Written by Troy Cramer
While calling an ambulance for an emergency is an incredibly stressful moment, an ambulance not arriving quickly makes this moment even more traumatic. For some communities in the US, that is a real threat. This threat is close to home in Ann Arbor, as seen in Flushing, a town just an hour north. The mayor of Flushing, Joseph Karlichek, stated that “in 2022, there were 20 sudden cardiac arrest calls in Flushing, of which only 35% of the time did an ambulance arrive in less than nine minutes . . . there were six other occasions where ambulances were responding from outside Genesee County because the county had no licensed ambulances that were available” (Gagnon 2023). Although this is a dramatic example, it firmly highlights this pressing issue and shows why it is important to address. Albeit not every call handled by EMS is life-threatening, as illustrated by a study from 2016, stating that “About 6 percent of 911 patients have time-sensitive ALS needs” (Schrader 2016). However, for those 6%, a rapid response from EMS means the difference between life and death.
The three groups of first responders that actively respond to 911 calls include the police, fire services, and emergency medical services, yet there is a stark dissimilarity between EMS and the others. EMS remains unrecognized as an essential service by the governments of 37 states, while every state acknowledges the other first responders as such. Multiple prominent figures have highlighted this issue within EMS, one of them being Mark McCulloch, the deputy chief of emergency medical services for West Des Moines, Iowa, and a licensed paramedic since 2001. McCulloch stated, “EMS professionals have been advocating for essential designation and more sustainable funding ‘for longer than I’ve been around — longer than I’ve been a paramedic’” (Hassanein 2023). Another figure who brought attention to the lack of EMS recognition and support is the chairperson of the National EMS Advisory Council, Brendan Hayden, stating “the fact that people expect it, but yet it’s not listed as an essential service in many states, and it’s not supported as such really, is where that dissonance occurs” (Hassanein 2023).
Aside from being unrecognized as an essential service, there are additional significant challenges that EMS faces, one of them being difficulty in securing funding and reimbursement for treatment and transport. “EMS is a victim of underfunding,” says Dr. Christine Brent, the EMS Fellowship Program Director with Michigan Medicine. Dr. Brent continues to identify an issue seen in the reimbursement from patients whose primary healthcare is Medicaid, explaining that Medicaid “cover[s] about 20% of what it costs to provide the service to the community” (Reardon 2022). Another interesting note on Medicaid and Medicare reimbursement is that over the past 20 years, it has been stagnant for ambulance reimbursement despite rising costs of care since then. Additionally, a study done by the Journal of American Medical Association in 2016 illustrated that “of the 14.6 million transports by ambulance in the US in 2016, (of those transports with complete billing information), 33% were billed to Medicare, 31% to private insurers, 20% to Medicaid, and 15% were self-pay” (JAMA 2016). That being said, over 50% of all payments are billed to Medicaid/Medicare. With Medicaid covering only about 20% of the cost and Medicare reimbursements remaining stagnant, it is obvious that a serious financial burden is levied on ambulance services.
A deeper dive into the reimbursement for treatment and transportation shown by the National EMS Advisory Council Committee Report and Advisory states, “Based upon a subtotal of the payer mix data above, ambulance providers receive below-cost reimbursement for 72% of all transports—the charity care delivered to the uninsured and the under-compensated care resulting from below-cost Medicare and Medicaid reimbursement. Therefore, uncompensated care, if left unaddressed, threatens the financial stability of the entire EMS safety net” (NEMSAC 2016). The term “charity care” refers to care that is provided to those who seek and need it, but are otherwise unable to pay. However, “charity care” is necessary and important to ensure the health of millions of Americans; no one should ever be denied the right to health services due to their inability to pay.
A solution to the funding/reimbursement issue is a bill recently passed in the state of Michigan last year that has changed Medicaid reimbursement for ground ambulance transportation. This bill is House Bill 4437, and it is changing the Medicaid reimbursement rate “for ground ambulance services at not less than 100% of the medicare base rates for Locality 01 for those services in effect on January 1, 2023” (House Bill 4437, 2023). An important detail to note surrounding this is that Medicaid reimbursements are less than Medicare and according to an American College of Radiology study they found that “in general, Medicaid reimbursement rates tend to be much lower — usually equaling only about 78% of Medicare reimbursement” (Pelzl 2023). So for those ambulance services in Michigan, the Medicaid reimbursement will now be substantially larger.
The other issue plaguing EMS is the recruiting and retention of EMS workers such as emergency medical technicians (EMTs) and paramedics. Pat Boberg, CEO of Mercy EMS in Calumet on the Keweenaw Peninsula, said that Mercy EMS has struggled to fill positions in recent years as well because of a variety of issues. Pat continued to say, “Really, there is just a shortage of EMTs and paramedics. It’s a nationwide situation” (Parker 2023). There are numerous reasons why this shortage exists, varying from the straining mental, emotional, and physical toll that is faced while working, to the desire for higher-paying jobs found elsewhere. One survey highlights this systemic retention issue by demonstrating how widespread it is: ”A survey involving nearly 20,000 employees working at 258 EMS organizations — found that overall turnover among paramedics and EMTs ranges from 20 to 30 percent annually” (American Ambulance Association 2021).
In response to the aforementioned issues, there is a plethora of potential solutions for recruitment within the communities and legislation across all levels of government nationwide. One of these possible resolutions within Michigan was legislation proposed earlier this year changing the minimum age of eligibility to obtain an EMT license from 18 to 17. This is the goal of Michigan House Bills 5154 (2023) and 5155 (2023), which have been referred to the Health Policy Committee and Regulatory Reform Committees. While these may aid in attracting more candidates to work in EMS, some people have expressed concerns. One prominent figure, Matthew Sahr, president of the Michigan Professional FireFighter Union, commented in an interview with Michigan News Source that, “17 years old . . . is a little young” (Gergins 2023). Although they may be qualified, the impact of traumatic calls can adversely affect the mental health of 17-year-olds.
Another possible solution to the retention problem was brought up by the National Emergency Medical Services Advisory Council (NEMSAC), which has recommended introducing a new EMS license which would be a graduate-prepared paramedic. This level of licensure “with an expanded scope of clinical practice become[s] the out-of-hospital equivalent to the hospital-based physician’s assistant (PA) or nurse practitioner (NP). One of the aims is to provide a clinical ladder for paramedics. This would be an optional pathway that could potentially help with EMS recruitment and retention” (NEMSAC 2023).
In short, there has been significant progress in recent years, with some of this significant progress seen in Flushing this year. Flushing has addressed its critical issue by starting a new program in October of 2023. This program is a medical response unit staffed by paramedics that is “ able to respond to any call in the city within 4 minutes” (Gagnon 2023). This program will be funded by a “city established millage-based special assessment . . . costing $150-$160 to the average homeowner annually” (Gagnon 2023). Progress and the further evolution of the EMS system as a whole will continue for years to come, and leaders in EMS will continue to push for change until all of the systemic issues have been addressed and remedied.
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