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What if you had a disaster & no ambulances came?

EMS is in trouble. And that should concern all first responders, because of the central role paramedics and EMTs play in both everyday emergencies and large-scale disasters.

In this month's Hot Zone, Paul Maniscalco and Gregg Lord explain how and why EMS gets shortchanged in federal preparedness funding, leaving many EMTs and paramedics unprotected at WMD responses. But that's a small part of the dismal situation for EMS in the United States today.

Ambulance services nationwide struggle with inadequate and shrinking budgets, soaring call volumes, a shortage of paramedics and vanishing volunteers-who provide most EMS in rural areas. To make matters worse, the population is aging and rural hospitals are closing, resulting in more calls and longer transports.

As usual, money-or the lack of it-lies at the root of this problem.

Medicare and Medicaid are huge culprits. Many-if not most-patients transported by ambulance are on these programs, which have reimbursement rates so low that they often don't cover the cost of the service provided. In 2002, Medicare instituted a national fee schedule for ambulance service that has made matters worse for many, many EMS organizations.

"Since the Medicare change has been implemented, we've steadily been losing money every year on providing service to Medicare patients, to the tune of about $2.4 million a year," says Commissioner Fred Tilman of Ada County, Idaho, where a county-run ambulance service provides EMS transports.

The American Ambulance Association (AAA) is leading an effort to convince Congress to raise Medicare rates, but it's a hard sell when lawmakers are cutting spending for practically everything except the military.

But perhaps the biggest drain on EMS comes from the tens of millions of Americans without health insurance-most of them low-income and many in poor health.

Unlike other health-care providers, EMS can't simply say, "You must pay to play." The law requires an ambulance dispatched to an emergency to transport the patient (unless that patient refuses to go). So EMS "eats" most bills for patients without health insurance.„

Hospital emergency departments (EDs) have the same problem, because federal law requires them to at least examine and "stabilize" all comers. And increasingly, those comers are folks with no insurance who visit an ED as a last resort.„

As such patients clog the nation's EDs, arriving EMS crews must often wait hours for an open bed so they can offload the patient. With paramedics and EMTs tied up at the hospitals, EMS must field more ambulances to respond to new emergency calls.

EMS providers would gladly lighten the ED load by having paramedics simply treat patients who don't need transport or take those with minor injuries or illness to more appropriate destinations. But, currently, EMS gets paid only for transports.

"We need to get [the Centers for Medicare and Medicaid Services] to change the rules on paying for such things as treat and release and transporting people to someplace like a doctor's office or clinic," says John Sinclair, fire chief of Kittitas County (Wash.) Fire District and chair of the International Association of Fire Chiefs EMS Section.„

This reimbursement squeeze leaves ambulance services with little money to pay EMTs and paramedics. No wonder paramedic education programs have problems finding students when paramedics make an average of $33,000 a year (according to the 2004 JEMS Salary Survey) but nurses average $54,000 (according to the U.S. Department of Labor).

So what can first responders do to help? They can support the initiative to get Congress to change Medicare and Medicaid rates and rules.

Even better, why not start a movement to have the federal government simply pay for every emergency ambulance transport and for required ED care? Health plans could contribute the amount they now spend for such services; EMS, Medicare and Medicaid could cut the costs of sending and processing claims; and the nation would preserve the services that provide its day-to-day emergency safety net and form a critical link in homeland preparedness and response.

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