural ambulance services have been scraping by to continue to provide emergency response to their communities. As the number of volunteers dwindles each year, so does the medical safety net that can be provided.

Ann M. Smith, EMS program director for the North Country Regional EMS Agency, said in Jefferson, Lewis and St. Lawrence, N.Y., counties, there are 80 first-response and transport agencies. In the past few years, two have officially closed.

Croghan Volunteer Fire Department gave up its ambulance in 2015, as did Edwards Fire Department. Lewis County Search and Rescue has been picking up the coverage for Croghan, while Gouverneur Rescue Squad has helped with Edwards since its EMS closure in early 2017.

Most recently, Cape Vincent Ambulance Squad was set to disband in November, but the official end date of that service is not yet determined, nor is the coverage plan once it ends. A meeting to determine a short-term and a long-term solution was held on Thursday, but no decisions were made.

Justin R. Astafan, chief of operations for Lewis County Search and Rescue, said the group’s Lowville base has a 25-minute drive to the farthest end of Croghan, but the village is only eight minutes away. He also said search and rescue has a post at Croghan Volunteer Fire Department for his staff to be at during shifts. The more challenging coverage area is in the southern parts of the county, which can take the ambulance upward of 45 minutes in good driving conditions.

With 76 people on his roster, 20 of whom are paid, Mr. Astafan said Lewis County Search and Rescue isn’t currently struggling to find volunteers.

“It comes and goes; sometimes we do struggle,” Mr. Astafan said. “We feel the same crunch as anyone else does. When you’re drawing from the same pool, it’s hard to build a solid base.”

Even with a strong roster at the moment, though, Joe A. Kuehnle, EMT at search and rescue, said there are days when EMS personnel still can’t handle all of their calls.

“We’re short-staffed at times, even with more staff than most,” Mr. Kuehnle said.

The protocol for when a certain EMS base is unable to respond to a call for dispatch to reach out to the second-closest ambulance. On a non-emergent call, dispatch’s policy is to wait four minutes before calling the second-closest ambulance. With emergent calls, though, dispatch is likely to call the next ambulance sooner, according to Joseph D. Plummer, director of county Emergency Management.

Mark A. Deavers, executive director of the Gouverneur Rescue Squad, said before Edwards’ ambulance service officially closed, the rescue squad was picking up most of its slack.

“We were doing about 90 percent of their responses because of a lack of manpower on their end,” Mr. Deavers said.

That directly relates to a lack of volunteers in the area, according to Mr. Deavers. For people who work full-time jobs, it’s difficult to have the time or energy to dedicate to an ambulance service.

“It is always going to take two hours minimum when there’s an ambulance call,” Mr. Deavers said. “It’s a struggle to get out of bed at 3 a.m. when you have to go to work in the morning.”

But for most, paying a full staff is next to impossible. Most places in the north country have at least part of their staff paid, but are still in need of more participants to help.

This is related to the lack of reimbursement rates for patients on Medicaid and Medicare, according to Ms. Smith. For the north country, about 80 percent of patients are on Medicare or Medicaid or have no insurance coverage, forcing ground EMS to rely on private insurance companies.

The cost of a new ambulance is about $110,000, with the cost of disposable supplies and cardiac monitors amounting to $50,000. The costs for workers compensation and insurance can run into the thousands of dollars per vehicle and employee, Ms. Smith said. In addition, the same cost-readiness applicable to air medical services applies to ground ambulances.

Even private ambulance agencies are suffering in the north country, according to Bruce G. Wright, president and CEO of Guilfoyle Ambulance Services. Mr. Wright said the company is losing about 70 percent of its expenses due to Medicaid, Medicare and no-insurance patients.

“Trying to get Medicaid and Medicare reimbursement rates raised and to work on direct-payer legislation where insurance companies would have to pay us directly is important,” Mr. Wright said. “As of now, insurance companies try to bargain a discounted rate and if we don’t agree, a lot of times they’ll send the payment check to the insured, instead of us, and then we might not see payment.”

Maintaining the volunteers once an agency has them is also an issue, according to Robert A. MacKenzie III, director of fire and emergency management for Lewis County. State and regional councils require specific training sessions and conferences to retain certification, regardless of whether the person is a volunteer or paid.

“It’s difficult for volunteers to leave their families to go on calls when the local ambulance is paged, maintain the supplies on the ambulances, then be expected to attend trainings and conferences to maintain certifications,” Mr. MacKenzie said. “Most have full-time jobs and the communities they serve don’t fully understand the amount of hours these dedicated individuals have to sacrifice to maintain their certification levels.”

For those who are willing to dedicate this time for both training and on-the-job hours, though, there’s limited access to paramedic or EMT courses in the area, leaving those who want to volunteer unqualified. Ms. Smith said Jefferson Community College had the only paramedic program nearby, but it currently is not holding the courses.

“It has been extremely difficult to get qualified people,” Ms. Smith said. “Even our agencies who hire staff are having trouble finding folks.”

Jefferson Community College’s paramedic program enrollment has steadily declined over the last several years, according to Linda Dittrich, associate vice president for the Math, Science, Health and Technology Division. The past two years, applications have not been accepted into the program because the college is “unsure about its future.”

The program started in 2000 and has had 47 graduates. In the fall of 2014, the number enrolled was 20, dropping to 11 in the fall of 2016.

The college still offers EMT and EMT-Advanced courses in conjunction with Jefferson County EMS while determining how to move forward with paramedic training. Potential students are being recommended to Herkimer County Community College, about a two-hour drive from Watertown.

Ms. Smith said this commute is unrealistic for many students. On top of getting the basic education classes hours away, paramedic students also have required clinicals, which could have them tacking on even more travel time.

Air medical services are also struggling with reimbursement rates, but are imperative for critical care patients in rural areas.

AirMethods’ LifeNet of New York, with bases in 10 locations across the region, services emergency patient transports to Albany, Syracuse or Burlington, Vt., to get patients to the appropriate medical facility. With these facilities at least an hour away by car, the 30-minute helicopter ride is the only viable option for critical care patients.

On each base, there are four flight nurses, four flight paramedics, four pilots and two mechanics, with one of each on a shift. Flight nurses and paramedics work 24-hour shifts, while a pilot works 12 hours.

The helicopter, stored in a hangar at the Watertown International Airport, has three seats — two facing front, one facing backward, not including the pilot’s seat in the upper right — and a skid for the patient. The inside is equipped with ventilation tubing, ventilator, defibrillator, oxygen tank and two IV pumps that can pump up to three medications at once. The helicopter itself carries about 62 medications, compared to an ambulance’s 30.

Russell G. Johnson, flight paramedic for LifeNet 7-10 at the Watertown base, said its helicopter typically gets about 200 calls annually, which include transports from hospitals and from the scenes of the emergencies. In 2018, the crew was active 236 times.

The helicopter is worth $5 million, even as the most cost-effective model on the market. The hefty cost doesn’t include any of the medical equipment inside.

“If you divide that cost up, consider the employees, stocking the equipment, fuel... it’s huge,” Mr. Johnson said.

Mr. Johnson said 70 percent of its patients are on Medicaid and Medicare or have no insurance coverage. Depending on where the patient is in the country, the medical flight can cost up to $25,000, with many states’ Medicaid providers covering only about $200. With the reimbursement rates under the true costs of providing service — the average Medicare reimbursement covers only 50 percent of actual transport costs — many air medical bases have been forced to shut down across the country. That places the cost largely on businesses and those who have the ability to pay.

“Our biggest issue across the line with any health care, including ambulances and hospitals, is dealing with Medicare and no insurance,” Mr. Johnson said. “We don’t get what we need to survive off of Medicare and Medicaid, so where do we make up that money? That is 70 percent of our patients. We can’t survive off of that reimbursement.”

The cost of the around-the-clock readiness needed to run an air medical service averages nearly $3 million per year for each base, according to an independent air medical provider cost study, conducted and published last year by Xcenda. Further, about 85 percent of air medical costs are fixed costs associated with operating a base, giving companies little leeway in reducing costs on their own, said Doug Flanders, AirMethods spokesman.

A small amount of variation in price is caused by the specific mileage and fuel cost in the area or medicines administered in flight; the inequity that is often talked about is due to Medicare’s low reimbursement rates, which exert a trickle-down economic effect on air medical service rates for private payers and patients.

Medicare established the current air medical service payment rates in 2002 based on an estimated 1998 cost pool. Since then, however, Medicare has increased the payment rates solely by an inflationary factor and has not revalued the payment system to reflect significant market changes. Every year since 2002, annual health care cost growth has been greater — often doubling or more — than consumer price growth.

Rural areas are most at risk, with rural hospitals closing at a rate of nearly one per month since 2010, resulting in a heavier reliance on transporting patients by air to get the appropriate care.

Steve B. Anderson, regional business development manager for AirMethods’ LifeNet of New York, said that 17 EMS services across the state closed down in 2017, and by halfway through 2018, there were already 22 closings.

To benefit all air medic bases, the Save Our Medical Resources campaign was put into place to provide education and resources to the public, as well as decision- and policy-makers. The largest part of the campaign is a bipartisan piece of legislation that would protect access to air medical services by modernizing the Medicare Air Ambulance Fee Schedule, which hasn’t been updated in nearly 20 years.

The legislation, the Ensuring Access to Air Ambulance Services Act, requires air medical operators to collect and submit transparent cost data to the U.S. Department of Health and Human Services so that it can develop an accurate payment system based on actual costs of providing care.

Additionally, it would establish a mandatory air medical quality reporting program, implement a value-based purchasing program to promote high-quality air medical services and provide immediate relief to providers while the data collection occurs.

The legislation was introduced to the House and Senate last year, but no action has been taken since.

Carter Johnson, spokeswoman for the campaign, said the only other bill proposed involves giving states the right to regulate air medical providers and their services, which Ms. Johnson considers problematic.

“Thirty percent of flights that happen go beyond state borders, so if this were to pass, there would be virtual borders in the sky and transports would not be able to take place across the border,” she said.

Ms. Johnson said it was proposed to Congress last year and didn’t pass.

For ground ambulances, Congress passed a funding resolution in 2018 that includes Medicare add-on payments that will be in effect for five years, including the 3 percent increase for ground ambulance trips originating in rural areas, the 2 percent increase for ground ambulance trips originating in urban areas, and a “super rural” add-on of 22.6 percent for ambulance services in the “lowest population density” areas. In addition to extending ambulance add-on payment, the law requires the Centers for Medicare and Medicaid Services to collect certain cost, revenue and utilization information from a representative sample of providers and suppliers of ground ambulance services. Beginning in 2022, ambulance providers and suppliers failing to submit this information will have payments reduced by 10 percent.

In regard to lack of volunteers, though, there are no initiatives put in place yet.

“This is nothing new...it seems like a broken record,” Mr. Wright said. “Every year we participate, we go to Albany, we meet with our local legislators who are supportive, but when it gets to the floor, they don’t recognize a problem.”

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